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.