Adolescent Nurse Care Plan Diagnosis: A Comprehensive Guide for Healthcare Professionals

About the Authors

Marilyn Hanser, RN, BSN, MA, a graduate of Baylor University School of Nursing (1976), served in the U.S. Navy Nurse Corps, achieving the rank of Lieutenant Junior Grade. With a Master’s degree in Humanities from California State University Dominguez Hills (1993), she has extensive experience in women’s health education and consulting.

Shelda L. Hudson, RN, BSN, PHN, holds a Baccalaureate Degree in Nursing and a Public Health Certificate from Azusa Pacific University. As Director of Healthcare Information at NCCE, she oversees course development and author selection for continuing education programs for healthcare professionals, leveraging over 20 years of experience in this field.

Purpose and Goals

This course aims to equip nurses with the knowledge and skills necessary to understand and effectively address the critical issues faced by adolescent girls and their families. The focus is on normal physiological, cognitive, and psychosocial development, and evidence-based nursing interventions to manage deviations from healthy development.

Instructional Objectives

Upon completion of this course, learners will be able to:

1. Identify the key characteristics of each stage of adolescence.
2. Enumerate the primary cognitive and psychosocial developmental tasks of early, middle, and late adolescence.
3. Summarize essential nutrition and exercise recommendations for adolescent females.
4. Recognize lifestyle choices and psychosocial factors that can complicate the normal development of adolescent females.
5. Describe the symptoms and major health risks associated with different types of eating disorders.
6. Define sexual abuse and its various forms.
7. Outline prevalent sexually transmitted diseases among adolescent girls.
8. Identify factors that enable nurses to recognize adolescents at risk.
9. Formulate relevant nursing diagnoses and implement appropriate interventions for adolescent girls.
10. List at least two community resources available to support adolescent girls.

Introduction

Nurses bring a vital holistic perspective to patient care, uniquely positioning them to address the multifaceted issues affecting adolescents. Unlike physicians who often focus on physical health and psychotherapists who concentrate on emotional and social well-being, nurses are trained to assess and integrate the physical, emotional, social, intellectual, and spiritual dimensions of health. This comprehensive approach is fundamental to the nursing process.

This course emphasizes the crucial role nurses play in the lives of adolescent girls. The primary goal is to guide nurses in empowering adolescent girls to integrate all aspects of their lives into a healthy self-concept, fostering a sense of purpose and direction.

Key challenges impacting adolescent girls today include diet and exercise, body image issues and eating disorders, physical, emotional, and sexual abuse, contraception and pregnancy, sexually transmitted diseases, and suicide. This course will equip you with the skills to recognize at-risk adolescents, implement appropriate nursing interventions, and connect them with vital community resources.

Normal Physiological Development

Adolescence is broadly divided into three stages – early, middle, and late – each marked by significant sexual and emotional maturation.

Early Adolescence

Typically spanning ages 10 to 13 and lasting for approximately one year, early adolescence is triggered by the release of pituitary gonadotropins and growth hormone during sleep. During this phase and continuing into adulthood, a female’s body fat content increases from about 8% to 22-25%. While overall growth in height and weight may not dramatically change initially, estrogen-driven fat redistribution towards the breasts, hips, and thighs, and an increase in total body fat, begins.

Early in this stage, the pituitary gland starts secreting follicle-stimulating hormone (FSH), which stimulates ovarian growth. The ovaries then produce estrogen, initiating breast development, thickening of the vaginal mucosa, and uterine enlargement. Estrogen also causes increased pigmentation, vascularization, and sensitivity of the labia, along with clitoral enlargement. The endometrium thickens and undergoes cellular changes, increasing levels of actinomycin, creatine kinase (CK), and adenosine triphosphate (ATP), preparing the body for menstruation. Estrogen also elevates glycogen levels in the vaginal mucosa, fostering acid-forming bacteria, which lowers vaginal pH and increases susceptibility to yeast infections.

Other physiological developments include the eruption of permanent premolars, cuspids, and molars. Neurodevelopment continues with increased alpha and decreased beta brain wave production. By age 12, girls should exhibit a “mature” response on standard neurodevelopmental assessments.

These rapid physical changes often lead to body preoccupation. Girls may spend considerable time observing their transforming bodies, becoming fixated on minor perceived flaws and exaggerating their significance. Minor grooming issues can feel catastrophic.

Middle Adolescence

Table 1: Development of Secondary Sex Characteristics

	Stage 1	Stage 2	Stage 3	Stage 4	Stage 5
Breast Development	Papilla elevation	Breast bud development and enlargement of areola	Further enlargement of areola and breast	Projection of areola and papilla	Maturity – projection of papilla only
Pubic Hair Development	Prepuberty – not developed past abdominal wall	Sparse growth of long hair along labia	Hair darkens, coarsens, and curls	Hair adult in type but not spread medially	Hair adult in type and spread medially to surface of thighs

Middle adolescence, typically between ages 12 and 14, is characterized by the most pronounced physical changes. A significant height increase (around 8-9 cm/year) is followed by weight gain within about six months. Teenagers in this stage may gain approximately 10 pounds annually between 10 and 14 years old. This weight gain often precedes full adult height, which can lead to a somewhat stocky appearance, potentially impacting self-esteem.

This stage involves increased fat tissue deposition and further development of secondary sex characteristics. Breast and areola enlargement continues, and pubic hair darkens, thickens, curls, and spreads, as outlined in Table 1. Menarche, the onset of menstruation, occurs on average at 12.5 years in the U.S., closely linked to the weight increase curve and influenced by genetics and nutrition. Sleep patterns may shift, leading to increased daytime sleepiness, possibly due to the energy demands of the adolescent growth spurt and hormone release during sleep.

Late Adolescence

Late adolescence, generally from ages 14 to 17, sees minimal further height increase, with the completion of secondary sex characteristics development. Pubic hair extends to the inner thighs, breasts reach full adult size and shape, and uterine fundal growth concludes. Neurodevelopment is largely complete at this stage.

Normal Cognitive and Psychosocial Development

Cognitive development from infancy to adulthood is often described using Piaget’s stages of cognitive development, which correlate with physical development. These theories provide a framework for understanding adolescent cognitive abilities.

Early Adolescence

Spanning ages 10 to 13, early adolescence sees younger girls primarily exhibiting concrete thinking, while older girls may transition to abstract thought. Although there is significant overlap, cognitive growth during this phase generally progresses toward increased abilities in:

• Information processing
• Information organization
• Abstract thinking
• Metacognition (thinking about thinking) and enjoying intellectual challenges
• Autonomous moral reasoning

Early and middle adolescents often display black-and-white thinking and a tendency to overgeneralize.

The early adolescent girl navigates family, peer group, and school environments. Her primary psychosocial task is initiating separation from her family, primarily by seeking social fulfillment within peer groups. These relationships are activity-based rather than deeply relational, characterized by conformity, but serve the purpose of initiating separation from family bonds, even if true autonomy develops later. Simultaneously, girls may seek parental connection, sometimes initiating arguments to maintain emotional ties.

School functioning is usually smooth unless physical development is significantly earlier or later than peers, potentially leading to self-image issues. Studies suggest subtle biases favoring boys in secondary education, which may undermine girls’ confidence and academic progress.

Middle Adolescence

The shift from concrete to abstract thinking continues as a process, not an abrupt change. Peer and school groups remain crucial. Girls develop interpersonal skills, valuing loyalty, commitment, intimacy, and privacy in peer relationships. Increased arguments with mothers and emotional distancing from fathers are common during this phase.

Social circles expand to include the opposite sex, and dating may begin. Sexual identity solidifies, and a sense of sexual adequacy emerges. Vocational and educational paths may also start to become clearer during middle adolescence.

Late Adolescence

The key psychosocial task of late adolescence is developing the capacity for intimacy. This is contingent on successful navigation of earlier developmental stages and individuation from family and friends. Peer relationships prioritize loyalty, trust, and emotional availability. A gradual reconnection with family occurs, establishing a new family dynamic as adolescents begin to engage in dialogue with their parents.

Normal Nutrition Needs

Table 2: Normal Nutrition Requirements for Adolescent Girls

Nutrient	Age 11-14	Age 15-18
Calcium (mg)	1200	1200
Protein (g)	46	44
Vitamin A (µg)	800	800
Vitamin D (µg)	10	10
Vitamin E (mg)	8	8
Vitamin K (µg)	45	55
Vitamin C (mg)	50	60
Thiamine (mg)	1.1	1.1
Riboflavin (mg)	1.3	1.3
Niacin (mg)	15	15
Vitamin B6 (mg)	1.4	1.5
Folate (µg)	150	180
Vitamin B12 (µg)	2.0	2.0
Phosphorus (mg)	1200	1200
Magnesium (mg)	280	300
Iron (mg)	15	15
Zinc (mg)	12	12
Iodine (µg)	150	150
Selenium (µg)	45	50

During the rapid growth of adolescence, nutritional needs significantly increase. Adolescents require more calories, protein for muscle development, calcium for bone and teeth growth, and essential vitamins and minerals for metabolic processes. Table 2 provides a summary of these requirements. Dietary habits during these years have long-term implications, affecting not only the adolescent’s health but also that of her future children. Three balanced meals and three healthy snacks daily are recommended.

Adequate calcium intake is critical during adolescence. Insufficient calcium can limit bone growth and negatively impact adult height, substantially increasing the risk of osteoporosis later in life. The recommended daily intake is 1200 mg of elemental calcium, with some experts suggesting up to 1600 mg/day. This is equivalent to about a quart of milk or calcium-fortified orange juice. Other calcium-rich foods include yogurt, cheddar and Swiss cheese, and tofu.

Vitamin D is essential for calcium absorption and is found in milk and supplements. The recommended daily intake is 400 IU. Sun exposure also helps the body produce Vitamin D.

While dietary sources are preferable, supplementation may sometimes be needed. Calcium carbonate is common but can cause stomach upset or constipation. Calcium citrate, gluconate, or phosphate are alternatives. Dosage recommendations refer to elemental calcium content; for example, Oscal 500 tablets contain 500 mg of elemental calcium per 1250 mg tablet. Antacids like Tums are a cost-effective source, providing 200 mg of elemental calcium per tablet.

Table 3: Calcium and Phosphorus Content of Foods

Food	Serving	Calcium (mg/serving)	Phosphorus (mg/serving)	Ca/P Ratio
White Bread	1 slice	35	30	1/0.9
Whole Wheat Bread	1 slice	20	74	1/3.7
Skim Milk	1 cup	302	247	1/0.8
Whole Milk	1 cup	291	228	1/0.8
Plain Yogurt	1 cup	415	326	1/0.8
Cheddar Cheese	1 oz.	204	146	1/0.7
Apple	1	10	10	1/1
Banana	1	7	22	1/3.1
Oatmeal	1/2 cup	9	89	1/9.9
Ground Beef (cooked)	3 oz.	8	135	1/16.9
Chicken (dark meat)	1 piece	13	81	1/6
Corn	1/2 cup	2	39	1/20
Potatoes (baked)	1 baked	21	115	1/5.5
Green Beans	1/2 cup	30	16	1/0.5

The calcium-to-phosphorus ratio is also important. Phosphorus is crucial for bone and teeth development and cellular metabolic pathways. An ideal ratio is 1:1. Excessive phosphorus intake, common in adolescent diets high in chocolate, soft drinks, and processed food additives, can disrupt calcium homeostasis, leading to calcium loss and reduced bone mass (Table 3).

Normal Exercise Needs

Adolescent girls are increasingly less likely to engage in recreational physical activities. Limited physical education in schools, often with minimal active participation, contributes to this. Developing healthy exercise habits during adolescence is crucial for lifelong well-being. Exercise serves as a stress reducer and builds self-confidence as adolescents become more comfortable with their changing bodies. Aerobic exercise releases endorphins, which reduce tension, elevate mood, decrease anxiety, improve self-esteem and body image, reduce menstrual cramps, and promote healthy sleep. Daily aerobic activity is recommended, such as walking or biking to school, or participating in sports like tennis, swimming, or hiking. Good exercise habits established in adolescence increase the likelihood of active adulthood.

Complications to Normal Adolescent Development

Challenges to normal adolescent development can be broadly categorized into:

1. Lifestyle choices
2. Psychosocial factors

Assessing lifestyle choices involves examining current eating patterns, exercise levels, and screen time habits. Psychosocial factors include societal pressures for thinness, peer influence, history of sexual abuse, high rates of STIs among teens, and teen pregnancy.

Lifestyle Choices

Despite increased nutritional knowledge, adolescent diets often remain high in fat, refined sugar, and salt, and low in fiber, dairy, iron, magnesium, zinc, phosphorus, and essential vitamins. Middle-class teens may use vitamin supplements, but these do not replace phytochemicals found in whole foods, particularly fruits and vegetables, which have anti-carcinogenic properties. Fiber knowledge is lacking among teens, impacting healthy food choices. Rising soft drink consumption further compromises nutrition by displacing milk (reducing calcium intake), increasing phosphorus (disrupting calcium-phosphorus balance), and contributing high refined sugar intake.

These dietary patterns increase the risk of obesity, heart disease, diabetes, osteoporosis, dental caries, and diet-related cancers later in life. Sedentary lifestyles exacerbate these risks. For example, average teen screen time is about three hours daily, reducing exercise and increasing exposure to food advertising, over 60% of which promotes less nutritious options like soft drinks, coffee, and alcohol. Excessive TV viewing correlates with poorer physical fitness, increased snacking, and less nutritious snack choices, leading to higher calorie intake and lower expenditure compared to less screen-dependent peers. Screen time also displaces more active pursuits.

Psychosocial Factors

American society’s emphasis on thinness and body image creates significant pressure. The idealized “reed-like” body of media figures is unattainable for most, naturally occurring in only about 5% of the population.

Roberta Pollack Seid, PhD, in Never Too Thin: Why Women are at War with Their Bodies, describes thinness obsession as a cultural “religion” where women’s bodies are sacrificed. Adolescent girls are acutely aware of this ideal. Puberty brings body changes that deviate from this ideal, prompting attempts to control physical maturation, a process largely beyond their control. This struggle can lead to eating disorders. Weight loss and improved appearance are primary motivators for restrictive eating or fitness plans.

Even with supportive families who question societal thinness obsessions, peer influence is potent. Constant peer conversations about body size, weight, and dieting make it difficult for individual girls to resist body preoccupation and perceived “faults.” Peer acceptance often necessitates adopting this “religion.” Without family resistance, escaping this pressure is challenging.

Normal Eating Patterns

Internal signals regulating food intake primarily aim to maintain caloric and nutrient balance rather than volume regulation. This results in consuming less of calorie-dense foods and more of low-calorie, nutrient-poor foods.

Internal eating signals originate from the brain, stomach, intestines, and liver. Brain receptors respond to blood glucose levels. The stomach reacts to food volume and nutrient density. The duodenum releases cholecystokinin (CCK) in response to food presence; when CCK levels reach a threshold, eating is signaled to stop. Post-meal, abundant blood glucose is converted to glycogen and fatty acids in the liver for storage, also sending satiety signals.

External eating cues include taste, smell, texture, mealtime schedules, social eating, attractive food presentation, and learned responses to these stimuli.

Food selection is another key factor, influenced by cultural norms and serving as a means of symbolic expression, social differentiation, and asserting independence and identity.

Eating Disorders

Eating disorders often emerge during adolescence, a period of rapid physical changes, heightened social and cultural sensitivity, and challenging developmental tasks. Navigating adolescence can be difficult, involving issues of dependency/autonomy, power/control, intimacy, and self-efficacy. These challenges are amplified by cultural glorification of extreme thinness, equating weight loss and thinness with self-control, power, self-esteem, or even rebellion. Thinness can also mask physical and sexual development, causing conflict and confusion for some teenagers. Preoccupation with food, weight, or bingeing can serve to suppress or manage complex emotions. Consequently, many adults with eating disorders are emotionally fixated at an adolescent developmental stage, requiring them to address these tasks in adulthood to achieve healing.

Characteristics often observed in individuals before the onset of eating disorders include being overachieving, people-pleasing, feeling a need to prove themselves and be successful or perfect. They may be overly concerned with parental reactions and feel excessively responsible for others. Emotional suppression, particularly of negative emotions like hurt and anger, is common.

An eating disorder is defined as a disturbance in eating behavior that significantly impairs physical and/or psychosocial health. The three primary types are anorexia nervosa, bulimia nervosa, and binge eating disorder, each with distinct diagnostic criteria and medical and psychological risks. They typically originate in adolescence or late childhood.

Anorexia Nervosa is most prevalent among middle to upper-class white adolescent females. A weight loss of 15% or more of premorbid body weight (unexplained by medical conditions) is a diagnostic criterion. Individuals appear emaciated, but often have a distorted body image and do not perceive themselves as such, denying the problem and resisting intervention.

Anorexic individuals often come from families that prioritize achievement in academics, sports, or social status over personal growth, independence, and interpersonal relationships. Lacking a sense of control in other areas of life, they may seek control through food intake and body size. Food becomes a symbolic expression of identity, independence, and control, but paradoxically, anorexia ultimately controls them, leading to an inability to eat normally.

Athletic aspirations can also trigger anorexia, particularly in sports like gymnastics and dance where there is pressure to conform to an ideal body type. Voluntary food restriction can lead to nutrient deficiencies, endocrine imbalances affecting menstruation, eating disorders, and stress fractures. Early onset anorexia is particularly detrimental to peak bone mass. Girls with delayed menarche due to low body fat are at higher risk. Starting intense training before menarche increases the risk of menstrual irregularities and skeletal development issues. Studies show increased calcium excretion, decreased bone formation, and increased bone reabsorption in anorexics, indicating mineral metabolism deficiencies.

Physical signs of anorexia nervosa, besides emaciation and muscle loss, include lanugo on extremities, bradycardia, hypotension, abdominal pain and delayed gastric emptying, dry skin, brittle nails and hair, cold intolerance, constipation, and ankle edema. Heart murmurs may develop due to heart muscle shrinkage. EKGs may show abnormal blood flow patterns.

Anorexics typically experience amenorrhea or delayed menarche due to loss of body fat. A body fat content of 15-17% is needed for estrogen levels necessary for menstruation. Laboratory findings may include anemia, low WBC and platelet counts, low serum protein, and thyroid disturbances.

Bulimia Nervosa, more common than anorexia, involves binge eating followed by compensatory behaviors like self-induced vomiting, laxative misuse, excessive dieting, and over-exercising. Binge eating is often secretive and driven by anxiety rather than hunger, aiming for emotional soothing. Foods consumed are typically calorie-dense and require minimal chewing. A binge can involve up to 20,000 calories in one to two hours, ending with purging, abdominal discomfort, social isolation, diuretic/laxative use, fatigue, and sleep. This cycle can occur multiple times daily. Initially a home-based activity, bulimia can escalate to disrupt school and social life.

Unlike anorexics, bulimics are often aware of their abnormal eating patterns, leading to shame and guilt, self-deprecation, and depression. They are also more prone to impulse control issues like substance abuse, shoplifting, and sexual acting out, and often maintain a normal weight.

Bulimia poses serious medical risks. Bingeing can cause abdominal pain, gastric distention, nausea, and stomach rupture. Heart failure is a risk for those with a history of starvation as part of purging. High-calorie, high-sodium binges can predispose to hypertension, atherosclerosis, and elevated cholesterol and triglycerides. Self-induced vomiting can cause esophageal rupture and dental enamel erosion. Vomit aspiration can lead to life-threatening pneumonia. Frequent vomiting may cause painless parotid gland enlargement, a sign of recent bulimic activity.

Drugs used to induce vomiting or diarrhea can have serious side effects. Ipecac syrup can cause myocarditis with repeated use. Laxative abuse can cause dehydration, hypokalemia, and laxative dependence. Hypokalemia symptoms include fatigue, muscle cramps, weakness, headaches, heart palpitations, arrhythmias, and abdominal pain.

The diet-binge cycle is scientifically futile. Diets trigger metabolic changes like altered fatty acid synthesis, increased fuel mobilization, decreased energy expenditure, increased energy efficiency, and enhanced fat storage, leading to weight regain after dieting.

Psychological consequences of dieting are also negative. The initial mood elevation and energy surge are often followed by cravings and binges due to caloric restriction. Negative emotions after binges lead to renewed dieting attempts, perpetuating a cycle that can devastate self-esteem over time. Adolescents, lacking long-term experience, may attribute failure to willpower rather than the inherent limitations of dieting.

Both anorexics and bulimics are more likely to start smoking as a weight control method. Weight concerns can be an early predictor of smoking risk, as the desire for thinness may outweigh health risks. However, they also tend to gain weight more rapidly when they quit smoking.

Obesity is defined as weight 15%-20% above ideal weight according to Metropolitan Life Insurance Standards, with excess body fat. Obesity often begins in infancy and worsens at puberty, showing familial patterns, likely a combination of genetic predisposition and home environment psychosocial factors. Feeding children according to caregiver schedules rather than internal hunger cues may disrupt internal regulation, leading to eating in response to external cues. Parent-child conflict may also contribute, with tense mealtimes or using the child as a scapegoat in marital conflict potentially leading to emotional eating for comfort.

Cultural and ethnic influences on food and eating habits are also important to consider when evaluating a child’s environment.

Sexual Abuse

Sexual abuse is defined as using children, adolescents, or vulnerable individuals in sexually exploitative behaviors, including fondling, masturbation, clothing removal, genital and/or oral contact, and object use for perpetrator sexual gratification. Incest is a specific form of sexual abuse involving sexual activity on a child by a family member for the perpetrator’s sexual gratification.

Sexually abused adolescents are frequently hospitalized for related symptoms such as guilt, anger, dissociation, depersonalization, memory and sleep disturbances, substance abuse, impaired social functioning, self-mutilation, and eating disorders. Failure to integrate the abuse experience into their developing personality prevents self-protection and increases re-victimization risk. Early betrayal can lead to existential doubts.

Sexual abuse victims may behaviorally reenact the trauma in three forms: harming others, harming self, and re-victimization. Violence towards others may indicate identification with the abuser and their power. Self-harm, more common in girls, includes cutting, mutilation, eating disorders, and suicide. Survivors are more likely to be re-victimized in adulthood through rape, marital violence, prostitution, pornography, and unwanted sexual advances from authority figures. Their children are also at higher risk of abuse, perpetuating intergenerational cycles. Early intervention by healthcare professionals is crucial.

Pregnancy, Contraception, and Adolescence

While detailed discussion of pregnancy is beyond this course’s scope, the prevalence of teen pregnancies necessitates addressing its specific implications for adolescents. Eighty percent of teens seeking pregnancy tests do not want to be pregnant, facing difficult decisions about their sexual behavior. Nurses can counsel on abstinence, contraception, safer sex, and STI screening.

Cultural pressure for thinness, already impacting adolescent nutrition, intensifies during pregnancy. Fragile body image is challenged by rapid pregnancy-related physical changes. Many teens are still growing themselves and must meet their own nutritional needs along with those of the fetus.

Pregnant adolescents need 1200-1500 mg of calcium and phosphorus daily, with increased needs for iron (30 mg/day), protein (60 g/day), folic acid (400 micrograms/day), and calories (300+ daily), along with slight increases in other vitamins and minerals. If supplementation is used, calcium and iron should be taken separately as calcium can interfere with iron absorption.

Normal pregnancy weight gain is 25-35 lbs. Underweight teens may need to gain up to 40 lbs. Obese pregnant teens should limit gain to about 15 lbs. Weight loss during pregnancy is contraindicated due to risks of low birth weight and maternal nutrient depletion.

Adolescence and pregnancy both present psychological challenges related to body image, societal gender roles, parenting anxieties, and separation/abandonment issues. Concurrent adolescence and pregnancy are particularly challenging. Pre-existing eating disorders further complicate the situation.

Currently, condoms and oral contraceptives with condoms are the most effective and widely accepted contraceptive methods for teens. Teens need to consider the ease, efficacy, and safety of different methods. The most effective methods for pregnancy prevention offer less STI protection. Dual method use is widely recommended.

Sexually Transmitted Infections

Many adolescents report multiple sexual partners by high school graduation, leading to high rates of STIs, including HPV, syphilis, gonorrhea, chlamydia, and HIV (Table 4). Contributing factors include early sexual activity, unprotected intercourse, and high-risk partners.

Table 4: Common Sexually Transmitted Infections (STIs)

STIs can have serious short-term and long-term consequences. Gonorrhea and chlamydia increase the risk of pelvic inflammatory disease (PID), potentially causing infertility, chronic pelvic pain, and ectopic pregnancy. HPV is linked to cervical dysplasia and certain cancers. HIV infection is often fatal.

Chlamydia is the most reported STI in the U.S., often asymptomatic or with mild symptoms like burning urination and vaginal discharge, appearing 1-2 weeks post-exposure. Diagnosis is simple via urine test, without pelvic exam.

Nonsuicidal Self-Injurious Behaviors (NSSI)

An estimated one to two million people in the U.S. engage in deliberate and repeated self-harm, such as cutting, burning, bruising, scratching, or mutilating, often without suicidal intent.

Self-Injurious Behavior (SIB) includes self-injury (SI) and self-poisoning, defined as intentional, direct tissue damage, typically non-suicidal. Skin-cutting is most common, but SIB encompasses a range of behaviors like burning, scratching, hitting, wound interference, hair-pulling (trichotillomania), and ingestion of toxins or objects. While not intended as suicide, SIB is potentially life-threatening and increases suicide risk; 40-60% of suicides involve self-harm history.

SIB is associated with mental disorders, listed as a symptom of borderline personality disorder in DSM-IV-TR, and also seen in depression, anxiety disorders, substance abuse, eating disorders, PTSD, schizophrenia, and personality disorders. Symptoms vary but may include somatic complaints, emotional suppression, trauma-related distress, impulsivity, and other self-destructive behaviors. SIB also occurs in high-functioning individuals without clinical diagnoses. Motivations vary, serving as a coping mechanism for intense feelings like anxiety, depression, numbness, failure, or self-loathing, and is often linked to trauma and abuse history.

Treatment approaches for SIB focus on underlying causes or the behavior itself. Antidepressants may be effective for depression-related SIB. Avoidance techniques and replacing SIB with safer coping methods are also used.

SIB is most common in adolescence and young adulthood, typically starting between 12 and 24. Childhood SIB is less common but has increased since the 1980s.

Suicide

The emotional volatility of adolescence increases suicide risk. Triggers may seem minor to adults, but adolescents lack life experience to understand the cyclical nature of emotions. Adults know that difficult periods are temporary, but adolescents may not. This, combined with hormonal and emotional fluctuations, can lead to perceiving situations as more catastrophic than they are. Caring, non-judgmental adults can offer perspective and support.

Recognizing the Adolescent at Risk

Factors affecting adolescent girls’ health are complex and multifaceted. Differentiating physical, emotional, spiritual, and cognitive influences in general, and in individual assessments, is challenging.

The initial step is a holistic assessment covering physical, emotional, cognitive, social, and spiritual dimensions, using questions to highlight areas needing further evaluation (Table 5).

Table 5: Holistic Assessment of Adolescent Girls

Emotional Dimension

Affect

• What is the adolescent’s affect?
• How appropriate is her affect?

Mood

• What is your predominant mood?
• Do you have mood swings?
• How well do you control your emotions?
• How well do you express your feelings?
• What are your fears and anxieties?
• Are you depressed, suicidal, angry?
• Do you feel hopeless?
• What are your coping skills?

Social Dimension

Self-concept

• Describe yourself, including your strengths and limitations.
• What kind of person would you like to be?

Interpersonal relations

• Who is your best friend?
• How do you get along with your parents, your brothers and sisters, your peers, and people at school, at work, and in the community?
• How much time do you spend with your family?
• Who is supportive for you?
• How do you get along with authority figures?

Cultural factors

• What traditions do you and your family observe?
• What conflicts arise from these traditions?

Environmental factors

• What situations or events are stressful for you?
• In what risk-taking events do you participate?

Level of socialization

• How conforming or nonconforming is the adolescent?
• What evidence is there of legal difficulties?
• How well does she accept responsibility?

Trust-mistrust

• How suspicious is the adolescent?
• How naive is the adolescent?

Dependence-independence

• What evidence is there of dependence-independence conflicts?
• In what areas does the adolescent demonstrate autonomy?
• In what areas does she demonstrate dependence?

Spiritual Dimension

Philosophy of life

• What is the purpose of life?
• What is important about life to you?
• Who is your hero?

Sense of transcendence

• Are you an optimist or a pessimist?
• Do you think life can be better?
• What can you do to make it better?

Concept of deity

• What is your view of God, or a higher power?
• How similar is it to your parents’ or family’s view?
• How comforting is your relationship with God, or a higher power?

Spiritual fulfillment

• What is beautiful to you?
• What are your creative abilities?
• What do you believe about life and death?
• Are you preoccupied with religion?
• What conflicts arise from your religious beliefs?
• How much do you question or reject your parents’ beliefs?
• How do you implement your own belief system?

Physical Dimension

Genetic history

• Who in your family has had any of the following mental or emotional illnesses?
  • Depression
  • Suicide
  • Drug addiction
  • Schizophrenia

Health history

• What illnesses, injuries, hospitalizations, or surgeries, have you had?

Growth and development history

• Describe your physical growth.
• Describe your sexual growth.
• Tell me about your experiences in kindergarten, elementary school, high school, college, or work.

Activities of daily living

• Describe your typical day beginning with when you get up in the morning through the day until you go to bed at night.

Diet and elimination

• What changes in your appetite and weight have occurred and over what period of time?
• What problems are you having with elimination?

Exercise and activity

• What kinds of activities do you participate in? How often? For how long?
• What kinds of exercise do you participate in? How often? For how long?

Sleep and rest

• How many hours of sleep do you get? Is it adequate?
• What difficulties do you have going to sleep or staying asleep?

Tobacco, drugs, alcohol

• How much do you smoke?
• What drugs or medication do you take?
• How much alcohol do you drink? What kinds of alcohol?
• In what ways do drugs or alcohol interfere with your daily activities?

Leisure activities

• What do you do for fun and recreation?

General appearance

• The nurse notes any unusual physical characteristics, the style of dress, grooming, gait and posture, and general behavior.

Body Image

• Describe yourself physically.
• What do you think about your body?
• Do you see yourself as normal?
• What would you change about your body if you could?

Sexuality

• What are your worries, concerns about your sexual self?
• What problems are you having with menstruation, birth control, intercourse, or masturbation?
• What is your sexual preference?

Intellectual Dimension

Sensation and perception

• Do you see, hear, feel, smell, or taste things that others do not?
• Do you believe that your actions are outside your control?
• How realistically does she perceive events and situations?

Memory

• Immediate: Ask adolescent to repeat a question you asked.
• Recent: Ask for events leading up to the adolescent’s seeking help.
• Remote: Ask for descriptions of events in the adolescent’s early childhood.

Cognition

• Is the adolescent oriented to time, place, person?
• What is her knowledge of current events?
• How well is she functioning academically?

Judgment

• How does the adolescent make decisions?

Insight

• Does the adolescent recognize that she is ill and needs help?
• How much does she blame others for her difficulties?
• How much awareness does she have of the impact of her behavior on others?

Abstract thinking

• What is the adolescent’s style of thinking, concrete or abstract?

Attention

• What is the adolescent’s ability to listen and concentrate?

Communication

• What is the rate of speech?
• What is the tone of speech?
• Does the adolescent have any speech impediments/Is she verbally active?
• Does she respond freely to questions?
• Are her responses relevant?
• How well organized are her thoughts?
• Does she demonstrate blocking, circumstantiality, tangentiality, flight of ideas, loose association, neologisms?

Flexibility-rigidity

• How open to new ideas and alternatives is the adolescent?
• How upset does she get when her routine is disrupted?

Adapted from Kempe, A., & Tarmelle-Rawlins, R. (1993). Mental Health/Psychiatric Nursing: A Holistic Lifecycle Approach (3rd ed.). Mosby.

Physical development assessment includes height and height velocity (requires serial measurements), weight and body fat (skin fold tests), system development, sexual development (Tanner staging, menarche), and skin condition. Rapid or slow growth patterns may indicate orthopedic or endocrine issues, respectively. Family history provides further context.

Physical exams are opportunities to explore family, academic, peer, and sexual development concerns. Inquiring about a typical day reveals sleep and eating patterns, social engagement, and health habits. Questions about sexual activity and contraception are important.

Eating and sleep disturbances can signal depression, anxiety, or eating disorders. Social withdrawal may indicate substance abuse. Substance-abusing teens may appear disinterested, moody, impulsive, and self-destructive. Sexually active teens not using contraception need pregnancy assessment, approached sensitively due to potential incest or reactive promiscuity.

Sexually active teens should be assessed for STIs (symptoms like genital burning, itching, sores) and educated about STI risks and symptoms.

The National Cholesterol Education Program recommends cholesterol screening for:

• Offspring of parents/grandparents treated for atherosclerosis before age 55.
• Offspring of parents/grandparents diagnosed with angina, MI, vascular disease, or cardiac arrest before age 55.
• Offspring of parents with cholesterol ≥ 240 mg/dL.

Assess for healthy patterns in sleep, exercise, eating, and elimination, and balance between leisure and academics. Imbalances warrant nursing diagnoses and interventions.

Emotional status assessment is challenging due to normal adolescent emotional lability (ages 12-15). Emotional difficulties are indicated by sleep problems, eating pattern changes, friendship disruptions, family conflicts, mood swings, body preoccupation, and impulsivity, suggesting depression assessment. Look for withdrawal, loss of interest, acting out, low self-esteem, negative attitude, hopelessness, unpredictable behavior, inattention, flat affect, mood swings, and appetite changes.

Differentiate event-related depression (3-9 months post-event, less disruptive) from chronic depression (higher risk of substance use and suicide attempts).

Suicide warning signs include:

• Personality changes (e.g., social withdrawal)
• Sudden mood swings
• Inability to concentrate, declining grades
• Apathy
• Loss of friends, change in peer group
• Significant losses (divorce, breakups)
• Hopelessness, loss of interest in activities, neglect of appearance
• Death obsession, suicidal threats
• Putting affairs in order (giving away possessions, making a will)

Anxiety reactions may present with similar but milder symptoms like distractibility, future fear, and irritability, which can be event-related or chronic. Determine symptom onset and related events (deaths, divorces, illnesses). Anxiety symptoms usually develop within 3 months to 2 years; depression within 3-9 months of an event.

Cognitive abilities rapidly develop in adolescence. Academic records indicate intellectual development; inconsistencies may signal emotional or intellectual issues. Investigate causes of poor academic performance, considering family, school, and peer factors, especially recent declines.

Annual abuse screening is recommended due to risk of acting out behaviors. Suggestions include:

• Inquiring about treatment by each caregiver (mother, father, grandparents) separately.
• Using direct and indirect questions: “Were you ever mistreated?” “How did your father act when drunk?”
• Non-threatening approaches: “How did you get that injury?”
• Follow-up questions: “Did anyone else hurt you?” “Tell me more.” “Has this happened before?”

Disclosure barriers include incomplete recall, belief of deserved abuse, and family loyalty. Disclosure may follow denial, tentative admission, and recanting under family pressure, but often reaffirms over time with patience.

Abuse indicators include fear, anxiety, sadness, guilt, hopelessness, depression, suspicion, withdrawal, hostility, mood swings, substance abuse, suicidal tendencies, erratic behavior, fear in parental presence, academic and school behavior problems, poor attention span, memory impairment, and spiritual conflict (feeling unworthy of God’s love).

Physical signs of physical abuse include facial bruising, hematomas, neck marks, rope burns, blisters, burns, bite marks, fractures.

Adolescent identity formation is a key developmental task (“Who am I?”). Peer interaction helps define self through similarities and differences, shifting from family identity to individual identity.

Assess social development by asking about identity: “Fantasies about yourself?” “Where do you see yourself in three years?” “If you could be anyone, who and what?”

Parental, family, and peer conflicts are inherent in identity formation. Relationship difficulties impact autonomy, self-esteem, and communication. Ambivalence about intimacy is common. Acting out behaviors like running away, curfew conflicts, shoplifting, reckless driving, substance abuse, promiscuity, eating disorders, and suicide attempts signal social development difficulties.

Assess family emotional climate for warmth, emotional freedom, honesty, unconditional love, age-appropriate expectations, and encouragement of individuality. Assess peer relationships by:

• Relationship duration (lasting or transient?)
• Time spent with peers
• Active/passive friend-making
• Parental conflict over social activities
• Peer pressure regarding sex, drugs, alcohol.

Spiritually, adolescents seek life meaning and apply it to decision-making, questioning parental religion and rejecting institutionalized religion. Mortality awareness emerges, prompting existential questions. They seek perfection in self and others, often leading to disappointment, especially with role models contradicting stated values. This may lead to rejecting adult values and bonding with peer moral codes. Uncover this code using hypothetical moral dilemmas (e.g., shoplifting boy scenario) and probing for underlying principles like fairness, honesty, loyalty, family importance, peer pressure, and dependence vs. independence. Assess belief importance, application in decision-making, peer similarity, integration consistency, and flexibility to new information.

Nursing Diagnosis

Potential nursing diagnoses derived from assessment include:

1. Altered Nutrition: More Than Body Requirements
2. Altered Nutrition: Less Than Body Requirements
3. Disturbed Thought Processes and Anxiety related to Unrealistic Body Image
4. Sleep Pattern Disturbance related to Repeated Abuse
5. Self-Esteem Disturbance related to Repeated Abuse
6. Fear related to Abuse
7. Spiritual Distress
8. Personal Identity Disturbance
9. Impaired Social Interaction

These diagnoses underscore the need for a holistic adolescent assessment. Nutrition, exercise, body image, self-esteem, eating disorders, and abuse are interconnected. Diagnoses require further investigation to determine related factors. For example, altered nutrition necessitates determining the cause (sedentary lifestyle vs. binge eating). Binge eating may be linked to abuse. Abuse-related diagnoses require specifying abuse type, cessation, perpetrator, and necessary interventions.

Nursing Interventions

Develop a treatment plan for each nursing diagnosis, including: diagnosis, short-term and long-term goals, outcome criteria, specific interventions, and rationales.

Altered Nutrition: More Than Body Requirement (Obesity)

Determine the cause of overeating (sedentary lifestyle, emotional eating, external cues). For sedentary lifestyle-related obesity, goals involve balanced diet (Tables 6 and 7) and moderate aerobic exercise. Outcome criteria include weight loss goals based on body frame and height, daily calorie tracking via food diary, and aerobic class attendance thrice weekly.

Table 6: Instructions for Food Diary (72 hr.)

1. Record everything eaten or drunk.
2. Note eating location.
3. Describe food preparation (raw, cooked, fried, boiled, sauces, dressings).
4. Include portion sizes.
5. Connect eating to preceding feelings and record them.

Time	Place	Food	Feeling

Educate about activity for weight loss. Incorporate enjoyable activities into the plan. Identify emotional eating triggers and teach healthier coping mechanisms. Challenge negative beliefs like “obesity runs in my family.” Replace them with reality-based concepts like “I control my eating.” Set short-term goals (e.g., meal-specific control) to build confidence.

Develop a support system. Support groups are beneficial for sharing experiences and gaining understanding. Family involvement is crucial; address nagging and criticism, which can be counterproductive. Family therapy can improve communication. Therapy can also address social skills deficits from peer ostracization.

Consider dietary taboos (cultural, religious, preferences) to foster respect and discourage hopelessness and depression.

Successful intervention is indicated by balanced diet, regular exercise, improved self-esteem, and awareness of emotional eating triggers.

Altered Nutrition: Less Than Body Requirement

For anorexia, long-term goals are restoring normal nutrition and reaching 10% above ideal weight. Short-term goals address irrational weight gain fear with cognitive interventions for rational weight gain attitudes. New thinking patterns are crucial for long-term recovery.

Outcome criteria include establishing a pattern of calorie, protein, and complex carbohydrate intake, monitoring and maintaining goal weight, and reduced weight gain fear.

Develop a nutritious, calorie-dense food plan and weight goal. Explain the fear-anorexia link to promote rational thinking. While assisting with goal setting, avoid taking responsibility for outcomes; anorexics must take ownership of recovery. Teach assertiveness and independent functioning skills. Instill hope by exploring life purpose to discourage self-destructive behaviors.

Anorexia treatment often involves family therapy for a supportive home environment. Combined therapies (group, individual, family, behavioral, nutritional, self-help, medication) are most effective.

For bulimia, care plans should include long and short-term goals to restore nutrition, establish realistic weight, replace weight gain fear with rational thinking, identify binge triggers, and teach alternative coping mechanisms. Outcome criteria include regular eating patterns, cessation of vomiting, and reduced weight gain fear. Develop a nutritionally sound plan using USDA’s MyPlate guide (Table 7). Dietary counseling is often needed to correct misconceptions. Reassure that normal eating will not cause obesity. Help reconnect with hunger cues. Contract to stop purging behaviors. Monitor vital signs and lab values. Refer for dental issues.

Table 7: USDA MyPlate Guide

Gradually reintroduce “forbidden” binge foods in moderation, teaching coping strategies for discomfort. Address emotions arising from stopping the binge/purge cycle (guilt, depression, helplessness, anxiety, frustration, anger) through observation, acceptance, expression encouragement, and alternative coping skills.

Antidepressants may be needed, determined by psychiatric evaluation based on depression severity. Effectiveness is measured by binge behavior reduction.

Effective bulimia treatment results in normal eating, weight maintenance, new coping mechanisms, realistic body perception, reduced thinness preoccupation, and focus on healthy relationships and life enjoyment.

Abuse-related Interventions

Care plans for sexually abused adolescents may have multiple diagnoses, each requiring separate goals, interventions, and evaluations. For example, “sleep pattern disturbance related to fear of abuse” goals include fear reduction and normal sleep patterns. Interventions include encouraging fear expression and providing community resource information. Outcome criteria include normal sleep, verbalized fears, and resource knowledge.

Remain with sexually abused girls during pregnancy and STI risk assessments. Be non-judgmental and supportive, emphasizing that abuse is not their fault. For pregnancy, allow expression of feelings like anger, hostility, and ambivalence. In hospitalization, create a safe, predictable environment: consistent unit and nursing staff, regular contact. This is crucial for flashbacks and nightmares.

Sexual abuse therapy groups are often effective. Victims often suppress anger, but hearing others’ experiences can trigger their own anger. Individual therapy is also effective; combined group and individual counseling is often optimal.

Teach the right to say “no” to uncomfortable touch, especially adult sexual contact. Address negative sexuality attitudes to prevent lifelong dysfunction.

State laws mandate reporting child sexual abuse. Consult state Boards of Nursing and Child Protective Services. Clergy can assist with spiritual issues. Judeo-Christian traditions portraying God as “Father” can be spiritually challenging for girls abused by fathers. Adolescents question life meaning; abuse disrupts this process. Healing requires integrating the abuse experience. Compartmentalization leads to self-destructive acts. Addressing pain is crucial for future self-protection and avoiding re-victimization (date rape, marital abuse).

Suicide

Take all suicide threats seriously and seek immediate professional psychological intervention.

Without threats, watch for warning signs. Suicidal teens may answer “Who am I?” with “Nobody.” Interventions should shift self-perception:

• Discourage black-and-white thinking.
• Encourage option identification and internal alternatives.
• Use active listening for emotional expression.
• Encourage group therapy for emotional identification and expression.
• Promote future-oriented thinking: “Where will you be in five years?”
• Explore intimacy needs and fulfillment.
• Encourage positive “I” statements.

The Pregnant Adolescent

Prenatal care includes nutritional risk assessment, weight gain goals, and healthy eating education. Intervention is needed for non-compliance. History includes eating habits, activities, medications (including supplements), substance use, and smoking. Screen for eating disorders: “How much do you limit food to control weight?”

Educate about risks. Smoking increases risks of low maternal weight gain, low birth weight, and perinatal morbidity. Alcohol/drugs increase risks of nutritional inadequacy and teratogenic birth defects.

Prenatal visits offer nutritional assessment and education. Encourage varied diet with fruits, vegetables, whole grains, protein, and dairy, considering cultural background for compliance. Nutritional risk may require vitamin/mineral supplementation (caution against excess intake). Vegetarians need B12 and zinc; twin gestation, seizures, blood pathologies may need extra folate; low sun exposure or dairy intake requires Vitamin D and calcium. Iron supplementation is vital. Refer to nutritionist for compliance issues.

Moderate aerobic exercise during pregnancy can reduce depression and improve self-esteem. Encourage (with physician approval) low-impact exercise 2-3 times weekly (60-65 min sessions with warm-up/cool-down).

Pregnant adolescents, especially with suspected eating disorders, may need therapy to make the fetus “real.” Provide gestational growth and development information, linking problematic eating to fetal impact. Stress complications of continued behaviors, while being sensitive to weight gain fears. Explain physiological reasons for pregnancy weight gain and its temporary nature.

Contraception

Counseling should emphasize abstinence as 100% effective. Even sexually active teens can choose abstinence. Encourage considering responsibilities and consequences of sex (pregnancy, STIs, emotional ties). Address peer pressure by noting less than half of 15-19 year olds are sexually active.

For sexually active teens, Depo-Provera is highly effective contraception, requiring only quarterly injections, safe, reversible, and estrogen-free. Side effects may include menstrual changes, amenorrhea, weight changes.

Sexually Transmitted Infections (STIs)

STI symptoms may include:

• Vaginal discharge, itching, odor
• Burning urination, frequency
• Bleeding between periods
• Bleeding/pain with intercourse
• Pelvic pain
• Fever, flu-like symptoms
• Genital rashes/sores
• Partner with genital rashes/sores or STI diagnosis

Abstinence is the best STI prevention. For sexually active teens, education can reduce risk. Recommend limiting partners and using latex condoms (not natural membrane condoms) for most STI protection (condoms may not protect against HPV and herpes lesions outside the penile shaft). Non-condom birth control does not protect against STIs. Recommend dual method use (condoms with other methods).

Teach proper condom use: consistent use, new condom per act, application before penetration with tip space, withdrawal while erect, holding condom base, water-based lubricants only.

Teens are more likely to use condoms with comprehensive sex education, belief in condom effectiveness against HIV, perceived peer acceptance, comfort discussing with partners, condom possession, and easy access. Barriers include confidentiality, cost, transportation, partner objection, perceived risk. Condom placement behind counters and judgmental attitudes can deter purchase. Objections to school-based condom education and availability often stem from concerns about encouraging sexual activity. Emphasize abstinence as best prevention, with latex condoms as the next best option.

Community Resources

Schools are key community resources, with education as their primary goal. Target audiences include adolescents, parents, teachers, and staff. Age-appropriate education and interventions are crucial for success.

Integrate topics into existing curricula (health, PE, home economics). Teach media influence resistance. Address adolescent developmental tasks (identity vs. role confusion, etc.) and “Who am I?” questions. Other key topics include:

• Normal adolescent physiological, social, psychological changes
• Food, emotions, body image connection
• Exercise and physical activity for weight management
• Physiological effects of binge-eating and dieting
• Women’s societal roles and eating disorder links
• Autonomy, independence, self-esteem
• Stress management skills
• Pregnancy and STD prevention
• Health risks of smoking and substance abuse
• Suicide prevention

Role-playing and small group discussions can enhance internalization and behavior change.

The internet offers invaluable resources for local and national organizations providing adolescent support. Nurses can search for community associations offering assistance, support, and advocacy.

Twelve-step groups (AA, NA, OA) are resources for substance abuse and family violence, based on psychological and spiritual principles. Consult local directories for meetings, including adolescent-specific groups.

Twelve-step groups have limitations: leaderless structure, variable quality, potential for exploitation. Nurses should be transparent about these issues and address them in follow-up care, especially for abuse survivors. Twelve-step involvement can empower self-awareness and self-protection, crucial for eating disorder and abuse recovery, helping to live in reality alongside outpatient therapy.

Adolescence is inherently challenging, marked by significant physical changes impacting emotional, social, intellectual, and spiritual well-being. Constant adjustments are needed in diet and exercise. Rapid physical changes can lead to body image issues, exacerbated by societal thinness ideals.

Societal and familial pressure for thinness can lead to strict dieting, binge eating, obesity, and eating disorders. Nurses must recognize these dynamics for appropriate intervention.

Eating disorders can indicate underlying trauma like abuse. Nurses should screen for abuse, as treating eating disorders in abusive environments is ineffective.

Nurses uniquely assess the whole person holistically, bridging gaps between physicians and therapists, especially in outpatient settings. Holistic assessment informs comprehensive nursing diagnoses and care plans, addressing all dimensions of adolescent life. Nurses support families and connect them with community resources, and may implement community programs in schools.

Nurses play a unique supportive role for adolescent girls and families, providing holistic, patient-centered care through the nursing process, addressing needs unmet by other healthcare team members.

Suggested Reading

• Allen, P. L., & McGuire, L. (2011). Incorporating mental health checkups into adolescent primary care visits. Pediatr Nurs, 37(3), 137–140.
• Beck-Little, R., & Catton, G. (2011). Child and adolescent suicide in the United States: a population at risk. J Emerg Nurs, 37(6), 587–589.
• Cooper, G. D., Clements, P. T., & Holt, K. E. (2012). Examining childhood bullying and adolescent suicide: implications for school nurses. J Sch Nurs, 28(4), 275–283.
• Davis-Alldritt, L. (2012). School connectedness/parent engagement: critical factors in adolescent health and achievement. NASN Sch Nurse, 27(6), 286–287.
• Edelman, M., & Ficorelli, C. T. (2012). Ending the epidemic of adolescent obesity. Nursing, 42(11), 1–3.
• Ford, J. L., & Rechel, M. (2012). Parental perceptions of the neighborhood context and adolescent depression. Public Health Nurs, 29(5), 390–402.
• Foti, K., Balaji, A., & Shanklin, S. (2011). Uses of Youth Risk Behavior Survey and School Health Profiles data: applications for improving adolescent and school health. J Sch Health, 81(6), 345–354.
• Gance-Cleveland, B. (2013). Motivational interviewing for adolescent obesity. Am J Nurs, 113(1), 11.
• Ghaddar, S. F., Valerio, M. A., & Garcia, C. M., et al. (2012). Adolescent health literacy: the importance of credible sources for online health information. J Sch Health, 82(1), 28–36.
• Kao, T. S., Guthrie, B., & Loveland-Cherry, C., et al. (2012). Cross-cultural variations in adolescents’ perceived maternal expectancy and sexual initiation. J Transcult Nurs, 23(4), 377–388.
• Morrison-Beedy, D., Carey, M. P., & Crean, H. F., et al. (2011). Risk behaviors among adolescent girls in an HIV prevention trial. West J Nurs Res, 33(5), 690–711.
• Robinson, L. M., & Vail, S. R. (2012). An integrative review of adolescent smoking cessation using the Transtheoretical Model of Change. J Pediatr Health Care, 26(5), 336–345.
• Spurr, S., Bally, J., & Ogenchuk, M., et al. (2012). A framework for exploring adolescent wellness. Pediatr Nurs, 38(6), 320–326.
• Tillett, J. (2011). Legal issues in adolescent care. Nurse Pract, 36(9), 8–9.
• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision [DSM-IV-TR]).
• Crosby, A. E., Ortega, L., & Melanson, C. (2011). Self-directed Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.
• Klonsky, E. D. (2009). The functions of self-injury in young adults who cut themselves: Clarifying the evidence for affect-regulation. Psychiatry Research, 166(2-3), 260–268.
• Rodriguez-Ramos, L. J., Llaurador-Castillo, M., Sifonte-Rodriguez, M. N., & Rivera-Alonso, B. A. (2012). Understanding and Treating Self-Injurious Behavior. Correctional Health Care Report, 13(2), 17.
• Martinez, G., et al. (2011). Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006-2010 National Survey of Family Growth. Vital and Health Statistics, Series 23, No. 31.