Why is it important for a adolescent
health clinicians to know the basics
about adolescent development?
They are frequently asked the question by
parents, Is this normal or a sign of pathology?
(e.g. moodiness, withdrawal, rebelliousness,
defiance, irrationality, argumentativeness)
They can be faced with teen emotions while
interviewing adolescent patients that impede
diagnosis and treatment.
Why is it important for a clinicians to
know the basics about adolescent
development?
They may experience personal reactions that hinder effective
medical transactions if they dont understand the dynamics of
adolescent development.
My 15 year old son
My 15 year old son, Randy, is rude, wont talk at dinner, wants to just
hang out in his room, wont share any information with us, cares more
about his electronics than anything, becomes irrational when we
confront him, hogs the bathroom, is highly emotionally reactive, and
has lied, snuck out and drank alcohol at a party and violated our
internet rules.
A website on drug abuse cited these warning signs:
withdrawal
moodiness
increased family conflict
argumentativeness
over-reactivity to criticism
sloppiness in appearance
spending time isolating in room
poor attitude
disrespect
loss of interest in family activities.
Does my son have a drug abuse problem?
Adolescent Psychological
Development
Physical development
Cognitive development
Social development
Identity development
Moral development
Physical development
Pubertal development
Bodily changes resulting in increased selfconsciousness, preoccupation and questions
of Am I normal?
Alterations in sleep (and less!)
Sexual interests and changes in social
responses
Sexual identity development
Cognitive Development
(historical review)
Shift from concrete to formal operations, allowing
for greater abstract thinking skills, symbolic
reasoning and hypothetical analysis (Jean Piaget)
Cognitive style is characterized by egocentricism
magical thinking; imaginary audience; myth
of immunity; and personal fable (Elkind)
And then the game-changer~ Brain
imaging research
Emotion Brain-(limbic system)
Amygdala-fear and anxiety center (fight,
flight, flood)
(this is an amygdala
hijack in action)
Also hypocampus, ventral striatum,
hypothalamus, nucleus accumbens
Brain Maturation
Recent research shows that much of which has
been attributed to hormones is probably related
also to changes in brain structure (Giedd, 1999).
The prefrontal cortex (CEO) of the adolescent
(~13yo) becomes pruned, sloughing off up to 40%
of its neural branches, as it grows new
neural connections for more
sophisticated functioning.
Greater refinements in neural connectivity and
extensive myelination continue through
adolescence; the brain does not fully mature until
the early 20s.
Teen Brain
NASCAR
Metaphor
Big enginematuring bodies,
independence-striving
Poor Driverimmature PFC and judgment
Faulty Brake systemimmature
inhibitory mechanisms in PFC
High octane fuelhormones
Put
simply
During adolescence, behavior is often
more governed by the emotional centers
than the thinking centers of the brain,
especially during high arousal situations
and in peer presence.
Adolescence:
Storm and stress theory
Adolescent difficulties are neither inevitable or
universal
Research on large populations of adolescents
indicates that teens experience more rapid mood
changes but no more depression/anxiety/pathology
than adult samples (Csikszentmihalyi & Larson)
Surveys reveal that most adolescents describe
themselves as mostly happy and are adequately
adjusted (Offer)
Developmental research qualifiers:
Marked changes in moodiness, emotional reactivity and
risk-taking among adolescents are neither universal or
inevitable (cultural and class differences exist)
Although gender, culture and age differences among
adolescents can be important, temperament is a powerful
predictor of behavior
Discussions with parents about their interpretations
regarding their teens behavior is tricky terrain
What is interpreted as normal depends on the clinicians
psychosocial assessment, sophistication of knowledge
about adolescence and personal filters.
Neuroendocrine system changes
Testosterone in boys can increase by 100% by the
end of puberty, and 20 X more than girls of same
age.
Amygdala has receptors for testosterone, which
probably contributes to increased novelty seeking,
territoriality and exploration for stimulation.
Hormones have impact on neurotransmitters,
moods and symptoms: norepinephrine (energizer);
dopamine (pleasure); and serotonin (mood
stabilization, relaxation, confidence)
Sensitivity of the teen brain to
substances
Alcohol stimulates the release of dopamine during the
sensitive period of adolescence, decreasing the natural
production.
Heavy alcohol use interferes with memory and glutamate
functioning.
Nicotine stimulates dopamine supply and affects other
neurotransmitters, allowing rapid addiction.
Dopamine squirts result from computer games,
stimulating media, gambling and other high arousal
pursuits.
Changes in circadian rhythms alter alert-fatigue signals,
affecting memory and biorhythms
In sum, the impact of brain changes on
adolescent reasoning, behavior and mood:
Decision-making models dont apply in high arousal
situations ( cold logic, as compared to hot arousal
situations)
Impulse control reduction
Poor risk assessment
Executive functioning impairment
Desire to escape boredom and negative affect by revving
up and seeking stimulation
Parental disciplinary efforts at times of high arousal can
result in explosive conflict
Social Development
Desire for increased independence
Preference for spending time with peers, orienting
increasingly to peers for social influence and
values clarification
Most teens are more attached to their parents,
but they prefer the company of their friends
Individuation from the family
Cultural context plays a large role in determining
diverse paths within these developmental and
universal trajectories.
Ethnic Diversity
Developing a strong ethnic identity contributes to
high self-esteem among ethnic minority
adolescents (Carlson et al, 2000).
Parents and role models are key for establishing
pride in shared values, traditions and practices of a
cultural group.
Adolescence may be the first time they reflect on
the implications of their group identification.
Identity development
Erik Eriksons major task of adolescence was
constructed as identity v. role confusion (Who
am I uniquely?)
Researchers have documented how teens explore
beliefs with various levels of crisis and
commitment (e.g. religion, politics, sexuality,
educational and vocational choices).
By their twenties, they will have an integrated set
of values reflecting their experiences and parental,
generational and cultural influences.
Moral development theories focus on moral
reasoning (highly dependent on environment and
cognitive maturity)
Lawrence Kohlbergs theory demonstrates that
adolescents moral reasoning reflects a maturing
value on the rights of others, the importance of law
and justice and universal principles.
Carol Gilligan pioneered the special value that
females place on responsibility and the caring of
others for moral reasoning.
Jonathan Haidt and others emphasize that moral
reasoning doesnt necessarily dictate moral action.
Kohlbergs stages of moral reasoning
Level 1
1.
Obedience and punishment orientation (How do I avoid punishment?)
2.
Self interest orientation (Whats in it for me?)
Level 2
3.
Interpersonal conformity orientation (Ill be good to you if you are good to
me)
4.
Authority and social order orientation
(Law and order morality)
* ***
Level 3
5. Social contract orientation
(What makes a society run smoothly; concepts of liberty,
justice, democratic principles)
6. Universal principles
(principled conscience, e.g. Golden Rule,
civil disobedience)
Adolescence as a period of
normal risk-taking and
behavioral experimentation
Adaptive identity development for most, but can
carry high risks and long term harm for others
Early adolescence as a time of particular
vulnerability (school failure, STDs, substance use)
Family cohesiveness and authoritative parenting
are significant predictors for successful and safe
adolescent outcome (Baumrind; Shedler and
Block; Blum)
Parenting strengths that predict optimal
adjustment in late adolescence
Close relationship to caring parent figure
Authoritative parenting: warmth, effective
communication, monitoring and structure.
Socioeconomic advantages
Connections to extended supportive family networks
Bonds to prosocial adults outside the family
Connections to prosocial organizations
Attending effective schools
My 15 year old son
Remember Randys warning signs:
withdrawal
moodiness
increased family conflict
argumentativeness
over-reactivity to criticism
sloppiness in appearance
spending time isolating in room
poor attitude
disrespect
loss of interest in family activities.
In the context of positive reports about functioning in family, school,
extracurricular activities, emotional/social life, Randy is likely
experiencing normal adolescent development.
Take homes
Remember your own teen vulnerabilitiesit will enhance
your empathy
Normal adolescent development is usually messyso
youll hear about messy behaviors and see them tooeven
when they are healthy!
A comprehensive teen, parent, and social system review is
the only way to evaluate many of the problems you are
consulted about (e.g. drugs, depression, etc).
Most morbidity and mortality among adolescents has
psychosocial/behavioral components, so focusing just on
medical issues is not an option.
Because teens are vulnerable, fascinating and challenging,
they can be among your most rewarding patients when you
connect with them in a genuine way!
A clinicians crash course in
adolescent development.
In summary,
Assess the big picture of a teens life
Appreciate that diversity includes many
domains
Find something in the teen to appreciate
Be curious
Remember your own vulnerable teen
moments
Be authentic, humble and sincere