Mature minors (able to comprehend the risks and benefits of evaluation and treatment) All exceptions should be documented clearly in the patient’s health record.
*Determined by individual state laws.
During the physical examination, a choice between the parent and a chaperone being present needs to be offered.
Breast budding under the areola (thelarche) and fine straight pubic hair over the mons pubis (adrenarche or pubarche)are early pubertal changes occurring around 11 years of age (range, 8 to 13 years) (see Chapter 174). These changes mark the sexual maturity rating, or Tanner stage, II of pubertal development (Figs. 67-3 and 67-4). Completion of the Tanner stages should take 4 to 5 years. The peak growth spurt usually
Stage 1 The breasts are preadolescent. There is elevation of the papilla only.
Figure 67-3 Typical progression of female pubertal development, stages 1 to 5. A, Pubertal development in the size of female breasts. B, Pubertal development of female pubic hair. Note that in stage 1 (not shown) there is no pubic hair. (Courtesy of J.M. Tanner, MD, Institute of Child Health, Department of Growth and Development, University of London, London, England.) occurs approximately 1 year after thelarche at sexual maturity rating stage III to IV breast development and before the onset of menstruation (menarche). Menarche is a relatively late pubertal event. Females grow only 2 to 5 cm in height before menarche (see Chapter 174).
The mean ages of thelarche and adrenarche are approximately 9 and 10 years for African American and white girls, respectively. The mean ages of menarche are 12.2 and 12.9 years for African American and white girls, respectively. The interval from the initiation of thelarche to the onset of menses (menarche) is 2.3 ± 1 years. Pubertal changes before 6 years of
Stage 2 Breast bud stage. A small mound is formed by the elevation of the breast and papilla. The areolar diameter enlarges.
Stage 3 There is further enlargement of breast and areola with no separation of their contours.
Stage 4 There is a projection of the areola and papilla to form a secondary mound above the level of the breast.
Stage 5 The breasts resemble those of a mature female as the areola has recessed to the general contour of the breast.
Stage 2 There is sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, primarily along the labia.
Stage 3 The hair is considerably darker, coarser, and more curled. The hair spreads sparsely over the junction of the pubes.
Stage 4 The hair, now adult in type, covers a smaller area than in the adult and does not extend onto the thighs.
Stage 5 The hair is adult in quantity and type, with extension onto the thighs.
age in African American and 7 years of age in white girls are considered precocious.
Testicular enlargement (≥2.5 cm) corresponds to sexual maturity rating, or Tanner, stages I to II (Figs. 67-5 and 67-6). Testicular enlargement is followed by pubic hair development at the base of the penis (adrenarche) and then axillary hair within the year. The growth spurt is a relatively late event; it can occur from 10½ years of age to 16 years of age. Deepening of the
Figure 67-4 Sequence of pubertal events in the average American female. More recent studies suggest that onset of breast development may be 9 years of age for African American girls and 10 years of age for white girls. (From Brookman RR, Rauh JL, Morrison JA, et al: The Princeton maturation study, 1976, unpublished data for adolescents in Cincinnati, Ohio. Reprinted from Assessment of Pubertal Development, Columbus, Ohio, 1986, Ross Laboratories.)