INTRODUCTION

Adolescence is a unique and significant period of life for any person, mainly due to the universal aspects determined by developmental processes, such as accelerated growth, sexual maturation, expansion of cognitive and psychosocial functions, and progression toward achieving socioeconomic independence and autonomy in the social group(1).

Over the last hundred years, clinical practices and research have brought information that has helped us improve our understanding of the processes of growth, development, and maturation, thus providing better medical, psychological, and social care for adolescents in their family contexts.

Understanding the health needs during adolescence has stimulated the development of the subspecialty of adolescent medicine, currently considered an area of ​​pediatrics in most countries, including Brazil, but always with a multidisciplinary approach and integration with several areas of knowledge, such as gynecology, endocrinology, psychiatry and psychology, public and collective health, nutrition, nursing, social work, dentistry, and many others that work interconnected with the health care of this population. Many care services have been created with different approaches, such as assistance, research, community prevention work, risk screening and basic health education interventions.

HISTORICAL RESEARCH

The concept that adolescence is a time of stress and storms was introduced by Hall in 1904. When Stuart(3) described the characteristics of the growth and development process in a scientific journal, at the same time that psychoanalysts began to debate the problems related to the resolution of childhood sexual conflicts and the intrapsychic problems associated with the bodily and hormonal changes of puberty, the period of adolescence became a topic of scientific and medical interest.

Piaget and Inhelder(4) described the ability of adolescents to construct ideals as an advance in cognitive development, and, later, Erikson(5) described the eight stages of human development, with adolescence being a period of tasks and challenges of emotional development before reaching adulthood, a theme explored in depth by Aberastury and Knobel(6), who developed the concept of normal adolescence syndrome , emphasizing the losses and mourning that accompany the gains in emotional development.

In 1950, Greulich and Pyle(7) described the evolution of bone maturation during childhood and puberty in a Radiographic Atlas that is still used today as a parameter for diagnosing bone age. However, the scientific work with the greatest impact was the publication, by Tanner(8), in 1962, of the book Growth at Adolescence, on growth during puberty, with the description of the pubertal stages of body development and sexual maturation – breasts and pubic hair in females and genitalia and pubic hair in males -, which became known as the Tanner criteria and which were also incorporated into international medical knowledge about adolescents(9,10). These authors also described the duration and characteristics of the pubertal spurt, in addition to having published several articles and books on human growth(11).

Scientific studies on hormonal patterns and the secretion of estrogens in females and testosterone in males and the discovery of the increase in gonadotropins and growth hormone as biological indicators for identifying puberty occurred later, as did knowledge of the neuroendocrine control of the onset of puberty(12-16).

The secular trend toward accelerated growth rate and weight gain during puberty and decreased age at menarche has been observed, as well as differences in age at onset of puberty and final height that occur in different countries, according to their socioeconomic and nutritional conditions(17-20).

Over the last hundred years, the number of children with diseases considered fatal or that became chronic who did not reach adolescence has now decreased thanks to scientific advances, such as surgical techniques, chemotherapy, vaccines, and medications. The mortality rate due to natural causes decreased by almost 90% between 1933 and 1985, while external causes, which can be prevented, such as homicides, accidents, and suicides, have emerged as the main causes, secondary to the violence and social problems of the last three decades(21). Social changes, such as industrialization and technological devices such as television and, currently, computers, women’s emancipation movements and also the sexual revolution , with the advent of the contraceptive pill, and several other political and cultural events, including current globalization, have influenced the expression, including sexuality and risk behaviors, of adolescents in their family and contextual environments.

CURRENT RESEARCH

Advances in the field of gynecology, with the introduction of combined hormones in the form of oral and injectable contraceptives, emergency contraception (22) and the techniques of colposcopy, laparoscopy and preventive Pap smear examination have influenced the sexual life of adolescents and their gynecological care. New microbiological techniques for screening and treating cervical infections, such as chlamydia and gonococci, have facilitated the diagnosis and prevention of pelvic inflammatory disease, as well as other sexually transmitted diseases (STDs).

Even so, teenage pregnancy rates have remained high, and early teenage pregnancy is increasingly becoming one of the most important risk factors for sexual behavior. In addition to new challenges such as viral diseases, the human immunodeficiency virus (HIV) and human papillomavirus (HPV) are associated with an increased risk of developing cervical cancer and are a cause of death. New psychosocial models for understanding sexual behavior and developing health information and education materials have become national and international priorities as a strategy for preventing risk situations in adolescence(23).

New challenges have emerged, including those related to the use of drugs, alcohol and cigarettes, which are increasingly being started at an early age, forcing countries to create new regulations and establish age criteria for the use of these drugs(24). The association between cigarette smoking and high-risk behaviors among adolescents aged 12 to 17 years, who use 11 times more illicit drugs and 16 times more alcohol, was established in studies that have been conducted since the 1960s and 1980s(25,26).

Sociocultural violence and various forms of abuse, including commercial sexual exploitation, sex tourism and pedophilia on the Internet, are also spreading among countries, influencing the health and well-being of adolescents across geographic and political barriers. Homicide remains the main external cause of mortality among male adolescents aged 15 to 19 in Brazil(27). International conventions, human rights and the millennium development goals, in addition to the Statute of the Child and Adolescent, Law 8.069/90, are commitments that Brazil has assumed, as a signatory country of the United Nations, and tries to implement every day, in the arduous task of building citizenship and exercising democracy(28,29).

New epidemics are emerging, including those related to eating and nutritional disorders. While primary chronic malnutrition still exists worldwide(30), resulting in delayed puberty and menarche, in Brazil the prevalence of iron deficiency anemia continues to be another public health challenge among adolescents. Overweight and obesity, as well as high blood pressure and atherosclerosis, have become important scientific issues. The National Health and Nutrition Examination Survey (NHANES-III) (1988-1994), conducted in the United States, revealed that 11% of adolescents between 12 and 17 years of age are already considered obese, with 14% at risk of obesity(31). Perhaps the main reason is the sedentary lifestyle adopted by many adolescents who spend hours sitting, both at school and at home, in front of the television and computer, in addition to the almost daily intake of highly caloric and fatty foods. Over the past 20 years, the incidence of eating disorders, such as anorexia and bulimia nervosa, has increased, as have magic diets and the use of anabolic steroids in problems related to body image and self-esteem disorders(32).

LEGAL AND PROFESSIONAL ASPECTS

Almost coincident with the emerging attention to the health needs of adolescents, new laws, rules and professional practices have emerged that have facilitated the rapid evolution of health care in this age group. Generally, the principles of consent allowed for self-care, especially in matters related to sexuality and confidentiality of information, are associated with the criterion of maturity , although most laws consider adolescents to be minors up to 18 years of age, as in Brazil(33).

But the most important thing, in addition to the legal and judicial decisions based on the Convention on the Rights of the Child, a commitment signed in 2002, is the recognition, by professional societies in the medical, psychological and social fields, of the rights of adolescents to health issues and free and free access to health care services. The formalization of an academic and university field, in addition to science and hospital care, and in addition to the support of governmental and non-governmental entities, gave rise to and guaranteed the evolution of adolescent medicine as an area of ​​professional, medical and public health interest, in favor of adolescents in Brazil and internationally.

Tracking health risks, care at primary or community levels; secondary or outpatient care and in health units; and tertiary or hospital care, in addition to diagnostic and treatment protocols in university hospitals and local and multicenter research that has been disseminated and multiplied in Brazil over the last 30 years, have made this population of adolescents increasingly integrated, assisted and included in government health programs.

In Brazil, pioneering work was established in several universities and, subsequently, with the support of the Brazilian Society of Pediatrics (SBP) and the creation, in 1978, of the Adolescence Committee, with representatives from several states, the publication of the first Adolescence Manual was organized in 1989. The activities of the committees in several Brazilian states gave a huge boost to adolescent medicine in our country, culminating in the holding of national congresses every two or three years since 1985. At the end of 1989, the Brazilian Adolescence Association (ASBRA) was created in Brasília, which aims, among its multiple purposes, to develop global health care, encourage scientific research and increase communication among professionals dedicated to the study of adolescence(34). For more information, visit www.asbrabr.com.br. Several books have been organized and published by various national authors, and since 2003 we have had our magazine Adolescência & Saúde , also accessible through the website www.adolescenciaesaude.org.br.

FUTURE CHALLENGES

The paths taken by many professionals have been long, arduous and full of cultural and scientific controversies regarding the meaning of adolescence as a period of life, and they still unfold in new paths and other challenges for the future.

The aspects of prevention and risk tracking in communities that suffer from social disparities have increasingly been the target of research work. Many sociological and anthropological studies have revealed the importance of resilience and the necessary caring relationships between adolescents and adults, of positive connection with family and school for the construction of protective factors for their self-esteem, in search of their autonomy and free expression, which are important characteristics of the healthy development of the transition to adulthood(35).

Other models are emerging: instead of specialized medical care for specific problems, such as pregnancy, drug use or depression, alternative and integrated spaces are being created between health services and appropriate places in the communities, where these prevention and guidance services are available. Many care networks involve adolescents themselves in the planning and evaluation of health promotion programs and activities, with characteristics of the local cultural context. The participation of adolescents and the support of adults are always fundamental to the success of these programs. Alliances for adolescent health are formed with common political agendas among several countries, leaving behind the biomedical paradigm and exclusive clinical work and creating activities of youth protagonism and social equity(36). International collaboration allows the exchange of knowledge among professionals dedicated to adolescent health, with the support of health policies organized at the global level by the World Health Organization (WHO) and the Pan American Health Organization (PAHO) in various technical documents and accessible on the Internet. Currently, several national and international collaboration networks are being formed, and telemedicine, videoconferencing and distance learning have been implemented and carried out successfully, uniting health and medical informatics professionals, including those from NESA/UERJ, www.mmissions.org, www.lampada.uerj.br/telemedicina.

However, the health and citizenship rights of adolescents, already guaranteed in the United Nations Conventions and the Millennium Development Goals and also ratified by Brazil, certainly remain an important milestone of the work developed in the past and as the greatest challenge for the future that opens up every day, in every family, in every community and in all services of the health system in our country.