The adolescent, his conflicts and escapes

Preface

Tue authors of this book have approached the problems presented by adolescence from somewhat different angles, as their interests, training, and experience arise out of the specialties of neurology and pediatrics. The part that each has had in the production of this book must here be specified in order that responsiblity may be justly distributed. Adolescence cannot be treated without due attention to the physical framework in which the adolescent energies are contained. No adequate handling of the problems that arise out of the effort at social and environmental adaptation can be possible without due regard to the physical questions that constantly arise. Hence it was thought best to include a general outline of this part of the problem. The first three chapters have been written by Dr. Veeder and should be read as an introduction to the more complex situations presented by the adolescent in his struggle with his environment. The remaining chapters of the book have been written by Dr. Schwab. Each of the authors accepts responsibility only for his share of the work, but the book as a whole represents a point of view which is mutually shared. This point of view, strongly emphasizing the social importance of adolescence, has been of service to them both in the handling of adolescent problems that have come to them in their medical work.

Sho: Bos. V.

PREFACE

Contents

CHAPTER

PuysicAL GRowTH AND DEVELOPMENT .

. PUBERTY AND SEX . ScHOOL AND PLAY

Chapter I Physical Growth And Development

T is customary to divide the life cycle of man into certain periods: infancy, childhood, adolescence, maturity, and senescence. The fully developed picture of each of these periods is characteristic and obvious to the casual observer. On analysis, however, these periods are not sharply defined by clear-cut strokes across a chronological chart, but they merge insensibly one into another from both a physical and a mental standpoint of development. Where one period begins and another ends is exceedingly difficult to say in the case of a given individual. The reason for this is that life is a continuous process, using this term in the sense of growth or development, and not a process marked by abrupt changes from one period to another. Growth, however, is not a uniform process, as its rhythm is constantly changing and is marked by periods of acceleration and retardation. It is a phenomenon which starts with a remarkable velocity in the prenatal state, which continues throughout early infancy, then is retarded throughout childhood, and again accelerated in the early adolescent years, slowing down finally as the individual reaches maturity. The terms infancy, childhood, and maturity need no explanation. Adolescence—the period of youth—is usually defined as I the period from the development of puberty to the attainment of full maturity. Puberty is the term used to indicate the time at which the individual becomes capable of reproduction. The age of puberty varies considerably among races and individuals of the same race. As a general rule it develops two years earlier in the female sex than it does in the male. The legal “age of puberty” is a purely arbitrary figure of common law. With pubescence—the period of developing puberty—childhood ends.

Such a division into periods gives no idea of what is actually taking place in the development of the individual. The important thing is the nature of the changes which take place, leading to the various phenomena that are more or less characteristic of each of these periods in their fully developed form. In order to understand a certain period it is necessary to study the changes in growth and development leading up to the period as well as the fully developed period itself. In other words the subject must be approached from a dynamic viewpoint. During late childhood—from the tenth to twelfth or fourteenth year—the body of the boy and girl begins to undergo changes which bring about puberty. These prepubescent years are much more closely related to the early years of adolescence than to the period of early childhood. To understand adolescence it is necessary to consider pubescence and the changes which precede and lead up to puberty. Nearly all discussion of adolescence begins with the establishment of puberty and discussion of childhood ends at this point. Such a presentation of the subject draws a line through the middle of one of the most interesting and important periods of development. It is as if an attempt were made to obtain a complete knowledge of a book by beginning near the middle and finishing before the end.

Throughout infancy and the pre-school period development is rapid, more so in fact than at any other period of the life cycle. We all must marvel at the speed with which physical and mental growth takes place during infancy and early childhood. This is followed by a period of childhood lasting approximately to the tenth year, when there is a marked slowing down of the growth curve. Beginning at this time and lasting into early adolescence is a second period of accelerated growth and development. This is the period of pubescence. In addition to sex development and differentiation, which is the outstanding phenomenon of this growth, a tremendous general physical growth and development take place in the individual. At the same time mental and psychological changes occur which are of far-reaching and fundamental importance. It is important to keep in mind that there is a close relationship between mental and physical development and that the two go hand in hand. Although for purposes of discussion the phases of physical and mental development are considered in different chapters this is purely an arbitrary division for convenience in presentation. The body and the mind of the pubescent and adolescent child are inseparably connected and the physical conditions and growth are intimately involved with the mental processes and reactions. In fact, probably at no other period of life are the psychological reactions of the individual so closely related to and dependent upon the physical changes which are taking place in the body.

The first question that arises is that of the factor or force or impetus which brings about and controls this growth. Why should the growth rhythm suddenly become accelerated at about the tenth to twelfth year, when not only do we find general body growth manifesting itself, but at the same time the more striking development in the reproductive organs? ‘The fundamental answer to this is as obscure as is the answer to the riddle of life itself. It is known, however, that this growth is closely related to, if not the result of, or at least controlled by, the internal secretions of the endocrine glands. This is the name given to certain glandular structures of the body which form in their tissues a secretion which is not excreted from the body, but which is taken up by the body fluids and which, as it circulates through the body, exercises a certain more or less definite action upon growth and metabolism. These endocrine glands, or the glands with an internal secretion, have beyond question an important part in the changes which take place in growth and development during adolescence. But the action of the individual glands and their apparent interrelationship is decidedly nebulous and theoretical. All sorts of influences have been attributed to the various glands and many of these functions or attributes are fantastic. It has only been possible to isolate a few of the internal secretions and thus work out in a scientific manner the action of the secretion in question. The thymus gland, whose function is unknown, becomes smaller from birth on. The adrenal glands, which secrete a known substance called adrenalin, are relatively very much larger during infancy than at any other time. The thyroid gland secretes an extract which has a definite influence on the body metabolism. The pituitary gland at the base of the brain has some important function related to growth, as adults and children with abnormal pituitary glands show definite alterations in growth. The true glands of reproduction, the testes and ovaries, which produce the two elements which unite to form a new being, have in addition an internal secretion which to a large extent controls the development of sex differentiation and characteristics.

A large part of our knowledge regarding the action of the various internal secretions has been built up from studies of abnormal functions. Thus individuals in whom an insufficient amount of thyroid extract is secreted show a low metabolism and have a tendency to obesity. Further, it is known that when the gland is not functioning properly or is absent in early life there is a marked retardation of both mental and physical development. Tumors of the pituitary gland have been found associated with giant growth. In individuals with abnormal sexual precocity, disease of the adrenal glands is sometimes observed. Removal of the testes before puberty leads to a marked retardation in development of the genitalia. It has not been possible to isolate many of the internal secretions and hence to study their direct action in a scientific manner. Much of our knowledge is rather indirect, but there can be no question as to the importance of the réle of the internal secretions in the regulation or control of growth. Granted that the adolescent growth is brought about by internal secretions, we are still in the dark as to why the various glands should take on new or added secretory activities at about the tenth to the twelfth year. There is seemingly an interrelationship between these various glands and secretions, as apparently the over- or under-secretion of one gland influences the secretion of another. The various glands seemingly have a balanced relationship which may be overthrown at a number of points.

Unfortunately some of the schema and theoretical explanations devised by overenthusiastic students of the internal secretions have been accepted as facts by psychologists and others interested in the subject of adolescence, and explanations of various phenomena have been built up on this basis without sufficient scientific data to support the assumption upon which the explanation is based. The only positive statement that can be made is that marked physical abnormalities in development and in sex function are apparently a result in large measure of disturbed endocrine gland functions. Therefore it may be assumed as a working basis that the various internal secretions of the endocrine glands have a regulating influence upon growth and the development of sex characteristics. To go beyond this and to specify the roéles of the different glands and their interrelationship leads rapidly into the field of theory and speculation.

In order to understand the physical growth and development of adolescence it is necessary to go back to the beginning of pubescence and to study the entire cycle of accelerated growth which begins at this time. It is impossible to understand what is taking place if one begins at the period of puberty and regards adolescence as beginning at that time. As life is a continuous process the characteristics of each period depend to a large extent on what has gone hefore. The age of physical puberty is not a fixed chronological period. We must consider the entire period of pubescence and the following years to maturity to obtain a picture of what we call adolescence.

The tenth to the seventeenth years of life cover in a general way this period of accelerated growth. For purposes of discussion it may be considered first as a period of general growth, in that almost every part of the body is involved; and secondly, as a period of special growth, for it is at this time that the sex organs which have heretofore been rudimentary suddenly take on a rapid development in size and function. Parents are apt to consider the special growth rather than the general development which is taking place, as the most striking and obvious physical changes center around the development of the reproductive organs, but the general growth is likewise of extreme importance from a practical standpoint.

The simplest way to picture or measure growth and development is by means of the height and weight of an individual. During infancy the rate of growth is extremely rapid. In the first year of life the weight of a baby increases some 200 per cent and the growth in length about 45 per cent. During the second year an increase of 100 per cent of the birth weight takes place. From this time on there is a rapid falling off in the rate of gain in weight and height until about the tenth year. There is very little difference during these years between the two sexes and the average annual gain in weight and height is approximately as follows:

Gain in weight, pounds| 5 4 5 4 4 5 5 Gain in height, inches} 2%4]| 3 314] 2+] 2 2 2

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About the ninth to tenth year the average American girl begins to take on weight and at the same time the growth in height increases. This increase reaches its maximum at about the twelfth year when the average annual gain is approximately fourteen pounds. The two sexes remain at about the same height until the thirteenth or fourteenth year, when the gain in height slows rapidly for girls, but continues for boys until the sixteenth year. After sixteen the gain in height for the average American boy is relatively slight. On the other hand, the boy does not begin the marked increase in weight until the twelfth year, and the fourteenth year as a rule is the year of greatest gain with an average gain approximately of fifteen pounds. The accompanying diagrams of average annual height and weight increments show this variation between the two sexes in a graphic manner.

These figures are average figures constructed from the weight curves of hundreds of individuals. As a matter of fact very few children follow the average curve. Gains of twenty pounds or more in a year are quite usual and are apt to be preceded or followed by years of gain much below average figures. The gain as a rule is fairly uniformly distributed throughout the year until the fourteenth year. After the fourteenth year the gain is far greater in the fall months as a rule. Normal children of the same age vary considerably from one another in both height and weight. This is dependent upon the body type or habitus, which in turn is dependent upon inherited factors. Parents of overaverage height are apt to have children taller than the average, and short parents children below the average. Children of the tall, slender type of body habitus are apt to grow and take on weight earlier

AVE ARS.

Io

AVERAGE ANNUAL INCREASE IN WEIGHT DURING PUBESCENT YEARS than children of medium stature, and children of the short type at a corresponding later period.

Marked deviations from the average growth figures are apt to have their origin in deep-seated abnormalities of the endocrine glands or may result from severe types of acute and chronic illness. Malnutrition, using the term as it is somewhat incorrectly used with younger children to mean a certain percentage below average weight for the height at a given age, is not common among pubescent and adolescent children and when present it is often the result of some serious chronic illness.

It is essential to recognize that the adolescent years are years of tremendous body growth. The human organism at this time is in a state of constant change. Its physical capacities are limited. While the growth of the reproductive organs is the most striking of the changes and the one which attracts our attention above all others, the fact must not be overlooked that this is likewise a period of general growth and development. In this growth nearly every organ and tissue of the body is involved. The increased growth of the skeleton—the bony framework of the body—makes up a large part of this general growth in height and weight. Until the twelfth year in girls and the fifteenth year in boys the gain in height chiefly involves the lower limbs, while the gain after these years is chiefly a gain in body height. The growth on the long bones of the arms and legs takes place near the ends. As a rule the ends of the bone do not become firmly united with the shaft of the bone until several years after puberty, and until this occurs growth in length is possible. At about sixteen years of age the skeleton makes up nearly one-fourth of the total weight of the body. The most striking difference between the male and female skeleton is in the pelvis. Although certain differences in the pelvis are seen early in life, at about eleven or twelve years a striking change takes place. In the girl the arch (iliac arch) broadens and the transverse diameter of the pelvis becomes greater than the anterior-posterior diameter.

This flattening out and change in diameter is coincident with the development of the female organs of reproduction which lie within the cavity of the pelvis. As a result of this change in shape of the pelvis, together with the muscle growth and the deposition of fat under the skin, the circumference of the body at the hips becomes from one and a half to two inches greater in the girl and the typical configuration of the female form is established. | The growth and development of the muscles which take place at this period are of tremendous importance. It has been calculated that at eight years of age the muscles form about 27 per cent of the body weight. At fifteen years the proportion has increased to 32 per cent and at sixteen years to 44 per cent. It has been found that between the thirteenth and fourteenth years the muscles of the arm of the boy, for example, increase 100 per cent more in size and strength than at any earlier period. This, moreover, is exceeded by the growth of the large muscles of the back, thighs, and legs which have such an important rdéle in maintaining the position of the body. Numerous strength tests have been made of the rapid and tremendous increase of muscle power during pubescence and adolescence. This muscular development brings about many practical questions regarding posture, muscular codrdination, fatigue, and the like, which will be discussed in a subsequent chapter. In early adolescence the muscles have a tendency to grow in length more rapidly than the bony framework of the body, which leads to faulty posture and improper and uncertain codrdination. It is this rapid skeletal and muscular growth that is in large measure responsible for the awkwardness of the child in his teens.

The heart is one of the most important factors of adolescent growth. Conforming to the general growth which is taking place, and in part as a result of the demand put upon it by this growth, the heart nearly doubles in size between the tenth and sixteenth years. Growth in itself is dependent upon proper materials for growth being carried to the different tissues and structures through the blood. In order to supply sufficient blood and to maintain the circulation through the new-formed tissues the heart must enlarge in capacity and increase in power. The development of the heart as a rule goes hand in hand with the general growth. If the heart has been injured in childhood—a result most commonly of rheumatism—so that its mechanical work is interfered with, there may be a difficulty in its development and so we find that these years are of particular danger to the child with heart disease. At birth and during early childhood the blood vessels are relatively large and the heart small. As the heart increases in size the ratio between the two changes rapidly. At birth the ratio is 25 to 20; at early puberty 140 to 50; at late puberty 200 to 50. Some interesting studies on the blood pressure in childhood and adolescence have been made. During childhood the pulse pressure— the difference between the systolic (heart active) and diastolic (heart at rest) pressures—trises uniformly until the prepubescent years. Then, as a result of a rapid increase in systolic pressure and a slower increase in diastolic, the pulse pressure increases rapidly until the seven- - teenth or eighteenth year, when it falls to the original level. This is interpreted as indicating a marked increase of work per unit of cardiac muscle during the pubescent years. At times the growth of the heart is slow or retarded in relation to the general growth and the heart of the child of sixteen may have only the functional capacity of the heart at eleven or twelve. As a rule the heart beats regularly with a definite rhythm. It is not at all uncommon, however, to find irregularities, or arrhythmias, which are usually of nervous origin and not organic in nature. An irregular heart in adolescence is usually an indication of need for careful watching. There is a practical side to the growth and demand upon the heart during this period for it is a very easy matter to put too much strain upon the cardiac muscle. This is most important from the standpoint of exercise and sport which will be discussed in a later chapter.

In order to maintain itself the body requires a constant supply of fuel in the form of food. Not only must material be supplied in the food which can be transformed by the body into material for growth and repair, but every action of every cell in the body requires fuel which has its source in the food which is eaten. (Few realize the tremendous food requirements of the growing boy and girl. First of all, growth, as has been pointed out, is very rapid at this time. The muscular activity of adolescent boys and girls is very great, as every one knows by observation of their play. In addition the rate of activity of the body tissues at rest (basal metabolism) has been shown to be 25 per cent higher in boys at puberty than the basal metabolism of the adult. These three factors are the cause of the tremendous food requirements of children during this period. In studies made a few years ago at one of the eastern preparatory schools it was found that the boys from thirteen to sixteen years of age took approximately five thousand calories daily in their food and apparently required this amount. This is nearly half again as much as a farmer at his daily work requires. The enormous appetites of children at this time, which never seem Satisfied, are not abnormal.)

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Much more could be said regarding the details of the general growth which takes place during the adolescent years, but sufficient has been said to point out the general character and importance of this development. The important fact is that this is a period of growth and development and hence the functional capacity of the organism is not only constantly changing but is limited and easily exceeded. No two individuals develop in exactly the same way and there is a marked difference between the two sexes. This is even more marked and striking when we consider the subject of the development of the sex characteristics.

CHAPTER II PUBERTY AND SEX HE most striking and important event in the life of

the child between the tenth and fifteenth years is

the development of puberty by which the body undergoes changes which enable it to fulfill a primary function of biological life, the function of the carrying on of the race. There is a voluminous literature regarding the many phases of the development which takes place—on sex function, psychology, sex education and hygiene, etc.—for it is one of the most important periods of the life cycle. The development of puberty, however, as has been pointed out, is only one phase of the general development which is taking place, although the sex differentiation overshadows everything else. Up until about the tenth year the growth and development of the two sexes are strikingly alike and the two may be considered and discussed as one. While many who have studied childhood consider that psychological differences between the two sexes can be traced from early infancy, there is no doubt that many of these differences have their origin in custom, environment, and education rather than a fundamental physical basis. As an example of this can be cited the change which has taken place in recent years with the introduction of physical play and sports into the life of the girl. Activities that once were looked upon as the abnormal development of “masculine” traits in the girl and stig-.

matized by the word “tomboy” are now regarded as per- 16

PUBERTY AND SEX rs fectly natural. Whatever sex differentiation exists before the tenth year is of comparatively little practical importance from the standpoint of physical development and psychology.

As the development of puberty is a development of a function, pubescence should be regarded as a physiological age period. This physiological age does not necessarily coincide with the anatomical or chronological age of the child and the two are often confused. Some boys reach puberty as early as the eleventh year and others as late as the sixteenth. Some girls begin menstruation at ten and others as late as sixteen or seventeen. It is difficult to determine the exact age of puberty in the male, but in the female the time of beginning menstruation is regarded as denoting this period. A number of investigations have been made of the age at which menstruation develops in American-born girls. In from 15 to 20 per cent it first occurs in the twelve- to thirteen-year period; in 35 to 40 per cent in the thirteen- to fourteen-year period; and in 20 to 25 per cent in the fourteen- to fifteen-year period. The mean is around thirteen years and nine months. This difference between the physiological age and the chronological age is of importance, as we usually group children chronologically, whereas their interests, mental attitudes, forms of physical play and games, and the like, are related to or dependent upon the physiological age. It is one of the reasons why one child of thirteen or fourteen is more “advanced” than another of the same age. It is of distinct practical importance to teachers and parents in their understanding and management of children, and is a factor which should be taken into consideration in such fields as that of child-labor legislation.

Beginning at about the tenth year, and more or less paralleling the changes in general development which have been described, the organs which have to do with sex functions show a rapid growth and development and sex becomes more sharply differentiated. We are accustomed to divide the anatomical changes which have todo with sex into two groups. Those are termed primary which involve the true reproductive organs, while the changes involving the accessory structures which are associated with the male and female types of body habitus are called secondary. The latter include such features as the growth and distribution of hair about the pubic region, the development of the mammary glands or breasts in the girl, and the growth of beard and change or break which takes place in the voice of the boy. They are important as a part of sex differentiation and also as indicating that the boy or girl is undergoing the development of puberty. These changes or characteristics are in all probability brought about by the internal secretions of the endocrine glands, as is shown by the failure of development of the secondary characteristics when the glands have been removed or are abnormal before puberty. The primary sex differentiation consists in the formation and secretion of sperm in the testes of the male and the development of the ova in the ovaries of the female, together with the growth and development which take place in the genitalia.

The changes which take place in the reproductive organs of the girl consist essentially of enlargement and growth of the external genitalia, growth in the size of the uterus, and an increase in size of the ovaries, together with the ripening of the ovarian follicles which have to do with the formation of the ova. This development and growth take place over a period of months and the establishment of puberty is signified by the appearance of menstruation. While menstruation in American children of native stock usually appears in the thirteenth year, it is modified by race and climate as well as by the functioning of the endocrine glands of the individual, and may appear as early as the tenth or eleventh year or as late as the sixteenth without being regarded as abnormal. The secondary sex characteristics usually begin to appear some months before menstruation itself takes place. Menstruation consists essentially of a discharge of an ovum from the ovaries into the uterus or womb and the preparation of the uterus to receive it. It occurs in cycles about every twenty-seven or twenty-eight days and is made up of a period of four days of congestion of the lining of the uterus, three to four days of menstrual flow, about seven or eight days while the lining is returning to its normal condition, and twelve days of rest. Not infrequently it takes some time for the periods to become regular, and so for many months after the initial flow, periods may be omitted or recur at irregular intervals, sometimes recurring in three weeks and at other times at five or six weeks without this denoting anything of significance or importance. Irregularity for a year after the initial menstruation may be disregarded and is not a cause for alarm. Coincident with the period, changes in disposition and temperament are apt to occur, particularly if the girl is of a nervous type. Hysterical manifestations, periods of unexplained and apparently causeless fits of weeping, lassitude, and the like are frequently seen. It is not at all uncommon for a girl who has been active in sports and play to change her attitude completely for a temporary period, desiring to stay home away from her friends and mope about the home. Sometimes cycles of © depression or unnatural exaltation are seen for some months before actual menstruation begins.