When my parents were 22, they were two years out of college. My mother was married and commuting from Dallas to graduate school in Houston, on the verge of another cross-country move and a metaphorical world away from her New York City upbringing. My father was the officer running the kitchen on a United States Navy frigate somewhere in the Mediterranean Sea, a literal world away from his Brooklyn childhood.
When I was 22, I was finishing my first year of medical school. I toured apartments, signed a lease, set up my utilities, bought furniture, and arranged to move. I spoke to my parents for ten minutes on Sunday afternoons by phone, after the rates went down.
I am now the mother of three college-aged children. They show remarkable resilience and can navigate stressful environments like technology and social media, which still elude me. Yet, I cannot imagine my twenty-year-old picking an apartment without sending me a video tour.
There is widespread agreement that 22 today is dramatically different from what 22 was thirty or sixty years ago. Plenty of pundits give interviews explaining that permissive and overly involved parenting have ruined the current generation of young adults. Parental micromanaging certainly impacts this generation, but the parental hypothesis ignores critical social changes and biological evidence.
If 22 today seems younger than it used to, this is partly due to changing social norms. When my mother was 22, the median age of first marriage for a woman in the United States hovered between 20.3 and 20.6 years old. For my daughter, the same statistic is just above 28 years old, an eight-year gap. Social and educational structural changes have pushed maturity milestones like marriage later and later.
Technology has dramatically changed this generation’s relationship with (some would say reliance on) their parents. Blogs and book tours claim that this instant communication prevents young people from becoming independent. Alternatively, perhaps technology enables age-appropriate communication when parents and children are physically distant. For thousands of years of human history, young adults lived near their parents—with easy access to advice on anything from hunting/gathering to child-rearing.
Our emphasis on young adult independence may be an attempt to justify the cultural phenomenon of geographical family separation. After all, I would have loved to show my first lease (and the only legal document I had ever seen) to my father before signing it. My failure to do so was not because I was bravely striking out on my own—it was because showing him the lease would have involved a copy machine, a trip to FedEx, and 48 hours I did not have. Educators, writers, and physicians ruthlessly demean this generation for using texts to depend on their parents. Instead, we could acknowledge that technology allows young adults access to parental advice in a historically normal manner.
From a neuroscience perspective, our understanding of brains has undergone a sea change. Extensive evidence—longitudinal MRI, prefrontal cortex function, neural plasticity, and neurotransmission—all indicate that brain maturation is complete around age 25, and certainly not at 18. Cognitively, an 18-year-old is different from a 14-year-old, but neither is truly mature based on our current understanding of brain development.
Just because we used to ask 18-year-olds to function as adults does not mean that was correct or appropriate in today’s biopsychosocial milieu. Sixty years ago, when we thought a 20-year-old was cognitively mature and half of them were married, transitioning to adult medical care at that age seemed like a no-brainer. That is no longer true. Life circumstances, cognitive stage, and health needs favor treating these patients in a pediatric arena.
Most 18 to 25-year-olds are on a merry-go-round of transitions. Many have left home, changed academic environments, and switched social peer groups—often more than once. Establishing care with a new doctor is logistically and emotionally challenging during times of upheaval. These patients frequently disappear from the medical system—without access to vaccines, mental health screening, or sexually transmitted infection treatment.
There will come a time when these patients should transition to adult care—when they will need someone more expert than this pediatrician in lipid management, and when the adult care model will meet their needs. But that time is no longer 18, just as my 22-year-old is not ready to run a navy ship’s kitchen.
As numerous country songs attest, every 18-year-old wants to grow up; leaving pediatric care is often considered a hallmark of that accomplishment. As a medical community, we should rewrite that milestone and agree to extend the border between pediatrics and internal medicine to the mid-twenties. Moving from pediatric to adult care should be based on cognitive age and life stage, not legal or outdated definitions of adulthood.
Eleanor Menzin is a pediatrician.
