Health in Adolescence

Adolescents tend to have more independence in what they eat and when they sleep compared to younger age groups. Furthermore, they are more independent (able to drive or are transported by peers). This section explores sleep, nutrition, disordered eating, and pregnancy.

Adolescent Sleep

According to the National Sleep Foundation (NSF),^[1] adolescents need about 8 to 10 hours of sleep each night to function best. A Sleep in America poll indicated that adolescents between sixth and twelfth grade were not getting the recommended amount of sleep. For the older adolescents, only about one in ten (9%) get an optimal amount of sleep, and they are more likely to experience negative consequences the following day. These include feeling too tired or sleepy, being cranky or irritable, falling asleep in school, having a depressed mood, and drinking caffeinated beverages.^[2] Lack of adequate sleep can also make adolescents more at risk for substance abuse, car crashes, poor academic performance, obesity, and a weakened immune system.^[3]

Why don’t adolescents get adequate sleep? In addition to known environmental and social factors, including work, homework, media, technology, and socializing, the adolescent brain is also a factor. As adolescent progress through puberty, their circadian rhythms change and push back their sleep time until later in the evening.^[4] This biological change not only keeps adolescents awake at night; it makes it difficult for them to get up in the morning. When they are awake too early, their brains do not function optimally. Impairments tend to be noted in attention, behavior, and academic achievement, while increases in late school attendance and absenteeism are also demonstrated.

Science demonstrates that melatonin levels (or the “sleep hormone” levels) in the blood tend to naturally rise later at night and fall later in the morning among adolescents. This may explain why many teens might stay up late and struggle getting up early in the morning. A lack of sleep makes paying attention difficulty, increases impulsivity and may also increase irritability and depression.^[5]

To support adolescents’ later sleeping schedule, the Centers for Disease Control and Prevention recommended that school not begin any earlier than 8:30 a.m. Psychologists and other professionals have been advocating for later school times, and they have produced research demonstrating better student outcomes for later start times. More middle and high schools have changed their start times to better reflect the sleep research. However, the logistics of changing start times and bus schedules are proving too difficult for some schools leaving many adolescent vulnerable to the negative consequences of sleep deprivation.

Nutrition

Adequate adolescent nutrition is necessary for optimal growth and development. Dietary choices and habits established during adolescence greatly influence future health, yet many studies report that teens consume few fruits and vegetables and are not receiving the calcium, iron, vitamins, or minerals necessary for healthy development.^[6]

One of the reasons for poor nutrition is anxiety about body image, which is individuals’ idea of how their body looks. The way adolescents feel about their bodies can affect the way they feel about themselves as a whole. Some adolescents may adjust their eating habits to lose weight due to their sudden weight gain. Adding to the rapid physical changes, they are simultaneously bombarded by messages, and sometimes teasing, related to body image, appearance, attractiveness, weight, and eating that they encounter in the media, at home, and from their friends/peers (both in person and via social media).

Much research has been conducted on the psychological ramifications of body image on adolescents. Modern day teenagers are exposed to more media on a daily basis than any generation before them. Recent studies have indicated that the average teenager watches roughly 1500 hours of television per year, and 70% use social media multiple times a day.^[7] As such, modern day adolescents are exposed to many representations of ideal, societal beauty. The concept of a person being unhappy with their own image or appearance has been defined as “body dissatisfaction.” In teenagers, body dissatisfaction is often associated with body mass, low self-esteem, and atypical eating patterns. Scholars continue to debate the effects of media on body dissatisfaction in teens.

Disordered Eating

Disordered eating affects all genders. Some individuals also have a distorted sense of body image referred to as muscle dysmorphia, or an extreme concern with becoming more muscular. Dissatisfaction with body image can explain why some teens erratically eat or ingest diet pills to lose weight and why some teens may take steroids to increase their muscle mass. Although disordered eating can occur in children and adults, it frequently appears during the teen years or young adulthood.^[8]

Risk Factors for Disordered Eating

Because of the high mortality rate, researchers are looking into the etiology of the disorder and associated risk factors. Researchers are finding that disordered eating patterns are caused by a complex interaction of genetic, biological, behavioral, psychological, and social factors.^[9] Disordered eating appears to run in families, and researchers are working to identify DNA variations that are linked to the increased risk of developing disordered eating habits. Researchers have also found differences in patterns of brain activity in females who have disordered eating in comparison with females who do not report disordered eating. The main criteria for the most common disordered eating patterns: anorexia nervosa, bulimia nervosa, and binge-eating disorder (see Table 1) are described in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition, DSM-5-TR^[10]

Table 1. Disordered Eating Diagnostic Criteria^[11]

Diagnosis	Major Criteria
Anorexia	Significantly low body weight, significant weight and shape concerns
Bulimia Nervosa	Recurrent binge eating and compensatory behaviors (eg, purging, laxative use); significant weight and shape concerns
Binge eating disorder	Recurrent binge eating; at least 3 of 5 additional criteria related to binge eating (eg, eating large amounts when not physically hungry, eating alone due to embarrassment); significant distress

Consequences of Disordered Eating

For those suffering from anorexia, health consequences may include an abnormally slow heart rate and low blood pressure, which increase the risk for heart failure. Additionally, there is a reduction in bone density (osteoporosis), muscle loss and weakness, severe dehydration, fainting, fatigue, and overall weakness. Individuals with anorexia nervosa may die from complications associated with starvation, while others die of suicide.

The binging and purging cycle of bulimia can affect the digestive system and lead to electrolyte and chemical imbalances that can affect the heart and other major organs. Frequent vomiting can cause inflammation and possible rupture of the esophagus, as well as tooth decay and staining from stomach acids. Lastly, binge eating disorder results in similar health risks to obesity, including high blood pressure, high cholesterol level, heart disease, Type II diabetes, and gall bladder disease.^[12]

Disordered Eating Treatment

To treat disordered eating, getting adequate nutrition and stopping inappropriate behaviors, such as purging, are the foundations of treatment. Treatment plans are tailored to individual needs and include medical care, nutritional counseling, medications (such as antidepressants), and individual, group, and/or family psychotherapy.^[13][14]

Adolescent Pregnancy

In the United States, adolescent pregnancy rates have declined, however, teenage birth rates are higher than in most developed countries. It appears that adolescents in the United States seem to be less sexually active than in previous years, and those who are sexually active seem to be using birth control.^[15]

Risk Factors for Adolescent Pregnancy

Miller, Benson, and Galbraith^[16] found that parent/child closeness, parental supervision, and parents’ values against teen intercourse (or unprotected intercourse) decreased the risk of adolescent pregnancy.  In contrast, residing in disorganized/dangerous neighborhoods, living in a lower SES family, living with a single parent, having older sexually active siblings or pregnant/parenting teenage sisters, early puberty, and being a victim of sexual abuse place adolescents at an increased risk of adolescent pregnancy.

Consequences of Adolescent Pregnancy

After a child is born, life can be difficult for teen parents. Fewer than 50% of teenagers who have children before age 18 graduate from high school. Without a high school degree, job prospects tend to be limited and economic independence can be difficult. Teen parents are more likely to live in poverty and a majority of unmarried teen mothers receives public assistance within 5 years of the birth of their first child. Further, a child born to a teenage mother is more likely to repeat a grade in school, perform poorly on standardized tests, and drop out before finishing high school when compared to their counterparts who are not born to teen mothers.^[17] All genders tend to become parents at an older age as their educational attainment increases.

Diverse experiences and outcomes within and between adolescents

Although similar biological changes occur for adolescents as they enter puberty, these changes can differ significantly depending on one’s cultural, ethnic, and societal factors.

Adolescent development does not necessarily follow the same pathway for all individuals. Certain features of adolescence, particularly with respect to biological changes associated with puberty and cognitive changes associated with brain development, are relatively universal. However, other features of adolescence depend largely on circumstances that are more environmentally variable. For example, adolescents growing up in one country might have different opportunities for risk-taking than adolescents in a different country and supports and sanctions for different behaviors in adolescence depend on laws and values that might be specific to where adolescents live. Likewise, different cultural norms regarding family and peer relationships shape adolescents’ experiences in these domains. For example, in some countries, adolescents’ parents are expected to retain control over major decisions, whereas, in other countries, adolescents are expected to begin sharing in or taking control of decision-making.

Even within the same country, adolescents’ gender, ethnicity, immigrant status, religion, sexual orientation, socioeconomic status, and personality can shape both how adolescents behave and how others respond to them, creating diverse developmental contexts for different adolescents. For example, early puberty (that occurs before most other peers have experienced puberty) appears to be associated with worse outcomes for females than males, likely in part because females who enter puberty early tend to associate with older males, which in turn tends to be associated with early sexual behavior and substance use. For adolescents who are ethnic or sexual minorities, discrimination sometimes presents a set of challenges that nonminority’s do not face.

Finally, genetic variations contribute an additional source of diversity in adolescence. Current approaches emphasize gene X environment interactions, which often follow a differential susceptibility model.^[18] That is, particular genetic variations are considered more riskier than others, but genetic variations also can make adolescents more or less susceptible to environmental factors. Thus, it is important to be mindful that individual differences play an important role in adolescent development.