Isn’t this an outmoded way of thinking about the period between childhood and adulthood? We know that in many countries social transitions to adulthood (such as marriage, childbirth and work) are taking place in the early, even late 20s. And, furthermore, the neurodevelopmental changes occurring in the pre-frontal cortex continue into the early twenties.
While all of this is true, there are many reasons to focus explicitly on adolescents (10–19 years), all of which have implications for policies and programmes:
Standardize the language. If we want to make comparisons, it is important to be consistent about the language that we use. The World Health Organization (WHO) and other United Nations (UN) organizations have been defining “adolescent” as 10–19 years for the past 20 years. We have, therefore, decided to focus on adolescents in a publication that has adolescents in the title. So, we avoid defining “adolescent”, “(10-19), youth”, (20-24) and “young people” (10-24) by age spans and then using the words interchangeably. Also, we have decided not to extend the upper limit of adolescence to take into consideration the changing timing of social transitions. We already have terms that incorporate people in their early 20s (youth and young people)—and, anyway, what 24-year-old wants to be called an “adolescent”?
Special human rights considerations. The rights of all people are protected in the Universal Declaration of Human Rights. But the majority of adolescents are given special attention through the Convention on the Rights of the Child (CRC). In Article 1 of the Convention “child” is defined as a person below the age of 18, unless the laws of a particular country set the legal age for adulthood younger. The Committee on the Rights of the Child, the monitoring body for the Convention, has encouraged states to review the age of majority if it is set below 18 and to increase the level of protection for all children under 18. So, focusing on adolescents rather than young people provides specific opportunities for advocacy and partnerships around the CRC, which may not be available for older age groups.
Transition to adulthood during adolescence. The widening gap between biological maturity and transitions to adulthood has implications for policies and programmes—for example, pre-marital sex and access to contraceptives. At the same time, however, in many countries and communities, this gap is not widening.
One of the most common and important life transition for young women often occurs in adolescence—marriage. The UNFPA 2012 report Marrying Too Young - End Child Marriage states:
Despite near-universal commitments to end child marriage, one in three girls in developing countries (excluding China) will probably be married before they are 18. One out of nine girls will be married before their 15th birthday.
It is important to remember, also, that the vast majority of adolescent pregnancies in most regions take place within marriage.
Similarly, the 2013 Report of the International Programme on the Elimination of Child Labour (IPEC) notes that:
[T]here were some 264 million children ages 5 to 17 in economic activity in the world in 2012 (16.7 per cent) … boys more exposed to employment than girls (18.1 per cent against 15.2 per cent). About one-tenth of the total child population—i.e. 168 million children aged 5–17 years—was involved in child labour in 2012 … and hazardous work, the worst form of child labour (WFCL), accounts for almost half of all child labourers (85.3 million), again boys outnumber girls in hazardous work (55 million and 30.3 million, respectively).
Although child marriage and child labour are decreasing in some areas, a significant proportion of adolescents are transitioning to traditionally “adult” roles during and even before adolescence, with serious long-term negative consequences for their health and development. This means that the advocacy messages are often quite different for adolescents and youth.1 For example, governments and nongovernmental organizations are advocating much greater access to employment for older youth, while at the same time there is pressure to limit and control the amount of time that adolescents work,2 particularly younger adolescents.
Social values and norms. In many societies adolescents are treated quite differently from people in their early twenties—the difference between “teenagers” and young adults. This has implications for many things, including roles and responsibilities, expectations (e.g. sexual activity) and use of services (e.g. access to condoms). So, lumping adolescents and people in their early 20s together is likely to give conflicting and confusing messages and may lead to the exclusion of younger adolescents if the discourse becomes more youth-oriented (15–24). It is also likely to have implications for policies and laws that are designed to protect adolescents but that would not be appropriate for older youth—limits on access to alcohol, for example.
Phase of development. Although some neurodevelopment continues into the early twenties, the most important physical, biological, emotional and psychological development that takes place between childhood and adulthood occurs before the age of 20 years. As outlined in Section 2 of this report, the changes taking place during the adolescent years that underlie health-compromising behaviours, health conditions and disease have implications for how adolescents think about the present and the future and how and by whom they are influenced This has many implications for the types of interventions that are designed for them: promotion, prevention and treatment.
Relationships and support. One of the hallmarks of adolescence is the move towards autonomy and independent decision-making. Parents and, subsequently, peers are important sources of influence and support during the adolescent years—something that changes during the early twenties as more individual intimate relationships develop. Most 20-year-olds have reached the age of majority, while most adolescents have not. Many young people in their early twenties are not living with their parents, unlike most adolescents. Significant numbers of 20-year-olds are earning money and living independently; most adolescents remain dependent on their parents for financial and other support. These differences have implications for the provision of health services and social protection.
Reaching adolescents through the schools. One of the key strategies for reaching adolescents is through schools: for information, skills and services and for the role that the school environment can play as a protective factor against the development of health-compromising behaviours and conditions (for example, mental health problems). This is not a setting that is generally available to people in their twenties, when other, different settings— for example, the work place—may become more important venues for health interventions.
Mortality and morbidity. As Section 3 of the report highlights, adolescence is a period of transition from the diseases of childhood to the diseases of adulthood, with overlaps with adjoining age groups in cause-specific mortality and DALYs at both ends of the 10–19 years period. Clearly 20–24 year olds have important health problems that require a response from the health and other sectors. However, when 20–24 year olds are included with adolescents in analyses of mortality and DALYs, the priorities shift. (For example, maternal causes and drug use enter the top 10 causes of DALYs only in the 20–24 age group.) These shifts are often at the expense of 10–14 year olds, since mortality rates are higher in 20–24 year olds, and, thus, the causes of mortality during the early twenties have more influence on aggregated statistics for 10–24 year olds.
Health-compromising behaviours during adolescence. Many behaviours that have implications for health start during adolescence: tobacco use, the use of alcohol and psychoactive drugs, sex and driving. Health-compromising behaviours are more likely to be illegal (e.g. alcohol, tobacco use) and have an adverse impact on development if they take place earlier (e.g. use of alcohol, psychoactive substances). Many of these health-related behaviours are, therefore, more normative during the early twenties (e.g. sex and alcohol use) while they are more likely to have a negative impact on health and development during the adolescent years, particularly early adolescence. This difference has implications for interventions designed to prevent, delay or change such behaviours.
Special considerations for health services. There are some specific issues for the provision of health services that are important for adolescents but not for people in their early twenties. Service providers serving adolescents need to be able to respond to their questions and concerns about the developmental phases that they are experiencing. Also, they need to be able to respond effectively to issues of informed consent by adolescents (mature minors), the involvement of parents and the gradual movement towards more autonomous decision-making (transitions of care) and the potential for providing a range of health services through schools. Many of these issues are outlined in Section 6 of this report.
Participation. Towards the end of adolescence, most people have reached the age of majority and are able to vote. For adolescents, other strategies need to be developed to provide opportunities for civic participation—opportunities that take into consideration their knowledge, skills and phase of development. In terms of encouraging and facilitation adolescents’ participation in programme design and implementation, and ensuring that their perspectives are adequately taken into consideration, when the focus is on young people (10–24), there is a tendency to engage with the older young people, which is easier in many ways, and, again, younger adolescents loose out.