Adolescents

The word adolescent means becoming an adult (the words adolescent and adult derive from forms of the same Latin word, adolēscere, meaning ‘to grow up’). Ambrose Bierce in The Devil's Dictionary (1911) defined adolescence cynically as a stage between infancy and adultery. At his wedding, a friend touchingly thanked his parents for putting up with the longest adolescence known to mankind. He was joking, of course, but we are regularly confronted with persons of adult years whose behaviour suggests that they have still not made the transition from adolescence to adulthood (Fig. 1). The author JM Barrie, who had his own problems with children, wrote famously of the boy Peter Pan, who never wanted to grow old and who lived in Neverland (or Never-Never Land) with the Lost Boys. These are poignant terms, indeed. Bacchus by Caravaggio. When I was a young paediatrician, I was afraid of neonates – complicated little physiological bundles who could not voice their feelings and concerns – but at least they did not tell me I was useless. I was much more afraid of adolescents, even more complicated melanges of hormones, and feared how I would communicate with them. With time and exposure to adolescents, patients and my own children, I realised that many adolescents were quite like human beings, and I began to like them. The boys would not communicate anything, it seemed, unless expressed in Neanderthal grunts, and the girls tried to communicate by shocking me with words or deeds, but I could cope with that. The use of humour helped. The floor of my adolescent daughter's bedroom was no longer visible because of piles of clothes. One day she asked if anyone had seen a particular dress. When asked where she had last seen it, she said, ‘Down the end of my room?’ ‘The deep end or the shallow end?’ I asked, and we all laughed. An adolescent physician who went on the radio expecting to be asked questions about confronting risk-taking behaviour received mostly queries about how to cope with untidy bedrooms. He said he liked the approach of one mother who allowed her children's bedrooms to be as untidy as they liked, on condition that they kept tidy whatever any visitors could see if the door was ajar. The psychologist G. Stanley Hall coined the phrase ‘storm and stress’ (taken from the German ‘Sturm und Drang’ movement) to describe adolescence, and described its three key elements as conflict with parents, mood disruptions and risky behaviour. Stephen Fry said, ‘No adolescent ever wants to be understood, which is why they complain about being misunderstood all the time.’ He may or may not have realised that he was echoing the great psychoanalyst Donald Winnicott, who also wrote in a famous essay on adolescence that the adolescent boy or girl does not want to be understood.1 Winnicott described each individual adolescent as ‘engaged in a living experience and a problem of existing’ for which the only remedy is ‘the passage of time’.1 Although often in conflict with parents, adolescents crave to belong to a peer group. Quentin Crisp said, ‘The young always have the same problem – how to rebel and conform at the same time. They have now solved this by defying their parents and copying one another.’ A recent editorial described how getting tattoos or piercings in adolescence has become more of a conventional rite of passage than a symbol of rebellion,2 although many parents will be shocked by their adolescent's flamboyant decoration. Adolescents are often adept at playing one parent off against one another. Parents are advised to decide together in advance on the ‘consequences’ (a better word than punishment) if an adolescent transgresses, for example stays out later than agreed. Adolescents certainly undergo massive hormonal changes as they go through puberty. To what extent is adolescent behaviour hormonally based and to what extent do cultural factors affect adolescent behaviour? A friend who worked in Africa for many years before returning to Australia commented that his teenagers were no problem in Africa, but as soon as they went to school with Australian peers they became defiant of their parents, to whom they quoted their ‘rights’. In his new book,3 Jared Diamond, author of the superb Guns, Germs, and Steel, describes that children in traditional societies spend far more time face to face than Western children, playing together rather than being passively entertained and talking directly to each other rather than by email, text or phone. Adolescents in traditional societies, he says, are not tormented by adolescent revolts and identity crises.3 Paediatricians and adult physicians used to vie to disown adolescents. Children's hospitals only accepted children up to 14 years old, but adult hospitals only accepted adults 18 years and older; teenagers aged 15 to 17 were left in limbo. Our adult colleagues find adolescents very confronting. Many adolescents adhere very poorly to medications, even in full knowledge of the likely serious consequences. Examples include adolescents with cystic fibrosis, diabetes and HIV infection. This example of the brinkmanship of adolescence illustrates three D's that I consider to typify some adolescent behaviour: denial, depression and delusions of immortality. Some adolescent colleagues have questioned the existence of the last, quoting high rates of adolescent suicide: Romeo and Juliet were adolescents. Nevertheless, adolescent risk-taking behaviour, such as dangerous driving, implies either a belief that they are invincible or an insouciance about injury and death. There are many other issues. Modern parents are generally more protective of children than in the past, but how does that affect adolescents? How do parents encourage their adolescent children to leave home if part of them wants their child to stay? Fortunately, there is a new generation of adolescent specialists who care for and about adolescents, who advocate for them and who strive to ensure a smooth transition to adult services. In this special issue of the Journal dedicated to adolescent medicine, our specialist editor, Simon Denny, has collated papers on some of the most pressing and controversial topics confronting paediatricians and adolescent specialists.

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