Perhaps the greatest transition in an adolescent’s life is the transition to college. The process of preparation, investigation, application, interviewing, waiting, choosing, and preparing to leave for college is one of the most exciting, exhausting, and challenging experiences in the life of an adolescent and his or her family. The final selection of a school can mark a shorthand summary of accomplishment and builds a major piece of a young adult’s identity.
Although there are certainly many steps to autonomy through childhood – walking, starting school, being home alone, driving a car – none compares to leaving the warmth and structure of home for the college experience. Once in the dorm, teens are probably more alone and independent than they have ever been before, likely without any long-standing friends, in an unfamiliar setting, and facing high expectations. College offers structure and support to help with this transition, and most adolescents are ready and even eager to start to manage their own lives pragmatically, academically, and socially. But there will be setbacks and failures, big and small, as they navigate new territory with virtually full independence. This transition would be a challenge to a mature adult and is daunting to someone who is doing this for the first time and with an identity that is still forming.
We know that most teenagers make this transition successfully. However, we also know that this new level of independence and responsibility and the loss of supervision and structure can place adolescents at risk for several problems. Some adolescents make poor or risky choices with serious consequences. Depression affects about 20% of all freshmen, with consequences that range from mild to severe, sometimes requiring a leave of absence. Many students who have managed mild problems with anxiety or body image may find that with more stress and less support, these problems grow into eating disorders and substance abuse disorders. It now appears that sexual assaults on campuses, often during “frat” parties and in the setting of substance use, are far more prevalent than previously acknowledged. Recently in the news was the tragic accident of a young woman under the influence of substances who was seriously injured when she fell out of a window. Finally, we know the most prevalent morbidity and mortality are from car accidents, many of which are related to risk taking and substance use.
Clearly there are critical developmental gains toward healthy adulthood when this transition goes well, and quite substantial risks when it does not. Pediatricians quite commonly follow their patients well into the college years, and at least treat patients during the time in which they are preparing to leave for college. Therefore the transition from high school to college can be considered a part of pediatric primary care. How can a pediatrician contribute to the adolescent’s preparations for this transition to essentially full, day-to-day autonomy? The pediatrician is in a position to offer meaningful guidance to these adolescent patients, and in some cases to their parents as well, particularly on the subjects of substance use, mental health, and sexuality. This process starts in early high school, with progressively more detailed and frank discussions into and through college.
Substance use
For purposes of this discussion, let’s focus on alcohol use. Talking about the risks of alcohol probably should start in late junior high and upon entry to high school. But if you have not yet had a discussion with your adolescent patient about drugs and alcohol, it is not too late to have one during the time before they start college. It would be helpful to learn about their personal and family history of alcohol and drug use. How has alcohol been discussed, and more importantly, used in the home by parents? What are your patients’ attitudes to drinking and related social pressure? Have they needed to be “rescued,” or have they needed to rescue friends? Have they been the designated driver? Have they passed out or seen someone pass out at a party? In these situations, how have they coped? What decisions have they made? Is there a pattern of self-monitoring or largely one of risk taking? What do they imagine college will be like with regard to drinking?
For your patients who have been decidedly sober through high school, it will be important to find out if they are curious about trying alcohol once they are on campus. Even if they voice shocked refusal, you might speak generally with them about the easy availability of alcohol at many parties on campus, particularly if they join a fraternity or sorority or even plan to be on a varsity sports team. Superior athletes are often surrounded by older students and often gain access to parties as freshmen or sophomores surrounded by far more experienced seniors. Speaking generally about how common it is to try alcohol in college, while offering details on how easy it can be for first-time drinkers to become drunk, can be very valuable. You might even offer them data and strategies on how to pace themselves: one drink per hour, no hard alcohol or “mysterious punch,” or two glasses of water for every beer are a few such strategies. You might note how quickly alcohol is absorbed and the risks of rapid ingestion of larger quantities. You should be clear that you are not endorsing underage drinking. Your goal is to ensure that they are equipped with knowledge about smart self-care, especially as intoxication can put them at risk for being victimized or exploited sexually, for serious accidents, for administrative problems, and even for medical consequences.
For your patients who have been risk takers, especially if they have had trouble with drugs or alcohol in high school, it will be important to speak with them about the likelihood that a risky pattern of substance use in high school will grow into a more serious problem in the less-supervised college setting. While this may sound to them like the exciting chance to have easier access and fewer restrictions or punishments, you have the opportunity to complicate their thinking about what this will actually mean. In all likelihood, their use will grow into a problem of abuse or dependence and could easily threaten their ability to succeed at college, landing them back in a far more restrictive setting. It may be valuable to talk with your patients about how they would know if their drug or alcohol use was becoming a problem. When would they say they have reached a limit they are concerned about? Would they be willing to see a therapist or psychiatrist about their substance use before leaving for college to make thoughtful plans for how to manage it? If they are willing, it may be protective to invite their parents into this conversation so that there is a better chance that they may discuss this with their parents outside of your office and once they are on campus.
Mental health
The prevalence of depressive and anxiety symptoms in the college years is very high, likely because of a combination of external stressors, loss of external supports, and continued rapid physical and neurologic development. For adolescents who have not experienced any mental health problems, it can be protective to have a conversation with them about the real risks of developing a mental health problem while they are at school and the value and efficacy of early treatment. You might tell them that while some anxiety and sadness are to be expected during a challenging transition, experiencing intense anxiety or sadness that is sustained (2 weeks or more) and that interferes with their functioning should prompt them to seek help from the student health services. They should be on the lookout for sustained disruptions in their sleep and loss of appetite and energy (the classic neurovegetative symptoms), and of course, any emerging hopelessness or suicidal preoccupation also should prompt them to turn to student health services for evaluation and support.
For your patients who have a history of psychiatric problems and treatment, it is critical – even if they are in remission – that you review with them when they should turn to the campus student health services for evaluation. What symptoms have indicated a worsening problem or relapse for them in the past? What might be the earliest signs of deterioration? If they are in active treatment, you should ensure that the treatment provider has built a transition plan for their treatment to continue on campus. Helping these patients to be smart about their self-care, just as you would if they were responsible for continuing treatment of their diabetes away from the supports of home, can be a powerful preventative intervention.
Sexuality
In all likelihood, you have already had a conversation about sex, even a brief one, with your adolescent patients by the time they are packing for college. But this is a key time to revisit the subject with them. You can begin an open-ended discussion about the fact that the years in college are commonly a time when adolescents start having sex (if they have not already done so). As such, it is important for them to learn about birth control and protection against sexually transmitted infections. This is normally a developmental stage in which sex becomes a more fully integrated part of their emerging identity and their healthy adult life. They may find that they develop a fuller awareness of whom they are attracted to and what they enjoy, and it is commonly a time of some experimentation or exploration. It is very meaningful for your young patients to hear about this nonjudgmentally from their pediatrician. This discussion should include some prevention, in the form of talk about the risks of sexual assault on campus. Help your patients, both male and female, to consider how new independence and access to alcohol can be a dangerous mix with the intense social scene on college campuses. Many situations in which they will be socializing with strangers will involve alcohol, even drugs. Would they have sex with someone if they or their partner were intoxicated? How would they know if the person they were connecting with was actually very intoxicated? How might they think about protecting a friend who seemed to be very intoxicated and at risk for sexual exploitation or assault? If they think they are witnessing a sexual assault or a risky situation, what could they do? If they are considering sex with someone, is it because they are attracted to and interested in that person, or are they feeling pressured, anxious, or bullied? Remind them that while exploration is healthy and should be fun, it also is wise to go slowly when something is new, and to be especially cautious when substance use is involved. They can protect themselves and their friends from the trauma of assault or of being accused of assaulting someone who could not meaningfully consent to sex with some thoughtful anticipation and planning. They took great care to arrange to get into college, and they can take equally great care with their own health and well-being.
Progressively relevant and honest discussions between a pediatrician and teenage patient can have a meaningful impact. Consider how teens could have access to you during their freshman year. Should they have your pager or your cell phone number if they feel they need your help? Should you schedule a psychosocial follow-up visit during a holiday break first semester and again as indicated? Doing what you can to anticipate and prevent harm during the transition to college is highly relevant to many if not all of your patients.
Dr. Swick is an attending psychiatrist in the division of child psychiatry at Massachusetts General Hospital, Boston, and director of the Parenting at a Challenging Time (PACT) Program at the Vernon Cancer Center at Newton Wellesley Hospital, also in Boston. Dr. Jellinek is professor of psychiatry and of pediatrics at Harvard Medical School, Boston. E-mail them at pdnews@frontlinemedcom.com.
