476 Adolescent Health
teenagers were most often concerned about their safety and
feelings of guilt and shame, parents were most often con-
cerned about retaliation and especially the sexual sequelae;
parental concern included immediate effects such as fear of
pregnancy (79%), physical damage such as infertility (67%),
and fear of sexually transmitted disease (52%), and long-term
effects such as increased risk of future sexual activity (66%).
This latter fear is not unfounded because there is a de“nite re-
lationship between the onset of sexual activity at a younger
age and a history of rape as the “rst sexual act; girls who
begin their sexual careers at ages 13 and 14 are four to “ve
times more likely to have had sex forced on them initially
than are girls whose sexual activity began at age 16 or 17
(Harlap et al., 1991).
Health Care and Physical Appearance
Given the preoccupation with physical appearance and in-
creased orientation to peers that emerge during adolescence,
it would be logical to expect that any aspect of health care
that relates to physical appearance would have even greater
salience for teenagers than for children or adults. For exam-
ple, it is no surprise that anorexia and bulimia almost always
have their onset during adolescence. Yet, remarkably little re-
search has focused on this aspect of health care.
Childhood obesity has psychosocial consequences„
rejection by peers, psychological distress, dissatisfaction
with one•s body, and low self-esteem (Wadden & Stunkard,
1985). Because the incidence of obesity increases during
adolescence, the psychosocial effects will affect more
teenagers numerically and may even have more pronounced
psychological impact. Measures of chronic stress, based on
adolescents• reports of daily hassles, include items on skin
problems and being overweight (see Repetti, McGrath, &
Ishikawa, 1999). A study of burn victims reported that prob-
lems with peer relationships intensi“ed during adolescence
(Sawyer, Minde, & Zuker, 1982). The dis“guring aspects of
burns suggest that this would be a particularly important area
of research, yet a review by Tarnowski and Brown (1999)
states, •To a large extent, the psychological aspects of pedi-
atric burns has been a neglected topic.Ž
A less serious, yet more common, example is acne. Acne is
the most common skin disease, and possibly the most common
health concern, experienced by teenagers; 85% of adolescents
have some degree of acne. Prevalence and severity increases
with pubertal development and peaks between ages 14 to 17
years in girls and 16 to 19 years in boys; acne varies from a
short, mild course to a severe disease lasting 10 to 15 years
(Pakula & Neinstein, 1996). Virtually all acne is treatable,
albeit not eradicable, given the advent of new medications such
as Accutane and surgical options (see Pakula & Neinstein,
1996). Clinical experience indicates that acne is of some con-
cern to most teenagers and a signi“cant obstacle to peer inter-
action (especially with opposite-sex peers) for some, yet little
information is available regarding its psychosocial impact.
The psychological impact of physical conditions would
appear to be most relevant when such information might
guide decisions about treatment and insurance coverage. For
example, when does acne cease being just a common hassle
and become a signi“cant obstacle to social development?
Similarly, under what circumstances is plastic surgery indi-
cated, and when should families with limited “nancial
resources receive assistance in obtaining surgery, which is
typically considered purely cosmetic? Currently, such deci-
sions represent a judgment call by clinicians and especially
by families. Cost may be a signi“cant deterrent because
health insurance rarely covers cosmetic procedures. Data
regarding the social and psychological bene“ts of cosmetic
treatment would be very useful in making decisions about
adolescents• health care. Even if costly treatment was not fea-
sible, research could suggest strategies to assist teenagers in
overcoming the social effects of acne or other conditions re-
lated to physical appearance.Effects of Illness on DevelopmentLarge-scale studies of children with chronic illness and phys-
ical handicaps indicate that they are twice as likely to evidence
behavioral and emotional disorders as their nondisabled
peers, with internalizing disorders being more prevalent than
externalizing disorders; sensory conditions (e.g., deafness)
and neurological conditions (e.g., seizure disorders) increase
risk more than other chronic illnesses (e.g., cancer or cystic “-
brosis; see Quittner & DiGirolamo, 1998). Some dif“culties
are the direct result of the disabling condition, such as associ-
ated neurological problems and hyposexuality in epilepsy.
Most problems, however, represent the indirect effect of dis-
ease on development because of its impact on parental and
peer attitudes. Parental worry can lead to altered expectations
and excessive restrictions on the child•s activities and
lifestyle, with family reactions ranging from overprotection
to rejection, resulting in a variety of developmental problems
such as low self-esteem, lack of social skills, guilt, or adopting
a sick role (see Aldenkamp & Mulder, 1999).
Such effects are also found with adolescents, whose func-
tioning is impacted negatively by having a disability, al-
though family connectedness has been identi“ed as having
an even greater effect on emotional well-being (Wolman,