Adolescent Health

Adolescence is a critical developmental period spanning approximately 10 to 24 years of age, characterised by rapid biological, psychological, and social change. General practitioners (GPs) are often the first point of contact for adolescents and play a central role in early identification of developmental concerns, mental health conditions, and risk behaviours. In Australia, approximately 16% of the population (over 4 million people) are aged 10–24 years, and this group accounts for a significant proportion of primary care consultations.

The Australian Institute of Health and Welfare (AIHW) reports that the leading causes of morbidity and mortality in Australian adolescents are mental health conditions, self-harm, unintentional injury, and substance use. Suicide remains the leading cause of death among Australians aged 15–24, with rates significantly higher among males, Aboriginal and Torres Strait Islander youth, and those in rural and remote areas. Despite this burden, adolescents are frequent "no-shows" in general practice, and when they do attend, critical issues may go unaddressed if consultations are not structured to facilitate disclosure.

Key epidemiological data for Australian adolescents:

• Approximately 1 in 7 (14%) Australians aged 4–17 experience a mental health condition in any given year (ABS National Study of Mental Health and Wellbeing).
• Self-harm presentations to emergency departments have increased by over 50% in the 12–17 age group over the past decade (AIHW, 2023).
• Chlamydia is the most commonly notified STI in Australia, with the highest notification rates in the 15–24 age group.
• Approximately 20% of Year 10 students report having consumed alcohol in the past week (ASSAD survey data).
• Obesity prevalence in adolescents aged 12–17 is approximately 8%, with a further 20% classified as overweight (ABS National Health Survey).

Understanding normal adolescent development is the foundation of effective clinical care. Development progresses through three broad stages, each with characteristic physical, cognitive, and psychosocial features. Clinicians must recognise normal variation to avoid unnecessary investigation while remaining vigilant for pathological processes.

Developmental Stages

Tanner Staging (Sexual Maturity Rating)

Tanner staging (also known as Sexual Maturity Rating, SMR) provides a standardised method for documenting pubertal progression. It is based on the sequential development of secondary sexual characteristics and is graded from 1 (prepubertal) to 5 (adult). Self-assessment questionnaires with illustrated staging are available for use in clinical practice and are preferred by both patients and clinicians where direct examination is not clinically indicated.

Key Developmental Milestones

• Females: Thelarche (breast budding, Tanner 2) is typically the first sign of puberty, occurring at a mean age of 10.5 years (range 8–13). Menarche occurs at a mean age of 12.5 years, usually at Tanner stage 3–4. Peak height velocity (PHV) precedes menarche by approximately 1 year (mean 9 cm/year).
• Males: Testicular enlargement ≥4 mL (Tanner 2) is the first sign of puberty, occurring at a mean age of 11.5 years (range 9–14). PHV occurs at Tanner stage 3–4 (mean 9–10 cm/year). Spermarche (first ejaculation) typically occurs around age 13.
• Normal variants: Asynchronous development (e.g., isolated pubic hair adrenarche without thelarche, or unilateral breast budding) is common and usually benign but warrants follow-up if progression does not occur within 6–12 months.

Delayed Puberty

Delayed puberty is defined as the absence of any signs of secondary sexual development by age 13 years in girls or 14 years in boys. It affects approximately 2–3% of adolescents and causes significant psychosocial distress. The most important clinical task is distinguishing constitutional delay of growth and puberty (CDGP) — a benign, self-limited variant — from pathological causes requiring treatment.

Investigations for Delayed Puberty

Treatment of Delayed Puberty

Precocious Puberty

Precocious puberty is defined as the appearance of secondary sexual characteristics before age 8 years in girls or 9 years in boys. It requires timely evaluation to identify and treat potentially serious underlying causes and to mitigate psychosocial consequences and compromised adult height.

Investigations for Precocious Puberty

Treatment of Central Precocious Puberty

Mental health conditions are the leading cause of disability in Australian adolescents. The 2020–2022 National Study of Mental Health and Wellbeing reported that approximately 39% of Australians aged 16–24 had experienced a mental health disorder in the prior 12 months, with anxiety disorders most common, followed by affective disorders including major depressive disorder. The GP is the most frequently accessed health professional for mental health concerns in this age group.

Screening

Universal screening for depression and anxiety is recommended at least annually for all adolescents, and at every consultation for those with identified risk factors. Validated screening tools suitable for Australian general practice include:

Depression — Severity and Management

Pharmacotherapy for Adolescent Depression

Suicide Risk Assessment

Any adolescent disclosing suicidal ideation, self-harm, or presenting with behavioural change suggesting depression must receive an immediate suicide risk assessment. The Columbia Suicide Severity Rating Scale (C-SSRS) is the recommended validated tool for Australian general practice and is freely available in a brief screener format.

Psychological Therapies

• Cognitive Behavioural Therapy (CBT): Most extensively studied and recommended first-line psychological treatment for adolescent depression. Typically 12–16 sessions. Accessible via Mental Health Treatment Plans (up to 20 sessions per calendar year under Medicare, with possible additional sessions in exceptional circumstances).
• Interpersonal Therapy for Adolescents (IPT-A): Effective alternative to CBT, particularly when interpersonal conflict or grief is prominent. Focuses on role transitions, interpersonal disputes, and grief.
• Dialectical Behaviour Therapy (DBT-A): Evidence-based for recurrent self-harm and emotional dysregulation. Typically delivered as a structured programme in CAMHS or specialist settings.
• Family-based interventions: Including Functional Family Therapy and Multisystemic Therapy for adolescents with conduct problems and depression comorbid with behavioural issues.

Key Australian Support Services

The "Mature Minor" Doctrine in Australian Law

In Australia, there is no fixed age at which a young person can consent to medical treatment. Under common law (based on the UK Fraser guidelines, applicable across all Australian states and territories), a young person who demonstrates sufficient maturity and understanding — a "mature minor" or "Gillick-competent" individual — may consent to their own medical treatment without parental knowledge or approval. This applies to contraception, STI treatment, mental health care, and other interventions.

Key principles for assessing mature minor competence:

• The adolescent must understand the nature, purpose, risks, and benefits of the proposed treatment.
• The adolescent must understand the consequences of refusing treatment.
• The assessment of competence is specific to the treatment proposed and the individual's maturity, not a blanket determination.
• Younger adolescents (12–14 years) may be competent for some decisions but not others; each consultation requires individual assessment.
• Legislation varies by state/territory regarding specific age thresholds for particular interventions (e.g., sexual health, mental health treatment orders).

HEADSS Assessment

The HEADSS psychosocial interview is the recommended framework for systematic risk behaviour screening in adolescents. It should be introduced with an explanation of confidentiality and its limits, and conducted with the young person alone.

Substance Use Screening — CRAFFT 2.1

The CRAFFT 2.1 (Car, Relax, Alone, Forget, Friends, Trouble) is a validated 6-item screening tool for substance use in adolescents aged 12–18 years recommended by the RACGP. A score of ≥2 indicates a positive screen requiring further assessment.

• C — Have you ever ridden in a car driven by someone (including yourself) who was high or had been using alcohol or drugs?
• R — Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in?
• A — Do you ever use alcohol or drugs while you are alone?
• F — Do you ever forget things you did while using alcohol or drugs?
• F — Do your family or friends ever tell you that you should cut down on your drinking or drug use?
• T — Have you ever gotten into trouble while you were using alcohol or drugs?

Key Risk Behaviours in Australian Adolescents

Preventive Health in Adolescents

Ongoing monitoring is essential for all adolescents under active management. The following schedule is recommended:

Monitoring — Delayed Puberty (on treatment)

• Height, weight, and Tanner staging every 3–6 months.
• Bone age annually.
• Hormone levels (testosterone, oestradiol, LH, FSH) every 6 months to guide dose titration.
• FBC and LFTs at baseline and annually (particularly if on testosterone — polycythaemia risk).
• Psychosocial assessment of self-esteem, peer relationships, and school performance at each visit.

Monitoring — Precocious Puberty (on GnRH agonist)

• Tanner staging, height, and weight every 3 months.
• Bone age every 6–12 months.
• GnRH agonist suppression (LH, oestradiol/testosterone) every 6 months to confirm adequate suppression.
• Monitor injection site reactions; switch formulation if persistent granulomas.

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