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6 ADOLESCENCE

William Garrison and


Marianne E. Felice

Vignette
Johnny P., a 15-year-old boy, is a long-standing patient of Dr. K., a primary care physician. His mother
brings him to the office now with a variety of parental concerns. After earning average grades
throughout his previous school years, his achievement in his sophomore year of high school has
been deteriorating rapidly. In the same time period, conflict with his parents, now divorced but
living in the same large city, has escalated dramatically. His mother brings him to see Dr. K. so that
she can talk some sense into him. Mother describes Johnny as more oppositional than in previous
years, secretive and withdrawn from the family, and more involved with his peer group, who are also
mysterious to Johnnys parents. In addition to the expected pubertal physical changes in her son,
the mother reports an increase in angry outbursts, lower frustration tolerance, a whatever attitude
to the tasks of everyday life, a growing obsession with video games, and near-constant computer
or cell phone contact with peers.
When alone with Dr. K., Johnny gradually admits to engaging in several risky behaviors, including
initiating sexual activity with one or more female friends (hooking up), weekly marijuana and
alcohol use (it relaxes me), occasional school truancy, and at least one incident of shoplifting with
friends. At this point, Johnny becomes silent and looks to his pediatric provider as if to say, OK, so
what are you going to do about it?
Dr. K. realizes quickly that she must sort out what is normal versus abnormal adolescent behavior
and hatch a plan to address the teens high-risk behaviors.

Adolescence is a transitional period between childhood Adolescence covers approximately one decade of
and adulthood marked by dramatic growth in physical, liferoughly ages 10 to 20 years. Most experts do not
psychological, social, cognitive, and moral development. view adolescence as one age group, but rather two or
G. S. Hall, a psychologist, coined the term adolescence three distinct but overlapping phases: early adolescence
in the early 1900s from the Latin derivative adolescere, (10 to 13 years old), mid adolescence (14 to 16 years
which means, to grow up. Some historians believe that old), and late adolescence (17 years old). Some authors
the concept of adolescence is a relatively recent phenom- prefer to use other terminology to describe these phases,
enon since the Industrial Revolution. Margaret Meads such as preadolescent, adolescent, and youth. Regardless
description of girls growing up in Samoa a century ago of the vocabulary, the concept is similar: A 13-year-old is
indicates, however, that even then common themes of different from a 19-year-old, and the social and psycho-
a burgeoning awareness of sexuality and notable peer logical needs of younger adolescents differ from those
interactions were clearly present in this different culture. of older adolescents. The age ranges noted are arbitrary
The observations of philosophers such as Socrates about and approximate and often overlap. Some 15-year-old
the divide between youth and their parents could describe teenagers may be grappling with early adolescent devel-
the arguments that occur in many homes today. In some opmental tasks, others may be in mid adolescence, and
of Shakespeares plays (i.e., Romeo and Juliet; A Winters a few may be ready for late adolescence. All three 15-
Tale), the playwright laments many of the behaviors that year-old teenagers would be considered developmen-
we observe today, including sexuality, independence, tally normal. Developmental phase also may depend
and adolescent pregnancy. These examples support the on cultural variables and life events. A chronic illness
argument that all young people undergo some universal may delay puberty and adolescence; a death of a parent
developmental changes as they journey from childhood may accelerate development and maturity. Psychosocial
to adulthood, from immaturity to maturity. What is developmental age can be at variance with chronologic
clearly different in modern times, however, is the rela- age, just as physical development may be at variance
tively longer length of time adolescence consumes today with chronologic age. An adolescent still can be com-
compared with many generations ago. pletely within normal variants.

62
Chapter 6 Adolescence 63

The term adolescence is sometimes used interchange- individuation process. Table 6-1 summarizes the devel-
ably with the term pubescence, but they are not the same. opmental tasks commonly attributed to the adolescent
Pubescence refers to physiologic changes, particularly age group (Felice and Friedman, 1982). These growth
sexual maturity and reproductive capability. Adolescence tasks occur concomitantly, but some tasks may be more
refers to psychosocial growth and development. These prominent in different phases of adolescence than in
two processes are interrelated and intertwined, how- others. Table 6-2 outlines the differences in the growth
ever. Generally, pubescence heralds adolescence. Psy- tasks in the three phases of adolescence.
chosocial attributes of the adolescent years usually are
first noticed by parents, teachers, and siblings shortly Gradual Development as an Independent
after a child experiences the onset of puberty (described
subsequently). The beginning of adolescence is easier to Individual
pinpoint than the completion of adolescence. Some indi- Before adolescence, most school-age children identify
viduals continue to grapple with adolescent issues well strongly with their families and look to one or both
past the legal age of 21 years. Regardless of when ado- parents as role models. During early adolescence, young
lescence ends, the transition to adulthood is complete teenagers may begin to separate psychologically from
when a physically and intellectually mature individual their parents in an effort to establish their own identity.
is able to formulate a distinct identity and develop the For many teens, this process may result in the adolescent
ability to respond to internal and external conflicts and taking issue with parental opinions, shunning parental
challenges with a consistent and realistic value system. viewpoints, and testing parental values. This verbal
jousting with parents is an attempt to establish inde-
PSYCHOSOCIAL GROWTH TASKS pendence. In mid adolescence, teens may be ambivalent
about the separation process as they experience unfa-
The psychosocial growth tasks of adolescence have miliar situations. They may find themselves retreating to
been described in various ways by many authorities and the comfort of the family and the familiar, and yet they
from different perspectives. Erikson (1968) character- can become angry with themselves for needing the com-
ized adolescence largely in terms of identity formation; fort of the family. In some families, this ambivalence is
Anna Freud (1966) marked adolescence as a time of expressed as hostility or bravado. By late adolescence,
struggles between a relatively strong id and a relatively older teens are comfortable being away from home and
weak ego; Blos (1967) wrote of adolescence as a second in unfamiliar situations. In this later stage of develop-
ment, many older adolescents are able to return to their
parents and seek advice and counsel without feeling
threatened or ashamed.
Table 6-1. Psychosocial Growth Tasks
For many parents, the adolescents efforts at separa-
of Adolescence
tion are confusing and bewildering. They may be hurt
Gradual development as an independent individual that they no longer have the same closeness with their
Mental evolvement of a satisfying, realistic body image son or daughter that they perceived previously. They
Harnessing appropriate control and expression of sexual drives may be angry that the teen seems to contradict every-
Expansion of relationships outside the home
Implementation of a realistic plan to achieve social and economic
thing they say. Parents need reassurance about the nor-
stability mality of this process. They may be able to relate to a
Transition from concrete to abstract conceptualization quotation attributed to Mark Twain: At the age of 17,
Integration of a value system applicable to life events I could not believe how little my father knew. When I
From Felice ME: Adolescence. In Levine MD, Carey WB, Crocker AC (eds): was 21, I could not believe how much he had learned in
Developmental-Behavioral Pediatrics, 2nd ed. Philadelphia, WB Saunders, just 4 years.
1992, p 66.

Table 6-2. Growth Task Characteristics of the Three Phases of Adolescence


Tasks Early: 10-13 Years Mid: 14-16 Years Late: 17 Years
1. Independence Emotionally breaks from parents Ambivalence about separation Integration of independence
and prefers friends to family issues
2. Body image Adjustment to pubescent changes Trying on different images Integration of satisfying body
to find real self image into personality
3. Sexual drives Sexual curiosity; occasional Sexual experimentation; individuals Beginning of intimacy
masturbation may be viewed as sex objects and caring
4. Relationships Unisexual peer group; adult Begin heterosexual peer group; Individual relationships more
crushes multiple adult role models important than peer group
5. Career plans Vague and even unrealistic plans Emerging plans may still be vague Specific goals and specific steps
to implement them
6. Conceptualization Concrete thinking Fascinated by new capacity Ability to abstract
for thinking
7. Value system Decline in superego; testing Self-centered Idealism; rigid concepts of right
of moral system of parents and wrong; other-oriented;
asceticism
From Felice ME: Adolescence. In Levine MD, Carey WB, Crocker AC (eds): Developmental-Behavioral Pediatrics, 2nd ed. Philadelphia, WB Saunders, 1992, p 69.
64 Part I LIFE STAGES

Mental Evolvement of a Satisfying Realistic for social gain. Late adolescence is distinguished by the
Body Image ability to be intimate, that is, to care deeply for another
person without the need for exploitation.
In early adolescence, most teenagers are experiencing
puberty and learning to adjust to the dramatic changes Expansion of Relationships Outside the Home
of pubescence. They are growing in height and weight; As adolescents move away emotionally from parents,
they are sprouting hair where it did not grow before. they turn to relationships outside the home, which in-
They have body odor and blemishes; breasts and genita- clude a peer group and other adults. For most young
lia have enlarged. Young adolescents are exquisitely self- adolescents, the peer group generally consists of mem-
conscious of their bodys changes. They also are aware bers of the same gender. This unisexual peer group pro-
of changes in their classmates and friends and naturally vides a psychological shelter in which youngsters can
compare their own changes with the changes of their test out ideas and forge dyadic friendships without the
friends. They worry that they may be developing too often intense sexual tension created by proximity to
quickly or too slowly, and every adolescent needs reas- the opposite sex (for heterosexual youth). Members of
surance about his or her physical development whether the peer group conform to certain group standards, such
or not those concerns are expressed. By mid adoles- as dress, hairstyle, or even group rituals such as meeting
cence, most teenagers have already experienced puberty, at the same time at the same place every week. It also is
but they may not yet be comfortable with the results. common for young adolescents to develop friendships
Young women and young men spend much time (and with adults outside the home (e.g., teacher, parent of
often money) trying to improve their faces and figures. a friend, another relative). Teens may prefer the com-
These improvements can take the form of experimenting pany of extrafamilial adults (i.e., teachers, coaches) to
with different clothing styles to find a self-image that is the company of their own devoted parents. For many
comfortable to them. In late adolescence, most young parents, this situation can cause hurt feelings and bewil-
people have begun to be comfortable with their bod- derment. Such parents need reassurance that this can be
ies, although some young men (particularly so-called normal behavior.
late bloomers) may continue to grow in height well into By mid adolescence, teenagers often expand their
their early 20s. Although body image problems are not peer group to include heterosexual friendships, and
of major concern to most adolescents in their late teens, for many teenagers, this period marks the beginning
adolescents who have severe acne, a chronic illness, obe- of dating patterns. Teens in mid adolescence also
sity, or anorexia nervosa may continue to have body have a tendency to turn to adults outside the home as
image issues that are unresolved. role models. Teens are exposed to family structures,
religious beliefs, and lifestyles different from their own
Harnessing Appropriate Control and Expression family, and this is an impetus for teens to try on dif-
ferent styles and philosophies. Parents may find this
of Sexual Drives situation confusing and hurtful. In reality, most teenag-
Sexual and aggressive drives may be stronger during ers return to the family fold as young adults. For youth
adolescence than at any other time of life. Learning to in late adolescence, individual relationships gradually
express and control these drives is a major and formi- assume more importance than the larger peer group
dable task of the teenage years at a time when the young relationships. Friendships are often more intense, and
person may seem to be ill-equipped to master them. Be- issues are discussed with more depth. The superficiality
coming comfortable with ones sexuality is a major com- of previous years should be on the wane. The bonds of
ponent of adolescent development. Early adolescence is friendship are particularly strong among youth who are
mainly marked by sexual curiosity, and masturbation working toward a common goal for a common task,
is common. In mid adolescence, teens begin further such as college roommates, sports team members, or
sexual experimentation, although not always full sex- military recruits.
ual intercourse. The percentage of high school students
who have had sexual intercourse by age 16 years has Implementation of a Realistic Plan for Social
decreased since the early 1990s; recent data indicate that
about 50% of high school students report having had
and Economic Stability
at least one voluntary sexual experience (Child Trends, Adolescents must decide what they want to do as adults
2005). These data may be obsolete in the next few years to support themselves financially and socially. For
because more teenagers are engaging in a phenomenon young teens, this is a vague concept and may even be
known as hooking up or friends with benefits, in unrealistic. Teens in mid adolescence give more thought
which they have friendships solely for sex and not for to this problem, but they may still be unrealistic. A typi-
romantic involvement, as in previous generations. Not cal 16-year-old may view a future job prospect as a way
all adolescents are heterosexual, and clinicians should to escape from home or the opportunity to do something
be sensitive to and aware of the needs of homosexual glamorous. For youths in late adolescence, the future is
and heterosexual teens. Some gay adolescents may delay a serious issue, and they are often faced with hard deci-
the onset of sexual activity as they emotionally grapple sions. This is a common problem among seniors in high
with their sexual orientation. school. Some teenagers find the final career choice so
During mid adolescence in both genders, there may be difficult that they avoid all decision making and sim-
a tendency to view ones sexual partner as an opportunity ply go along with decisions made for them by parents
Chapter 6 Adolescence 65

or teachers. Eventually, these teens may pay an emo- of hubcaps in response to a group dare or as a group
tional price and end up resenting the adults who made activity. Under ordinary circumstances, individual teens
the decisions for them. Clinical experience suggests that might never consider stealing hubcaps, but under group
an adolescent who struggles with this decision making pressure, they may feel forced to do so. If such teens are
and does what he or she wants to do, rather than what caught in this activity, they are usually embarrassed and
someone else wants him or her to do, is more likely to ashamed about their involvement.
achieve career satisfaction. Mid adolescence is marked by a narcissistic value sys-
tem (i.e., What is right is what makes me feel good;
Transition from Concrete to Abstract What is right is what I want); this partially explains
the sexual exploitation described previously. A clinical
Conceptualization consequence of this type of thinking is that many teens
Cognitive development is a key component of adoles- in mid adolescence engage in activities impulsively with
cence and is described in more detail later in this chap- little thought about the consequences, such as unpro-
ter. Briefly, in terms of the described growth tasks, tected intercourse. This self-serving behavior may be
cognitive development is differentiated across the three frightening and provoke anxiety in the adolescent. If
phases of adolescence. A young adolescent thinks more there are no checks on impulses, the teenager may feel
concretely with limited abilities for abstraction; this has out of control. To guard against this outcome, he or she
implications for health professionals who are taking may develop severe moral standards with rigid concepts
a history from a 12-year-old in early adolescence. If a of right and wrong, particularly in late adolescence. As-
clinician wishes to discover if a young teenage girl has ceticism and idealism are common. Older adolescents
been sexually active, it may not be wise to ask, Have are often very altruistic, and they may embrace moral
you ever slept with a boy? The answer, yes or no, may causes with much zeal. Issues are often viewed in terms
have nothing to do with sexual intercourse, just sleep- of black and white with self-righteous indignation and
ing. Teens in mid adolescence have a greater capacity for sometimes with self-imposed restrictions and prohibi-
abstraction and are usually more capable of introspec- tions. Although a youth in late adolescence may cham-
tion; mid adolescents can think about thinking. This pion justice and rightness, there is little tolerance
is a giant step in mental development, and some teens for opposing points of view. One could speculate that
become fascinated with this newfound intellectual tool. the transition to adulthood occurs when an individual
This aspect of adolescence may be another factor con- finds that there are suddenly more gray issues in life
tributing to the self-centered behavior of teenagers in than black-and-white ones.
mid adolescence.
Teenagers in late adolescence are often capable of
stretching their mental faculties immensely. Solutions to CHARACTERISTICS OF THE THREE PHASES
many problems are often thought through in great de- OF ADOLESCENT DEVELOPMENT
tail, but older teens often have a rigid value system that
may limit their problem solving skills. Creative achieve- As noted previously, adolescents grapple with all seven
ment may be quite remarkable at this age, particularly in growth tasks concomitantly, but some tasks are empha-
the arts. The social implications of the cognitive devel- sized more clearly in one developmental phase than in
opment of late adolescents are many. Older adolescents others (see Table 6-2). Growth in some tasks may influ-
can be very interesting and avid conversationalists with ence growth in other areas. Progression through all the
opinions on every issue. In addition, adolescents at this tasks is necessary for healthy adulthood and emotional
stage of development can now see a host of alternatives maturity.
to parents directions and may promptly point these out
to a beleaguered mother or father. Early Adolescence (10 to 13 Years Old)
The major developmental task of young adolescents is
Integration of a Value System Applicable establishing independence from their parents. This pro-
cess cannot occur in a vacuum, so adolescents turn to
to Life Events their peer group, who are usually members of the same
Moral growth is a key concept to gaining maturity and gender. This is a normal phenomenon for heterosexual
is discussed in more detail later in this chapter. With re- and homosexual adolescents. In addition, it is not un-
spect to the developmental growth tasks, there are clear usual for young teenagers to have crushes on adults
differences between early, mid, and late adolescence. In outside the home, or to idealize them compared with
early adolescence, it is not unusual for young teens to their all-too-familiar and imperfect parents. Early ado-
experience a temporary decline in the superego as they lescents are usually in the throes of puberty and must
make the transition from childhood under the watchful adjust to a rapidly changing body and a changing body
eye of parents to the more independent nature of adoles- image. Although young teens are curious and fascinated
cence when parents are not always present to tell teens with sexuality, most young teens have not yet begun to
what is right and wrong. The collective conscience of have sexual intercourse, even though they may reside
the peer group may be at odds with a teenagers parental within a larger society seemingly obsessed and titillated
standards. In some instances, a teen may feel the need to by sexual themes and innuendo. Young adolescents are
test the parents moral code. An example of the decline concrete thinkers and may have vague and even unreal-
in the superego in early adolescence could be the stealing istic plans for a future career. There may be some testing
66 Part I LIFE STAGES

of the parents value system as the teenager struggles to and the production of aromatase. LH stimulates ovarian
develop a moral code. Early adolescence is marked by a thecal cells to produce androgens; aromatase converts
unisexual peer group, concerns about puberty, and ac- androgens to estrogens in the FSH-stimulated granulosa
tive establishment of independence from parents. cells. Later in puberty, under separate control mecha-
nisms, a midmenstrual cycle surge of estradiol results
Mid Adolescence (14 to 16 Years Old) in an elevation of LH to trigger ovulation (Joffe and
The major developmental task in mid adolescence is Blythe, 2003).
sexual identity, that is, becoming comfortable with In addition to the above-mentioned gonadotropins,
ones sexuality. This task includes the need to become other hormones are released during puberty. The pi-
comfortable with ones body and with ones body im- tuitary begins to secrete human growth hormone; this
age. Many teens in mid adolescence try on different is regulated by growth hormonereleasing factor and
images in hopes of finding a true self; this may be somatostatin. Growth hormonereleasing factor is re-
expressed in their dress code or mannerisms and may leased in a pulsatile fashion during sleep. Insulin-like
change from week to week. Teens in mid adolescence growth factor I (IGF-I or somatomedin C) and IGF-II
generally begin heterosexual dating patterns. Gay or les- are produced by the liver and influence growth, particu-
bian adolescents have the same developmental growth larly growth rate, as does thyroxine and the corticoste-
tasks as heterosexual adolescents, but the timing of roids. Parathyroid hormone, 1,25-dihydroxyvitamin D,
their dating experiences may be delayed or influenced and calcitonin affect skeletal mineralization. The release,
by other factors, such as self-acceptance of their homo- surge, and interaction of all of these hormones result in
sexuality or perceived attitudes toward homosexuality the physical changes observed during adolescence.
in their environments. Teens in mid adolescence also Three areas show the dramatic changes of puberty:
begin to grapple with issues related to morality as their an increase in weight, an increase in height, and sexual
cognitive functions expand with the capacity and capa- development. Girls typically experience puberty about
bility for abstraction. They begin to think about think- 2 years earlier than boys. The first sign of puberty in girls
ing. Career plans usually begin to take some shape, but is usually the development of breast buds between the
may not be definite. ages of 8 and 10 years. The start of pubic hair, further
development of breasts, a height spurt, a weight spurt,
Late Adolescence (17 Years Old and Older) and menarche then follow in a well-described pattern
The primary focus of late adolescence is planning a (Tanner, 1962). Menarche signifies the end of pubertal
career or how one will contribute to society as a re- development in girls. In boys, puberty is signaled clini-
sponsible adult. This planning is accompanied by high cally by darkening of the scrotal skin, enlargement of
idealism, rigid concepts of right and wrong, and the the testes, and lengthening of the penis between the ages
newfound ability to think through problems with vari- of 10 and 12 years. The proliferation of pubic hair, ad-
ous alternatives. In addition, youth in late adolescence ditional enlargement of the genitalia, and a height spurt
can shed the strong need to belong to a peer group in follow over the next 2 to 6 years (Tanner, 1962). Other
favor of a close, intimate, and caring relationship with pubertal changes, such as acne, axillary hair, deepen-
another person. For many youngsters, finding a partner ing of the voice, and the growth of chest hair in boys,
or significant other becomes a major search, and this is also are characteristic, but vary from one individual to
the usual time of falling in love for the first time. another, depending on genetic and cultural factors. The
most dramatic changes of puberty usually occur in early
adolescence, but it is common for young men, particu-
BIOLOGIC BASIS FOR MAJOR DEVELOPMENTAL larly late bloomers, to continue to grow taller into
CHANGES their early 20s.
Hormonal Changes of Puberty Neurologic Maturational Changes
The onset of puberty marks the metamorphosis of a In recent years, there has been a shift in how biologists
child into an adult capable of reproduction. The ex- view the process of puberty. Previously, the process of
act trigger that begins pubescence is unknown. It is puberty was described solely by the hormonal aspects of
known, however, that puberty is associated with spe- puberty as related to reproduction. A large body of lit-
cific changes in the hypothalamic-pituitary-adrenal axis. erature has developed, however, that has focused on the
Sometime in late childhood, there is increased produc- neural control of hormone secretion and a gradual aware-
tion of adrenal androgens before there are any physical ness of extensive brain remodeling during adolescence.
signs of puberty. This increased production of adrenal This literature has led to an emphasis on a neuronal ba-
androgens is followed by an increasing pulsatile secre- sis for reproductive maturation (Sisk and Foster, 2004).
tion of gonadotropin-releasing hormone during sleep. In this model, the onset of puberty is viewed not as a
Gonadotropin-releasing hormone secretion results in gonadal event, but rather as a brain event.
increasing levels of luteinizing hormone (LH) and to Human adolescent development involves widespread
a lesser extent follicle-stimulating hormone (FSH). In changes in the gross morphology of the brain. The vol-
males, LH stimulates the Leydig cells in the testes to ume of white matter increases linearly as a result of
produce testosterone, and later FSH stimulates testicu- increased myelination of cortical and subcortical fiber
lar Sertoli cells to support the development of sperm. tracts. Gray matter volume takes an inverted U-shaped
In females, FSH stimulates follicle growth in the ovary course, first increasing and then decreasing. The age of
Chapter 6 Adolescence 67

peak gray matter thickness varies by gender, occurring Cognitive-Developmental Functioning


1 year earlier in girls than in boys and correlating with
Before the 1980s, much of the empiric work on cogni-
the earlier average age of puberty onset in girls (Sisk
tive development in adolescents was strongly influenced
and Zehr, 2005). The structural bases of adolescent
by the work of the major theorist Piaget. His stage
changes in gross morphology of gray matter have not
theory of human cognitive development was a useful
yet been determined, but many investigators interpret
rubric for the study and understanding of how a childs
the adolescent reduction in gray matter volume as evi-
burgeoning mental skills evolve over time from thought
dence for synaptic pruning (Sisk and Zehr, 2005). It is
based solely on the outward appearances of things to
now generally accepted that steroids play an important
concrete operations or mental skills that allow a child
role in brain development during the adolescent years.
to solve problems mentally through steps from begin-
Steroid-dependent organization of neural circuits is a
ning to end. Piaget also theorized that a young adoles-
fundamental feature of adolescent brain development,
cents thought processes gradually evolved further, to
broadening the influence of pubertal hormones beyond
a more abstract and multifactorial form of thinking
a purely activational role to agents of neural rearrange-
Piaget called formal operations. Developmental re-
ment (Sisk and Zehr, 2005). This area of neuromatura-
search in the last 20 years has cast doubt, however, on
tion of the adolescent brain is an exciting new topic that
the assumption that all adolescents (or adults, for that
is being studied and debated in the field. More informa-
matter) actually achieve the stage Piaget labeled formal
tion is unfolding on a regular basis and is expected to
operations. Some research has suggested that less than
add further to the body of literature on how and why
half of adults found in industrialized societies achieve
puberty occurs.
the formal operational stage Piaget described (Kuhn
et al, 1977).
DEVELOPMENTAL DOMAINS More recently, the field of developmental psychology
has adopted an information-processing approach to
Mastering the seven key psychosocial growth tasks
the study of cognition in teenagers (Steinberg and
listed in Table 6-1 typically determines the relative suc-
Morris, 2001). In contrast to a Piagetian view, these
cess or failure of teens as they transition into adulthood.
studies would argue that there is wide variation in in-
Most teenagers do well in this transition. The adolescent
dividual capacity to think and process information
years can be a time of elevated emotional vulnerability.
during adolescence. This variation is apparently due to
Adolescence as a stage in human development is not as
a complex interaction between overall cognitive abilities
catastrophic or dire, however, as early developmental
and the accrual of environmental experience.
theorists, and many contemporary parents, might sur-
Two concepts regarding cognitive development in
mise. The reality is that most teens manage to steer
adolescents hold particular value for clinicians seeking
successfully through the maze of adolescence, perhaps
to understand and help teenagers. First is metacogni-
awkwardly at first, then more skillfully as they mature,
tion, or the ability to think about thoughts, a process
and typically emerge as adults functioning well within
that largely explains an adolescents continuous growth
the range of normal.
in cognitive skills and the ability to draw on a useful
Pertinent to clinical work with teens, it seems that
store of knowledge accrued over time. Metacognition is
when adolescence becomes a persistently painful or
the process whereby one is able to use knowledge from
problematic phase for a young individual, it is a clear
past experience and merge such knowledge with the
sign that something has gone wrong in personal de-
challenges of a new task or problem, review and reflect
velopment or the environment itself, and it should not
on possible strategies, and eventually solve or resolve
be categorized simplistically as just a symptom of being
the tasks of everyday life, while navigating through the
a teenager. To understand how things go awry in ado-
major social and emotional challenges of adolescence
lescence requires a familiarity with several major devel-
and adulthood. Metacognitive processes are thought to
opmental domains, what should occur in those domains,
be largely responsible for helping adolescents success-
and various factors that can derail normal development.
fully counterbalance an array of conflicting thoughts
These domains each represent essential ingredients nec-
and emotions new to their experience, by virtue of
essary for the key tasks of adolescence cited earlier. Put
rapid biologic growth and dramatically expanding life
in simpler terms, each domain represents a basic build-
experiences.
ing block for successful human development during the
Second, a computational model of cognitive develop-
second decade of life. These domains can be captured by
mental functioning in adolescents seems to be more use-
three key questions:
ful than a stage model in explaining huge differences
1. How well can I think, reason and decide? (cogni- in the mental capacities of adolescents, which go beyond
tive-developmental functioning) numerical differences in measurable intelligence (i.e.,
2. How well do I interact with others? (moral and I.Q.). Generally, the effects of home milieu, schooling,
social development) and general life experience should combine to strengthen
3. Who am I, and do I like who I am? (emergence of an adolescents increasing mental capacities. The lack of
a sense of self) appropriate stimulation in any of these life contexts, or
the presence of considerable stress or trauma, also can
In the following sections, we attempt to examine and act to limit or stultify individual cognitive development
discuss each of these topics in greater depth. during adolescence.
68 Part I LIFE STAGES

According to the information-processing perspec- Emergence of Self


tive, general intelligence remains stable during adoles-
One reason psychological issues seem so dramatic during
cence, but dramatic improvements evolve in the specific
the adolescent years is simply due to the fact the issues
mental abilities that underlie intelligence. Verbal, math-
are new to the experience of the teens and those around
ematical, and spatial abilities increase, memory capacity
them, especially parents, teachers, and siblings. Biologic
grows, and adolescents are more adept at dividing their
and cognitive changes give rise to a re-definition of the
attention. In addition, their abstract and hypothetical
internal (Who am I?) and the external (What is the
thought grows; they know more about the world, and
meaning of life?). Too much has been written about
their store of knowledge increases (Feldman, 2006).
this journey of self-discovery to be reviewed here. A syn-
thesis of research and theory on the phenomenology of
This contemporary view of adolescent cognitive
adolescence might provide the following key points:
development helps us to understand wide differences
detectable in the overall cognitive and judgmental func-
tioning of teenagers. If all adolescents were equally able 1. Children generally evolve from a largely egocentric
to manipulate easily abstract concepts related to every- view of themselves, in terms of worldview and event
day life, we would expect far fewer problems arising causation, to a more realistic view during adoles-
from poor decision making in teens and young adults. cence and adulthood that takes into account others
Similarly, the broad variability in adolescent abilities perspectives and allows for multiple-factor causation
to employ acquired knowledge and scientific reasoning of events. A growing awareness of other peoples
helps to explain the real-life differences in achievement perceptions can be a double-edged sword, however,
observed in teenagers. heightening the adolescents fears of being scrutinized
and judged by peers or adults.
Moral and Social Development in Adolescence 2. Self-esteem processes evolve from evaluation that
From the 1960s through the late 1970s, Kohlbergs stems largely from What can I do/what am I good at
theory of moral development dominated thinking about and Who likes me/rejects me, to a more coalesced
adolescent social decision making. To this day, the the- sense of identity that derives from an emerging self-
ory holds heuristic value for clinicians seeking to under- appraisal based on past and current life experience.
stand a young persons moral transition from childhood In Eriksonian terms, the child moves from the task
through the adolescent years (Kohlberg and Gilligan, of Industry versus Inferiority during the preadoles-
1972). This theory suggests that a child (4 to 10 years cent years to one of Identity versus Role Confusion
old) moves from evaluating morality largely from judg- (Erikson, 1963). Less understood during this impor-
ments about good and bad (essentially derived from tant developmental transition is the role of individual
the cues of adult authority figures) to moral decision personality variables (at least partly due to biogenetic
making that relies on conventional definitions of right influences) on the expression of adolescent emotion-
and wrong, conventions that derive from an amalgam ality and self-appraisal. Although it is a given that
of parental, peer, and macrocultural influences. Much we would see heightened emotionality in most teens,
debate continues regarding the relative weight parental only personality differences seem to explain the wide
versus peer influence wields on adolescent moral and so- range in variation adolescents show in negative emo-
cial decision making, with the bulk of empirical research tions and poor coping with strong emotions.
supporting the view that most adolescents are affected 3. Becoming comfortable with ones sexuality and
by parents and peers in comparable measure, but in accepting of ones body is a major component of
competing and concerted ways (Harris, 1998; Steinberg, adolescent development, but often extends into adult-
2001). A central problem in using Kohlbergs theory of hood. Cultural and societal norms have a major influ-
moral development in clinical settings, however, is the ence in these areas of development. The emphasis
fact that advanced-stage moral thinking is not always on thinness in modern society as the ideal model for
accompanied by advanced-stage moral behavior. In beauty is a different cultural norm today than it was
other words, it is clear that many people, including teen- in previous centuries and may be influencing the wave
agers, often act or behave at odds with their capacity to of eating disorders that is pervasive among many teen-
recognize right from wrong. age girls in recent years. It is not unusual for women
As we learn more about social, emotional, and as well as adolescent girls to struggle with body image
moral growth during adolescence, we find that most issues. Although modern society is more open about
adolescents do well in their journey from childhood sexual activity and sexual orientation than it was in
to adulthood. Their social experiences appear rich and previous generations, there are many communities in
varied, and evolve rapidly from a view that is strongly which sex before marriage is unacceptable for adults
influenced by peer influences to one that incorporates and teenagers, and there are many areas of the United
personal, familial, and societal/community values. Ado- States in which gay and lesbian couples are not wel-
lescents who do not fare well are the ones health care comed. These external factors have a strong influence
providers and others seek to help. Teens who need help on body image and sexual identity acceptance.
in these areas are often those who have poor academic
or work achievement, dysfunctional social relations, Much research is being done to understand adoles-
drug and alcohol abuse, chronic risk-taking, and antiso- cent development in all of its facets. Developmental
cial behavior in general. theory and research seeks to help understand how it is
Chapter 6 Adolescence 69

that adolescents come to think about their internal and tend to perform at lower levels, receive lower grades,
external world, and how they make meaning of their and score lower on achievement tests, than Caucasian
emotions, social relationships, and their emerging sense students. When socioeconomic status is controlled for,
of selves as individuals in a crowded world of others. achievement differences diminish (Feldman, 2000).
Developmental theory and research helps clinicians to
see how adolescents come to hold values, beliefs, and Some research has suggested that culture-bound
attitudes that serve to guide their adult behavior, and disorders also may exist, and that attitudes toward
how all these factors help to set the stage for the discov- mental health problems vary by ethnic group, affect-
ery of lifelong goals and loving relationships that seem ing how and what treatments adolescents from minor-
necessary to achieve satisfying and well-adjusted adult ity populations seek (Bains, 2001). Community-based
development. prevention and intervention programs that begin well
before adolescence have been identified as most likely
CULTURAL VARIATIONS IN ADOLESCENCE to be effective in behavioral and mental health problem
areas (Baruch, 2001).
Changes in the ethnic makeup of American youth dur-
ing the past 20 years merit special attention in any con- CLINICAL IMPLICATIONS
temporary chapter on adolescence. Understanding the
diversity of American youth to develop healthcare and Adolescents receive clinical care in various settings: pri-
social intervention systems of care should be a high pri- vate physician offices, adolescent clinics, public health
ority for all. As with other areas of psychosocial and clinics, and school-based health clinics. Regardless of the
medical research, most studies of normal adolescent settings, there are commonly accepted guidelines for suc-
development have involved only samples of European- cessful interactions and interventions with teens. First,
American, heterosexual youth. In contrast, studies of the setting must be welcoming to the teen. For example,
teens judged at elevated risk for psychiatric and health there are chairs big enough for teens in the waiting room;
problems often contain samples almost exclusively com- there are magazines appropriate for teens; there are
posed of ethnic minorities (Hagen et al, 2004). This brochures available and posters on the wall all reflecting
schism in sampling techniques may underestimate levels the fact that adolescents are expected and welcomed.
of dysfunction in the general population of teens and Second, adolescents and parents must be interviewed
overstate the case that most problems occur in high- separately so that the clinician can take a history con-
risk youth in largely urban and poor communities. cerning sexuality or drugs or both without the teenager
Although it is clear that the risk-likelihood for mental being afraid to answer truthfully. When asking about
health disorders and stressful life events increases dra- drugs or sexuality, it may be helpful first to ask
matically with the presence of factors such as poverty about friends activities in these areas and then to ask
and its concomitant lack of resources, adolescents from about the teens activities. This is one way that the ques-
all social classes seem to be at elevated risk for adjust- tions may be less threatening. When asking about sexu-
ment issues. The sheer numbers of teens found within ality, it is important that the interviewer not presume
nonwhite groups is expected to continue to grow over that all adolescents are heterosexual and to ask questions
the next 10 years, and these youth would be overrepre- in such a way that the homosexual adolescent would
sented among the poor (at rates of double to triple that feel free to answer honestly. For example, the clinician
of white youth). It has been estimated that the number may ask: Do you have a boyfriend or girlfriend? or
of white juveniles will increase by 3% through 2015, Everyone has sexual thoughts and feelings sometimes.
whereas the number of Asian/Pacific-Islander, His- With you, do you find yourself having sexual thoughts
panic, and African-American adolescents will increase about sex with boys or girls or both?
by 75%, 59%, and 19% (Office of Juvenile Justice Third, adolescents should be told about confidential-
and Delinquency Prevention, 1999). At the same time, ity, and that the clinician will hold information in con-
approximately one in four teens from Hispanic and fidence except in those instances when the adolescent is
African-American families live below the poverty level a danger to self or others. Clinical sites should ensure
(National Association of Social Workers, 2001). that all staff, including the frontline staff, are educated
Studies of academic achievement in the United States about adolescents rights to confidentiality and the sites
are illustrative of how the risks of ethnic origins are expectations as to how adolescents should be treated. It
largely mediated by socioeconomic status (SES). is not unusual to find out that adolescents are reluctant
to use a certain facility not because of the clinician, but
On average, middle- and high-SES students earn because of an unpleasant experience they had with the
higher grades, score higher on achievement tests, and person who answered the phone.
complete more years of schooling than students from Fourth, all clinical sites should be familiar with the
lower-SES homes. Several environmental factors ex- laws of the individual state concerning the rights of mi-
plain this discrepancy including less adequate nutrition nors to receive health care without parental consent. In
and health, crowded conditions, attending inadequate most states, these laws allow adolescents to be seen for
schools, fewer places to do homework, a lack of books the treatment of sexually transmitted infections or the
and computers. In addition, parents living in poverty are prescribing of contraceptives without parental knowl-
less likely to be involved in their childrens schooling. edge or consent. Although some parents may question
On average, African American and Hispanic students these efforts, most parents understand the explanation
70 Part I LIFE STAGES

that the clinician is helping the young person become of similar dysfunction within the immediate and ex-
more responsible for his or her own health care, and tended family pedigree. It has become too common and
most parents are relieved that their son or daughter is convenient to blame all clinical problems teens encoun-
receiving special attention from a trusted health care ter on adolescence itself, rather than recognizing the
provider. larger biogenetic etiology of human psychological disor-
Returning briefly to the vignette described at the be- ders and maladjustment to life.
ginning of this chapter, we note that Dr. K. did inter- Adolescents who encounter significant adjustment is-
view Johnny P. alone. In doing so, she encountered a sues or come to the point where psychiatric diagnoses
common clinical scenarioa patient who has minor are appropriate often fall into broad categories of behav-
problems that are not unusual during adolescence, but ior description: internalizing and externalizing subtypes.
who also has some serious issues that need to be ad- Many of the teens encountered in health care settings
dressed soon. Johnny P. was not simply showing some may fall short of meeting all criteria for a formal psychi-
of the normal psychological changes adolescents often atric diagnosis, but present with significant problems of
display, he was also beginning to engage in a range of adjustment that merit attention and intervention. Some
risky behaviors that had the clear potential to derail his studies have estimated that 40% of adolescents show
development from typical to abnormal. The clinicians significant depressive symptoms, including dysphoric
evaluation phase must attend to underlying changes at- mood, low self-esteem, and suicidal ideation, at some
tributable to adolescence per se and specific risky behav- point during the teen years (Steinberg, 1983), and about
iors or attitudes that need intervention. Experimentation 15% of teens meet criteria for a depression diagnosis
with drugs and alcohol, increasing sexual activity (often (Evans et al, 2005). Most of these teens improve with
with multiple partners), and a strong, perhaps exclu- time and maturation, but all deserve evaluation and
sive sphere of peer influence all foretell potential serious intervention.
problems and may lead to significant psychosocial set- The most intensive research efforts in this area have
backs in a teenager. been focused on juvenile delinquency and its related be-
As the child proceeds from the early adolescent to havioral manifestations of criminal behavior and sub-
the mid and late adolescent phases, understanding how stance abuse. This focus is understandable in light of the
his or her individual development can be facilitated or fact that conduct disorder is the most prevalent psychi-
derailed is crucial to early detection and intervention in atric diagnosis seen in clinical settings that treat teenag-
teenagers lives. As we have seen earlier, the complex ers (although anxiety and depressive disorders are more
interplay among the different but equally important prevalent in the general population). Perhaps a reassur-
domains of developmentcognitive, emotional, social, ing finding from this body of work is that approximately
moral, and emergence of selfcan be daunting for 80% of adolescents cannot be formally labeled as of-
the clinician to sort out. Imagine what it must be like fenders (i.e., defined as being apprehended and found
for the adolescent! Significant disruption in any one or guilty of a crime), although many of this group have and
more of these areas can lead to psychological disorders do engage in illegal behavior, strictly defined. One large,
or serious issues of maladjustment during adolescence influential study of offending youth concluded that ado-
and beyond. lescent risk-taking was overly characterized as danger-
Our fundamental view of the adolescent period is as ous by adults, but that the more germane issues for teens
an important developmental transition characterized by involved increasing drug and alcohol use, problems as-
predictable change and overall stability in most young- sociated with the dyad of heightened emotionality and
sters, rather than a time of unmanageable or overwhelm- impulsivity (i.e., anger/violence, suicidality), and antiso-
ing storm and stress. When adolescent development cial behavior that fell considerably short of criminality
goes much awry in a young individuals life, it typically (Offer and Boxer, 1991).
is due to the presence of one or more well-known factors A high percentage of juvenile offenders, 80% (Kazdin,
known to put all humans at increased risk for psycho- 2000), also meet criteria for one or more psychiatric
logical disorders, including (1) the powerful and insidi- diagnoses. Various studies suggest that 50% to 60% of
ous effects of poverty, which clearly affect minority and juvenile offenders can be diagnosed with conduct dis-
urban families at higher rates (especially as related to order, followed by substance abuse (25% to 50%) and
parenting practices, academic achievement, and overall affective disorders (30% to 75%) (Grisso, 1998). Most
quality of the community milieu); (2) the overall level of juvenile offenders do not continue such behavior as
family cohesion during and preceding the adolescent pe- adults (Grisso, 1998). There is evidence, however, that
riod; and (3) the influence of genetic history and biologic psychiatric issues continue in such youths as they enter
vulnerabilities during adolescence. the young adult years.
Adolescence can be a time of heightened psycho-
social vulnerability, but the onset of behavioral, emo- RISKY BEHAVIORS
tional, and psychiatric problems in adolescents is more
typically heralded by preexisting issues or problems The most common risky behaviors in youth are likely
that can be seen brewing during the early and pread- to be related to premature sexual activity, alcohol use,
olescent years. Adolescence does not occur de novo; and poor impulse control in the operation of motor
it flows from infancy and childhood. These early prob- vehicles. Similar to Johnny P. in the opening vignette,
lems, often magnified during adolescence and so more most teens who engage in risky behaviors remain un-
easily discerned, can be traced directly to family histories known to police or judicial authorities (similar to their
Chapter 6 Adolescence 71

risk-taking elders), but are more likely to come to the at-


Table 6-3. HEADSS Interview Instrument
tention of parents, teachers, and often medical providers.
Much less likely to be identified, although equally at risk, H Home Who lives with the teen? Own room?
are the more prevalent number of youth with depressive What are relationships like at home?
and anxiety-based problems who are not or cannot be How often has the family moved?
Who does the teen turn to if
seen as conduct-disordered by the society at large. The problems?
fact remains that adolescents with psychiatric disorders What happens if parents are angry?
are much more likely than normal adolescents to engage E Education/ What grade is the teen in? School
in risky behaviors with some frequency over longer dura- Employment grades?
Favorite subjects? Best subjects?
tion (Flaherty, 1997), so screening for psychiatric issues Worst?
often addresses both problem areas at once. Any failures? Repeated classes?
Teens engage in risky behaviors at alarming rates. Truancy? Does the teen feel safe
It has been estimated that 12% of adolescents engage at school?
in heavy smoking, 15% engage in heavy drinking, 5% Who does the teen turn to if
problems?
engage in frequent marijuana use, and 3% engage in Future goals or ambitions?
frequent use of cocaine (Dryfoos, 1990). More recent A Activities What does the teen do for fun?
studies in the United States and abroad suggest that some Who are the teens peers?
of these risky teen behaviors are dramatically increasing Any organized sports? Clubs?
Any hobbies? Church attendance?
(Aggleton et al, 2000). Mean alcohol consumption by What does the teen do with peers?
teens, ages 11 through 15 years, was estimated to in- With family? Does teen have a car?
crease 50% in Great Britain during a 10-year period in Does teen use seatbelts?
the 1990s. Similarly, behavioral epidemiology has identi- D Drugs Used by peers? Used by teen?
fied illicit drug and alcohol use and teen sexual activity Alcohol? Cigarettes? Marijuana?
How much? When? Where? With
and its consequences as the key morbidities in the U.S. whom?
adolescent population (Friedman et al, 1998). Although Use by family members?
teen birth rates have consistently decreased since the early Source? How paid for?
1990s, the United States still has the highest teen birth S Sexuality Orientation? Sexual experience?
Number of partners? Masturbation?
rates of all developed countries, and sexually transmit- History of pregnancy or abortion?
ted infection rates have not decreased at all in that time History of STIs? Contraception?
period and may have increased (Child Trends, 2005). Type?
History of physical or sexual abuse?
S Suicide/ Sleep disorders? Fatigue? Appetite
ADOLESCENT CLINICAL SIGNS AND SYMPTOMS Depression changes?
Feeling of hopelessness? Isolation?
How we approach the clinical evaluation of youth at risk Boredom?
can vary widely from setting to setting. Some providers Withdrawn? History of past suicide
now use screening techniques shown to be more accu- attempts?
History of family suicides?
rate in identifying the full range of behavioral and emo- History of recurrent accidents?
tional symptoms, and which place the individual childs Decreased affect?
symptoms in direct comparison with large samples of Preoccupation with death? Suicidal
comparable youth (i.e., standardized norm-referenced ideation?
checklists, questionnaires, and structured interviews Adapted from Headss for Adolescents.
where possible). These techniques have the advantage Available at http://chipts.ucla.edu/assessment/Assessment_Instruments/
of saving time for busy practitioners, are usually more Assessment_pdf_New/Assess_headss_pdf.pdf. Accessed August 26, 2008.
thorough during the initial evaluation phase, and pro-
vide a baseline for monitoring change over time, but are
useful only in settings that are conducive to such ques- used psychosocial interview tool that many clinicians
tionnaires, such as middle-class practices that have find helpful is HEADSS (Table 6-3), which has been
English-speaking patients and parents. A good example used successfully in many clinical settings (Cohen et al,
of a screening questionnaire approach for teens is the 1991). Essentially all of these methods have the same
BASC (Behavior Assessment System for Children, Sec- goal: to identify and list the range of behavioral, emo-
ond Edition), a general approach to measuring symp- tional, and social symptoms for any given adolescent
toms and strengths in children and adolescents (Reynolds seen in a clinical setting and to gauge the severity of the
and Kamphaus, 2004). Similarly, the Beck Depression presenting problems.
Inventory for Adolescents (Beck, 1996) is an example
of a disorder-specific instrument that can be adminis-
tered and scored in the primary care setting. There are TREATMENT OVERVIEW: HELPING TODAYS
now many screening instruments to choose from, and TEENS AND TOMORROWS ADULTS
questionnaires for a wide range of specific adolescent
disorders or behaviors can be used. Ideally, there should be effective, comprehensive, pre-
The reality is that most health care and mental health vention programs in place to help at-risk teens avoid
providers use unstructured interview techniques to harmful behavior. The cost and limitations in ability
evaluate and diagnose most adolescents. A commonly to penetrate the most at-risk teen populations before
72 Part I LIFE STAGES

problems occur have hampered these efforts, however. abuse seems to be a problem that has a substantial ba-
Proactive, community-based interventions are more sis within the common adolescent experience in many
powerful than individually focused interventions, such Western cultures today.
as traditional psychotherapy, for adolescents. Because This discussion of substance use/abuse, one of the
of logistical constraints on, and political resistance to, most common and vexing risky behaviors that clearly
major overhaul of health care delivery to teens, public emerges during the teen years, provides a segue into some
health attempts to make significant strides in prevention final comments. First, this chapter has been focused on
of social and psychiatric disorders in adolescence have the period of development identified as adolescence, but
been far less than successful. Only about half of all high we must not forget that each developmental epoch is a
schools in the United States offer on-site mental health function, to a degree, of what has come before. Many
services. Despite this, it has been estimated that 70% aspects of mature adult outcomes can be traced directly
to 80% of teens who receive any mental health services back to the adolescent years. Good adult outcomes and
are seen in such school-based clinical settings (Burns bad outcomes have a basis in periods of individual for-
et al, 1995). This leaves a very large proportion of trou- mation in childhood and adolescence. School or work
bled youth who receive no professional mental health failure, substance abuse, relationship disasters, and ul-
attention at all. Many critics of our current programs timately the individuals sense of self and satisfaction
for youth have called for a major overhaul in the way derive partly and importantly from the history that
mental health services are provided to American youth, precedes the here and now. As adolescence comes to
starting with a merging of educational and health-related a closechronologically in the early 20s, although de-
services, and the funding that drives both. velopmentally the actual end point is much more open-
Psychopharmacologic interventions for troubled ado- endedthe distinctions between immature and mature,
lescents, although clearly often effective and important between teenager and adult, become merged and diffi-
treatments, have increased exponentially during the past cult to discern. As in all clinical and educational work
20 years (see Chapter 90). This sudden surge in use of with youth, our attempts to promote the well-being of
medicationsparticularly the burgeoning use of stimu- children and teens also represent a contribution to help-
lant medications for attention-deficit and disruptive be- ing the adults that teens soon become.
havior disorders, and the expanding range and volume
of antidepressant medications prescribed to American ADOLESCENTS AS PARENTS
teenagershas given rise to intense social critique
and revised federal guidelines regarding psychotropic Although adolescent pregnancy and birth rates have de-
medication and youth. Although psychopharmacologic creased immensely over the last 15 years (Child Trends,
agents have a valuable place in the armamentarium of 2005), most teenagers who give birth choose to keep
health care providers who help adolescents, they must their infants and do not give them up for adoption
not replace broader social, educational, and mental (Donnelly and Voydanoff, 1991). The clinician may care
health interventions for teens. Medical and public health for two patients, the young mother and the infant, and
models that overly rely on the use of psychopharmaco- both are at risk for certain problems. Teen parents often
logic interventions typically miss the point of much of come from home situations that have a high incidence
the social research concerning troubled youth over the of poverty, violence, drug use, and pregnancy at a young
past 50 to 60 years. age. In addition, these adolescent girls have a higher
Identification and treatment of adolescents with sub- than average history of learning problems and school
stance abuse problems has overlap with internalizing dropout (East and Felice, 1996), and some experience
and externalizing psychological symptoms and merits postpartum depression (Barnet et al, 1995). These is-
special attention in health care or school settings that see sues alone may make their own adolescent development
teenagers (see Chapter 45). Substance use/abuse rates in stunted, and the added responsibility of raising a child
U.S. teens have been relatively stable since 1996, with may lead to additional problems for themselves and their
minor decreases in some drug types and increases in oth- infants. Children born to teen mothers are at increased
ers (Johnston et al, 2006). Alcohol abuse, in particular, risk for behavioral, social, and learning problems (East
has been described as increasing alarmingly in college- and Felice, 1990, 1994) and for continuing the cycle of
age youth in the last decade. One popular psychological teen parenting. One cannot presume, however, that all
view has proposed that substance use/abuse is a form of adolescent mothers do poorly because some teen moth-
self-medication for troubled teens (and adults) who, ers do very well (Horwitz et al, 1991). Health care pro-
for whatever reason, perceive no other treatment options viders who are in the unique role of caring for a teen
readily available to them. Many adolescents and young mother and her child should be certain to address the
adults begin to engage in substance abuse behaviors psychosocial problems of both youngsters and take the
largely because of peer and perhaps larger societal pres- time to help the teenaged parent develop the parenting
sures or influences to do so (e.g., the smoking is cool skills necessary to care for her child.
advertising campaigns of the 1950s and 1960s; the
current symbiotic relationship between televised sport- SUMMARY
ing events in the United States and the consumption of
beer). The growing number of young individuals with Adolescence is a developmental period between child-
various addictions is not simply a product of individual hood and adulthood marked by quantum leaps in physi-
psychological processes or problems. Rather, substance cal, psychological, social, cognitive, and moral growth.
Chapter 6 Adolescence 73

Although this developmental period transcends about Erikson EH: Identity, Youth and Crisis. New York, WW Norton,
one decade of life, it is often viewed as three distinct 1968.
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