**2. Global trends in adolescent demographics**

In many parts of the world, only childhood and adulthood are seen as distinct phases of life. Adolescents, as defined by the World Health Organization and United Nations, are those individuals aged 10-19 years (United Nations Children's Fund [UNICEF], 2011). Though different healthcare organizations and societies may define adolescents differently because of societal, cultural, and economic conditions, the term adolescent in this chapter will refer to the above-mentioned age group.

There are currently 1.2 billion adolescents in the world, making up 18% of the world's population. Eighty-eight percent of adolescents live in the developing world, and more than half of the world's adolescents live in South Asia or East Asia and Pacific region (UNICEF, 2011) (Figure 1). Previously, much focus was given to preventing communicable diseases of childhood. Significant improvement in that regard has come about, and now leaders globally are recognizing the need to address and focus on the second decade of life, adolescence, in order to sustain and consolidate the achievements made during the first decade of children's lives (UNICEF, 2011).

Source: UNICEF, *The State of the World's Children 2011: Adolescence an age of Opportunity* (2011), as cited in United Nations, Department of Economic and Social Affairs, Population Division. *World Population Prospects: The 2008 Revision*, www.esa.un.org/undp/wpp2008/index.htm, accessed October 2010.

Fig. 1. Adolescent population (10-19 years) by region, 2009

There are some clear demographic differences throughout the world. This may be explained by the differences in initiation of decline in fertility and mortality rates. Those countries, many of which are in North America and Europe, that had the earliest initiation of decline

on them, experimentation with drugs and alcohol, sexual expression outside of traditional marriage, body image issues, and others. Healthcare practitioners can provide anticipatory guidance to parents and their adolescents, gathering data with sensitive, non-judgmental questioning. All of this must be based on an understanding of adolescent development.

In many parts of the world, only childhood and adulthood are seen as distinct phases of life. Adolescents, as defined by the World Health Organization and United Nations, are those individuals aged 10-19 years (United Nations Children's Fund [UNICEF], 2011). Though different healthcare organizations and societies may define adolescents differently because of societal, cultural, and economic conditions, the term adolescent in this chapter will refer

There are currently 1.2 billion adolescents in the world, making up 18% of the world's population. Eighty-eight percent of adolescents live in the developing world, and more than half of the world's adolescents live in South Asia or East Asia and Pacific region (UNICEF, 2011) (Figure 1). Previously, much focus was given to preventing communicable diseases of childhood. Significant improvement in that regard has come about, and now leaders globally are recognizing the need to address and focus on the second decade of life, adolescence, in order to sustain and consolidate the achievements made during the first

Source: UNICEF, *The State of the World's Children 2011: Adolescence an age of Opportunity* (2011), as cited in United Nations, Department of Economic and Social Affairs, Population Division. *World Population Prospects: The 2008 Revision*, www.esa.un.org/undp/wpp2008/index.htm, accessed October 2010.

There are some clear demographic differences throughout the world. This may be explained by the differences in initiation of decline in fertility and mortality rates. Those countries, many of which are in North America and Europe, that had the earliest initiation of decline

Fig. 1. Adolescent population (10-19 years) by region, 2009

**2. Global trends in adolescent demographics** 

to the above-mentioned age group.

decade of children's lives (UNICEF, 2011).

in fertility and mortality rates, now have low growth rates and an aging population. Countries that had a later initiation of decline in fertility and mortality rates, such as those in Latin America, the Caribbean, East Asia, and some parts of the Middle East and South Asia, continue to have moderate population growth. In most of Sub-Saharan Africa and some parts of the Middle East and South Asia, there has not yet been a decline in fertility and mortality rates, and so in these parts of the world, young and youthful populations are seen (Brown et al., 2002). These differences result in a contrast in the age structure and agedependency ratios of individual countries and impact the economic and social structure of a country in varying ways (Assaad & Roudi-Fahimi, 2007; Brown et al., 2002).

When it comes to health care, pediatricians in developed countries have been given the responsibility to care for adolescents (American Academy of Pediatrics, 1978). This is largely due to the fact that adolescents continue to grow and develop, a hallmark of pediatrics. Although the physical development is the first and earliest to be completed, adolescents continue to undergo cognitive and emotional development well into their 20's. The age limit of Pediatrics varies across the world. Many developed countries have extended the age limit to 18 or even 21 years, while other countries, mostly developing countries, have lower age limits.

Adolescents are generally the healthiest of the population, with their leading causes of death being accidents, homicide, and suicide (Brown et al., 2002). HIV/AIDS is the leading cause of death in some parts of the world (Brown et al., 2002). All of these causes are preventable, and so when it comes to adolescent health, an adolescent's contact with a healthcare provider, for whatever reason, can be seen as an opportunistic time to address these matters. Risk-taking behaviors exacerbate the problems that may be faced during adolescence, and in some developing countries, work-related disability and mortality is an additional problem (Brown et al., 2002). When discussing adolescent health, much attention is frequently given to the problems that may be encountered such as risky behaviors. It is important to note, however, that it is only a minority of adolescents who are involved with serious problems as substance use, teenage pregnancy, and acts of violence (United Nations [UN], n.d.). Most adolescents actually go through this stage of life without much turbulence. It is a time when many adolescents gain personal growth, development, and independence and attain certain skills. Adolescence can and should be viewed as a time of opportunity.

Some of the problems that face adolescents differ depending on where they live. For example, substance use, eating disorders, and lack of exercise are more prevalent in developed countries. There are gender gaps when it comes to education, with generally more males attending secondary school in comparison to females. In fact, two thirds of children who never went to school or dropped out are girls. In South Asia, for example, 52% of boys but only 33% of girls are enrolled in secondary school. In contrast, girls in Latin America and the Caribbean have higher secondary school enrollment rates than boys, 56% and 52% respectively (UN, n.d.). This is important to address because the more education a girl receives, the more likely she is to postpone marriage and motherhood (UNICEF, 2011). It has also been found that knowledge and skills obtained through formal education is less advanced in students coming from developing countries in comparison to those students from developed countries (Nugent, 2005).

Adolescent Psychosocial Developmentand Evaluation: Global Perspectives 183

mature in the early teen years, while the prefrontal cortex, the reasoning area of the brain and an important area for controlling impulses, emotions and executive functioning, appears to reach adult dimension in the early 20s, with girls developing earlier than boys (Geidd et al., 1999; Gogtay et al., 2004; Luna et al., 2010). Executive functions include the ability to inhibit impulses, weigh consequences of decisions, prioritize, strategize, long-term planning, decision-making, self-evaluation, self-regulation, and the coordination of affect and cognition. Second, changes in arousal and motivation brought on by pubertal maturation precede the development of regulatory competence (Blakemore et al., 2010). The brain's reward center, the ventral striatum, also is more active during adolescence than in

This creates a gap between the adolescent's affective experience and the ability to regulate arousal and motivation. While the adolescent brain continues to strengthen its connections between reasoning and emotion related regions, each adolescent progresses at varying rates

Adolescent thinking becomes more multidimensional and they are better to contemplate hypothetical situations and the relationship between varied actions or decisions and

Adolescent cognitive development can be characterized into 3 stages: early, middle, and late

In early adolescence, the use of formal logical operations is mainly focused on schoolwork and in home environments. This includes questioning authority and societal standards. There is development of enhanced ability to verbalize thoughts and views, starting with those related to their life. These include choices regarding engaging in sports, peer groups, dress, and parental rules that adolescents think should be changed. At this stage, they may

In middle adolescence, more complex thinking processes are used. The focus expands to include more philosophical and futuristic concerns. Middle adolescents tend to question and analyze more extensively in order to form their own code of ethics, identity, and possible future goals, which may begin to influence relationships with others. They may perceive

In late adolescence, complex thinking processes are used to focus on less self-centered concepts as well as personal decision-making. Adolescents may think about more global concepts such as justice, history, politics, and patriotism. They develop idealistic views on specific topics or concerns and may debate and develop intolerance of opposing views. They tend to focus on making career decisions and think about their emerging role in society. At this stage, they are able to think things through independently and weigh consequences before making decisions. Table 1 summarizes the cognitive changes that occur during

Understanding cognitive development during this period is helpful in understanding age differences in judgment and decision-making, risk-taking, sensation-seeking, and also why adolescence can be a time of increased risk for the onset of a wide range of emotional and behavioral problems, including depression, violent delinquency, and substance abuse.

in developing their ability to think and their own view of the world.

outcomes, but decision-making remains susceptible to emotions.

be unable to perceive long-term outcomes of current decision-making.

future implications, but may not apply it in decision-making.

(Cromer, 2011; Radzik et al., 2007).

adulthood.

adolescence.

Reproductive health also varies across regions. Adolescent females are less likely to use contraceptives than adult women, and adolescent mothers are more at risk of developing complications related to pregnancy than adult mothers (Nugent, 2005). An adolescent mother is also more likely to drop out of school and be less educated than an adolescent female who has not become pregnant. Marital age has increased in many parts of the world, yet in some regions, child marriage (marriage by 18 years) continues to occur and is largely driven by 'poverty, parental concerns about premarital sex and pregnancy, and other economic and cultural reasons' (Nugent, 2005).

Because of these differences, a pediatrician's approach to the psychosocial history of an adolescent needs to be tailored to meet the needs of different regions/countries. Although we recognize each country, and sometimes different parts within the same country, may have their own unique issues, it is impossible to address matters of every single country. For this reason, in this chapter, we have decided to focus on some regions of the world and give an example of one country per region, though keeping in mind that this may not apply to every single country within the same region.
