The adolescent

Tier one

The science of a body that finished before the brain did

Phase 1 — the foundational years, and anything called Beginnings, Growth and Development

• Puberty is staged, and on two scales, not oneTanner scores breast or genital development separately from pubic hair. There is no combined “Tanner 3”, and discordance is normal and informative — hair running ahead points at adrenal androgens. The age spread is wide enough that the stage tells you more than the birthday.
• The body finishes before the control system doesMaturation is asynchronous: the reward systems arrive before the prefrontal machinery that moderates them, and that gradient is part of why this age group takes risks. What is not defensible is the line you will hear everywhere, that the brain is not developed until twenty-five. There is no switch at twenty-five. Development is continuous, hugely variable between individuals, and group imaging says nothing about the patient in front of you.
• Airway and circulation are adultThe cords, not the cricoid ring, are the narrowest point; cuffed tubes, and cuff pressure is measured rather than guessed. Stroke volume is no longer near-fixed, so output is not rate-dependent. From twelve there is consensus on a mean arterial pressure of at least 65 — the first agreed number anywhere in this series.
• Weight-based dosing becomes the hazard rather than the safeguardAustralian safety guidance is explicit: above roughly forty to fifty kilograms, do not exceed adult upper dose limits, and calculating from total body weight can overdose. There is no single cut-off — it is drug by drug — but a seventy-kilogram sixteen-year-old dosed per kilogram out of habit is a recognised way to hurt somebody.
• Creatinine climbs with muscle, and no eGFR is reported under eighteenAustralian laboratories do not issue one, because the adult equations are not validated there. So a creatinine sitting inside the adult range can conceal real impairment in a small adolescent — and on a long admission, muscle wasting lowers creatinine and flatters kidneys that do not deserve it.
• The growth plates are still openWhich is why a limp or a knee complaint still sends you to the hip: slipped upper femoral epiphysis belongs to this age band and presents as knee pain in someone who looks well.

If you take one thing: the body in front of you is adult and the system steering it is not. Almost everything difficult about this age group follows from that asymmetry.

Likely to be examined as: a short answer on Tanner staging and what it actually stages, or on why creatinine is a poor guide to renal function across puberty. A good viva opener is at what weight do you stop dosing per kilogram, and why is that the wrong question?

Tier two

The consultation nobody taught you to have

Phase 2 — the clinical years, integrated clinical studies, and the ICE

• Ask the parent to step out, routinelyAustralian paediatric bodies recommend seeing the adolescent alone for part of every consultation, and none sets a minimum age. Do it as ordinary practice so it does not read as an accusation: I see everyone your age on their own for a few minutes. Note where the evidence actually sits — the randomised trial is for the confidentiality assurance, which lifted willingness to disclose from 39 to 47 per cent and willingness to return from 53 to 67. That the room should be empty is consensus, and sound, but it is consensus.
• Say what confidentiality covers before you startNever promise the unconditional version. The NSW formulation has four exceptions and fits in one breath: if you intend to harm yourself, if you intend to harm someone else, if someone is harming you, or if you know of someone else at risk. Then — everything else stays between us. Saying it first is part of the method, not a disclaimer bolted on.
• HEEADSSS, and the version to useHome, Education and employment, Eating, Activities, Drugs, Sexuality, Suicide and depression, Safety. The current form is HEEADSSS 3.0 (2014), whose addition is online life threaded through every domain rather than parked in a letter of its own. Two honesties: it has never been validated and is a consensus framework rather than an instrument, and the Spirituality and Strengths appended locally are not part of the published acronym.
• Consent: what the New South Wales law actually saysYou will be taught that section 49 of the Minors (Property and Contracts) Act 1970 lets a fourteen-year-old consent. It does not say that. It shields the practitioner from a claim in assault or battery, says nothing about negligence, gives the young person no priority over a parent, and expressly preserves the common law. Capacity comes from the common law — Gillick, received here in Marion’s case in 1992 — and that test is decision-specific, not age-specific: a graze needs less maturity than starting contraception. NSW has no statutory presumption at sixteen. South Australia is the national exception, with statutory adult-equivalent consent at sixteen.
• Refusal is not consent in reverseThe crude version — they can consent but cannot refuse — survives neither the NSW Health manual, which says a minor with capacity may refuse, nor the judgments. A competent adolescent’s refusal is legally real and must be taken seriously, but it stays subject to the court’s parens patriae jurisdiction in a way an adult’s does not. In H v AC (2024) the court found a seventeen-year-old Gillick competent and authorised treatment anyway.
• Mandatory reporting: know where the line fallsIn NSW the statutory duty attaches to a child, defined as under sixteen. For a sixteen- or seventeen-year-old, reporting is permitted and often right but not mandatory under that section — the opposite of what most people assume on an adolescent ward. As a student your position is simpler: take any suspicion straight to your supervisor, who is unambiguously a mandatory reporter. You do not discharge a concern by deciding alone that no duty applied.
• Ask about self-harm directly, privately, more than onceIndirect questions get indirect answers. Ask in the room you cleared, in plain words, and ask again later if the first answer arrived too quickly.

If you take one thing: the examination is the easy part of an adolescent consultation. Almost everything that matters is decided before it — by whether you got the room right, and whether you said what you would and would not keep to yourself.

Likely to be examined as: a long case or OSCE where the marks sit in the approach rather than the findings — whether you ask the parent out, whether you set out the limits of confidentiality unprompted, whether you address the young person rather than across them. A favourite viva: this fifteen-year-old refuses the operation — what now?

Tier three

What you will be expected to do

Phase 3 — the final clinical years, the pre-internship term, and your first nights on call

• For resuscitation, the Australian rule is not the American oneYou will read that a child becomes an adult at the signs of puberty. That is the American Heart Association. ANZCOR defines a child as up to the eighteenth birthday, with the rider that if the patient appears to be an adult you use adult guidelines. The paediatric numbers hold while you are on them: four joules per kilogram for every shock, adrenaline ten micrograms per kilogram to a maximum single dose of one milligram.
• Ketoacidosis: the adolescent risk is recurrence, not cerebral oedemaMost episodes in established type 1 diabetes follow omitted or interrupted insulin, and deliberate omission is a recognised event rather than a lapse — so the admission has a conversation in it, not just a fluid order. Cerebral injury complicates well under one per cent of episodes and kills about a fifth of those, but the risk is weighted towards younger children; teaching it as the adolescent hazard is a common inversion. About a third of Australian children still present in ketoacidosis at diagnosis.
• Anaphylaxis: the peak-risk group for fatal food reactionsLay them flat and do not let them stand or walk — that is what kills. Intramuscular adrenaline, 0.01 mL/kg of 1:1000 to a maximum of 0.5 mL, repeated after five minutes if the response is inadequate. An adolescent carries a 300 microgram device, with a 500 microgram option from fifty kilograms, and intranasal adrenaline is now registered here alongside the injectors. The bands were revised in 2026 — read the current ASCIA chart, not the one you memorised.
• Meningococcus: the funded vaccine misses the common oneMenACWY is on the National Immunisation Program at fourteen to sixteen, usually through school. Serogroup B causes the large majority of Australian notifications and is not nationally funded for healthy adolescents — only South Australia and Queensland fund it. So “fully vaccinated” in a sick sixteen-year-old with a rash excludes much less than it sounds like.
• Deliberate self-poisoning is an admission category of its ownAustralian intensive care units took 813 admissions of twelve to seventeen-year-olds for deliberate self-harm between 2015 and 2021, around two-thirds of them girls, and the monthly rate rose after March 2020. Each needs a mental health assessment, not merely a drug level, and it belongs to the admission rather than to the discharge.
• Injury is what kills themInjury accounts for roughly three-quarters of deaths between fifteen and twenty-four; suicide is the single leading cause at about a third. Keep those apart — you will hear the three-quarters attached to suicide, and it belongs to injury as a whole. On the ward: they compensate well and then do not, so a normal blood pressure in a bleeding adolescent describes their physiology, not their blood volume.
• Testicular torsion, and the sign that points the wrong wayPeak incidence runs right through this age band, and salvage falls from about ninety per cent inside six hours to about twenty by twenty-four. Two traps: relief on elevating the testis — Prehn’s sign — was present in the large majority of proven torsions, so the classic teaching is backwards; and a normal Doppler does not exclude it. It also presents as lower abdominal pain in someone nobody has examined below the waist.
• Know where they go, and call earlyAdolescents fall down a gap in the Australian data — the adult registry excludes under-sixteens, the paediatric one thins out above fifteen, and no national ranking of adolescent admissions has been published. The gap exists in the buildings too: whether your fifteen-year-old goes to an adult unit, a children’s unit or a retrieval depends on where you are standing. In New South Wales, NETS is 1300 36 2500.

If you take one thing: the error at your stage is treating them as a large child or a small adult. They are neither, and in this age group the traps are as often legal and conversational as they are pharmacological.

Likely to be examined as: an OSCE on the adolescent consultation, a viva on consent and capacity, or a resuscitation scenario where what the examiner really wants to know is whether you reach for paediatric or adult numbers, and whether you can say why.

And one for you. Medical students are not exempt from anything on this page. If this material lands closer to home than it should, Doctors’ Health NSW runs a confidential peer-support line for doctors and students on 02 9437 6552, and Lifeline is 13 11 14.