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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years, secretive and withdrawn from the family, and more involved with his peer group, who are also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 Johnny’s 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 teen’s high-risk behaviors.

Adolescence is a transitional period between childhood Adolescence covers approximately one decade of
and adulthood marked by dramatic growth in physical, life—roughly 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 Mead’s 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 Shakespeare’s plays (i.e., Romeo and Juliet; A Winter’s 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.

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but some tasks may be more refers to psychosocial growth and development. this ambivalence is Anna Freud (1966) marked adolescence as a time of expressed as hostility or bravado. Table 6-1. By late adolescence. Regardless of when ado.  Psychosocial Growth Tasks For many parents. Relationships Unisexual peer group. 1982). They may find themselves retreating to been described in various ways by many authorities and the comfort of the family and the familiar. In this later stage of develop- ment. 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. Value system Decline in superego. just 4 years. other-oriented. occasional Sexual experimentation. 1992. p 66. and testing parental values. rigid concepts of right of moral system of parents and wrong. individuals Beginning of intimacy masturbation may be viewed as sex objects and caring 4. 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. opmental tasks commonly attributed to the adolescent Pubescence refers to physiologic changes. viewpoints. and siblings shortly Gradual Development as an Independent after a child experiences the onset of puberty (described subsequently). ­Adolescence tasks occur concomitantly. Sexual drives Sexual curiosity. Table 6-1 summarizes the devel- ably with the term pubescence. Carey WB. . others. They may be able to relate to a Transition from concrete to abstract conceptualization quotation attributed to Mark Twain: “At the age of 17. 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. 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. Parents need reassurance about the nor- stability mality of this process. The beginning of adolescence is easier to ­Individual pinpoint than the completion of adolescence. tasks in the three phases of ­adolescence. Philadelphia. Table 6-2. When I From Felice ME: Adolescence. can become angry with themselves for needing the com- ized adolescence largely in terms of identity formation. Integration of a value system applicable to life events I could not believe how little my father knew. parents as role models. realistic body image son or daughter that they perceived previously. Carey WB. Psy. pubescence heralds adolescence. many older adolescents are able to return to their parents and seek advice and counsel without feeling threatened or ashamed. how.  Growth Task Characteristics of the Three Phases of Adolescence Tasks Early: 10-13 Years Mid: 14-16 Years Late: ≥17 Years 1. p 69. Crocker AC (eds): Developmental-Behavioral Pediatrics. teens may be ambivalent about the separation process as they experience unfa- The psychosocial growth tasks of adolescence have miliar situations. Some indi. Blos (1967) wrote of adolescence as a second in unfamiliar situations.” 1992. These growth sexual maturity and reproductive capability. Erikson (1968) character. chosocial attributes of the adolescent years usually are first noticed by parents. This verbal jousting with parents is an attempt to establish inde- PSYCHOSOCIAL GROWTH TASKS pendence. but they are not the same. young lescence ends. WB Saunders. During early adolescence. fort of the family. 2nd ed. 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. Table 6-2 outlines the differences in the growth ever. Before adolescence. WB Saunders. 2nd ed. In Levine MD. the adolescent’s efforts at separa- of ­Adolescence tion are confusing and bewildering. These prominent in different phases of adolescence than in two processes are interrelated and intertwined. adult Begin heterosexual peer group. testing Self-centered Idealism. particularly age group (Felice and Friedman. Conceptualization Concrete thinking Fascinated by new capacity Ability to abstract for thinking 7. asceticism From Felice ME: Adolescence. and yet they from different perspectives. teachers. Independence Emotionally breaks from parents Ambivalence about separation Integration of independence and prefers friends to family issues 2. is able to formulate a distinct identity and develop the For many teens. struggles between a relatively strong id and a relatively older teens are comfortable being away from home and weak ego. In some families. Generally. Individual relationships more crushes multiple adult role models important than peer group 5. In mid adolescence. Career plans Vague and even unrealistic plans Emerging plans may still be vague Specific goals and specific steps to implement them 6. I could not believe how much he had learned in Developmental-Behavioral Pediatrics. Body image Adjustment to pubescent changes “Trying on” different images Integration of satisfying body to find real self image into personality 3. Chapter 6    Adolescence 63 The term adolescence is sometimes used interchange. Philadelphia. i­ndividuation process. Crocker AC (eds): was 21. In Levine MD.

derment. the ­future is and heterosexual teens. They also are aware bers of the same gender. They are growing in height and weight. Some gay adolescents may delay a serious issue. teens begin further such as college roommates. They worry that they may be developing too often intense sexual tension created by proximity to quickly or too slowly. religious beliefs. which in- They have body odor and blemishes. to care deeply for another person without the need for exploitation. These data may be obsolete in the next few years to support themselves financially and socially. ual intercourse. clude a peer group and other adults. issues are discussed with more depth. the peer group generally consists of mem- conscious of their body’s changes. For most young lia have enlarged. For because more teenagers are engaging in a phenomenon young teens. Although body image problems are not peer group to include heterosexual friendships. is common. most teenagers are experiencing puberty and learning to adjust to the dramatic changes Expansion of Relationships Outside the Home of pubescence. that is. but they may still be unrealistic. Teens in mid adolescence also sity. school.. at the same time at the same place every week. Some teenagers find the final career choice so During mid adolescence in both genders. and every adolescent needs reas. or sexual experimentation. Teens in mid adolescence give more thought which they have friendships solely for sex and not for to this problem.. parent of often money) trying to improve their faces and figures. such or not those concerns are expressed. as in previous generations. a friend. for many teenagers. A typi- romantic involvement. For many comfortable to them. Late adolescence is distinguished by the Body Image ability to be intimate. In late adolescence.g. For youths in late adolescence. Such parents need reassurance that this can be ies. this period marks the beginning adolescents who have severe acne. Adolescents must decide what they want to do as adults 2005). teachers. Friendships are often more intense. they turn to relationships outside the home. coaches) to with different clothing styles to find a self-image that is the company of their own devoted parents. adolescents. of previous years should be on the wane. a chronic illness. The superficiality coming comfortable with one’s sexuality is a major com. Early adolescence is friendship are particularly strong among youth who are mainly marked by sexual curiosity. and of major concern to most adolescents in their late teens. and clinicians should to escape from home or the opportunity to do something be sensitive to and aware of the needs of homosexual glamorous. most young parents. hairstyle. or even group rituals such as meeting cence. and this is an impetus for teens to “try on” dif- ferent styles and philosophies. breasts and genita. This is a common problem among seniors in high with their sexual orientation. In reality. Members of surance about his or her physical development whether the peer group conform to certain group standards. and they are often faced with hard deci- the onset of sexual activity as they emotionally grapple sions.” in ­unrealistic. there may be difficult that they avoid all decision making and sim- a tendency to view one’s sexual partner as an ­opportunity ply go along with decisions made for them by parents . or anorexia nervosa may continue to have body have a tendency to turn to adults outside the home as image issues that are ­unresolved. individual relationships gradually express and control these drives is a major and formi. 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. most teenagers have already experienced puberty. teacher. recent data indicate that about 50% of high school students report having had and Economic Stability at least one voluntary sexual experience (Child Trends. as dress. For youth adolescence than at any other time of life. In early adolescence. late bloomers) may continue to grow in height well into By mid adolescence. although some young men (particularly so-called normal behavior. they are sprouting hair where it did not grow before. military recruits. Teens are exposed to family structures. sports team members.64 Part I   LIFE STAGES Mental Evolvement of a Satisfying Realistic for social gain. another relative). 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. although not always full sex. teenagers often expand their their early 20s. most teenag- Sexual and aggressive drives may be stronger during ers return to the family fold as young adults. The bonds of ponent of adolescent development. common for young adolescents to develop friendships Young women and young men spend much time (and with adults outside the home (e. Teens may prefer the com- These improvements can take the form of experimenting pany of extrafamilial adults (i. and lifestyles different from their own Harnessing Appropriate Control and Expression family. assume more importance than the larger peer group dable task of the teenage years at a time when the young relationships. Be. Parents may find this of Sexual Drives situation confusing and hurtful. As adolescents move away emotionally from parents. and masturbation working toward a common goal for a common task. obe. Not cal 16-year-old may view a future job prospect as a way all adolescents are heterosexual.e. In mid adolescence. of dating patterns. Young adolescents are exquisitely self. Learning to in late adolescence. role models. It also is but they may not yet be comfortable with the results. this situation can cause hurt feelings and bewil- people have begun to be comfortable with their bod. the opposite sex (for heterosexual youth). By mid adoles. this is a vague concept and may even be known as “hooking up” or “friends with benefits. and person may seem to be ill-equipped to master them.

Chapter 6    Adolescence 65 or teachers. One could speculate that become fascinated with this newfound intellectual tool. is more likely to ashamed about their involvement. particularly in late adolescence. This self-serving behavior may be cognitive development is differentiated across the three frightening and provoke anxiety in the adolescent. Mid adolescence is marked by a narcissistic value sys- tem (i. This pion “justice” and “rightness. it is not un- spect to the developmental growth tasks. mid adolescence. 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. Although young teens are curious and fascinated cence when parents are not always present to tell teens with sexuality. If such teens are and does what he or she wants to do. but older teens often have a rigid value system that may limit their problem solving skills. yes or no. Growth in some tasks may influ- can be very interesting and avid conversationalists with ence growth in other areas. Issues are often viewed in terms have nothing to do with sexual intercourse. to parents’ directions and may promptly point these out to a beleaguered mother or father. Older adolescents been sexually active. may causes with much zeal. With re. 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. OF ADOLESCENT DEVELOPMENT tail. but under group an adolescent who struggles with this decision making pressure. As noted previously. there are clear usual for young teenagers to have “crushes” on adults differences between early. this has out of control. Clinical experience suggests that might never consider stealing hubcaps. Although a youth in late adolescence may cham- tion. the teenager may feel concretely with limited abilities for abstraction. sized more clearly in one developmental phase than in opment of late adolescents are many. This is a normal phenomenon for heterosexual is discussed in more detail later in this chapter. this partially explains the sexual exploitation described previously. and late adolescence. in mid adolescence engage in activities impulsively with cence and is described in more detail later in this chap. they are usually embarrassed and someone else wants him or her to do. it may not be wise to ask. they may feel forced to do so. tions. The “collective conscience” of have sexual intercourse. In outside the home. in terms of the described growth tasks. of hubcaps in response to a group dare or as a group tional price and end up resenting the adults who made activity. “Have are often very altruistic. A young adolescent thinks more there are no checks on impulses. such as unpro- ter. This pro- cess cannot occur in a vacuum. The social implications of the cognitive devel. individual teens the decisions for them.e. and some teens for opposing points of view. particularly in growth tasks concomitantly. and homosexual adolescents. of black and white with self-righteous indignation and ing. just sleep. image. little thought about the consequences.. achieve career satisfaction. adolescents at this tasks is necessary for healthy adulthood and emotional stage of development can now see a host of alternatives maturity. or to idealize them compared with early adolescence. but some tasks are empha- the arts. adolescents grapple with all seven ment may be quite remarkable at this age. it is not unusual for young teens to their all-too-familiar and imperfect parents. tected intercourse. a teen may feel the need to by sexual themes and innuendo.” there is little tolerance is a giant step in mental development. Creative achieve. “What is right is what makes me feel good”. most young teens have not yet begun to what is right and wrong. Progression through all the opinions on every issue. In addition. Teens in mid adolescence have a greater capacity for sometimes with self-imposed restrictions and prohibi- abstraction and are usually more capable of introspec. mid adolescents can think about thinking. In addition. In some instances. finds that there are suddenly more “gray” issues in life tributing to the self-centered behavior of teenagers in than black-and-white ones. If phases of adolescence. 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. To guard against this outcome. and they may embrace moral you ever slept with a boy?” The answer. Young adolescents are test the parent’s moral code. even though they may reside the peer group may be at odds with a teenager’s parental within a larger society seemingly obsessed and titillated standards. A clinical ­Conceptualization consequence of this type of thinking is that many teens Cognitive development is a key component of adoles. Briefly. who are usually members of the same Moral growth is a key concept to gaining maturity and gender. Transition from Concrete to Abstract “What is right is what I want”). If a of right and wrong. mid. Teenagers in late adolescence are often capable of stretching their mental faculties immensely. rather than what caught in this activity. so adolescents turn to to Life Events their peer group. the transition to adulthood occurs when an individual This aspect of adolescence may be another factor con. Under ordinary circumstances. Older adolescents others (see Table 6-2). 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. Eventually. As- clinician wishes to discover if a young teenage girl has ceticism and idealism are common. Solutions to CHARACTERISTICS OF THE THREE PHASES many problems are often thought through in great de. these teens may pay an emo. There may be some testing .

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. depending on genetic and cultural factors. LH stimulates ovarian develop a moral code. concerns about puberty. this age. such as acne. This planning is accompanied by high cally by darkening of the scrotal skin. Girls typically experience puberty about bility for abstraction. Growth hormone–releasing factor is re- expressed in their dress code or mannerisms and may leased in a pulsatile fashion during sleep. The release. however. surge. or significant other becomes a major search. In boys. first increasing and then decreasing. 2003). FSH stimulates follicle growth in the ovary course. They begin to think about think. It is puberty was described solely by the hormonal aspects of known.” to continue to grow taller into CHANGES their early 20s. further development of breasts. development in girls. The most dramatic changes of puberty usually occur in early adolescence. 1. becoming comfortable with In addition to the above-mentioned gonadotropins. 2004). another. that is. Previously. enlargement of idealism. tion of gonadotropin-releasing hormone during sleep.25-dihydroxyvitamin D. such as self-acceptance of their homo. development. and caring relationship with pubertal changes. Gay or les. an increase in height. Career plans usually begin to take some shape.66 Part I   LIFE STAGES of the parents’ value system as the teenager struggles to and the ­production of aromatase. in their environments. that puberty is associated with spe. This task includes the need to become other hormones are released during puberty. sexual identity. sis for reproductive maturation (Sisk and Foster. finding a partner ing of the voice. Early adolescence is marked by a thecal cells to produce androgens. as does thyroxine and the corticoste- tasks as heterosexual adolescents. 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. and this is also are characteristic. ad- ous alternatives. under separate control mecha- nisms. In changes in the gross morphology of the brain. The vol- males. but it is common for young men. and ac. their dating experiences may be delayed or influenced and calcitonin affect skeletal mineralization. Insulin-like change from week to week. view the process of puberty. particu- BIOLOGIC BASIS FOR MAJOR DEVELOPMENTAL larly “late bloomers. and lengthening of the penis between the ages newfound ability to think through problems with vari. but vary from one individual to the usual time of falling in love for the first time. particu- bian adolescents have the same developmental growth larly growth rate. but the timing of roids. Other favor of a close. a height spurt. Gray matter volume takes an inverted U-shaped In females. Parathyroid hormone. rigid concepts of right and wrong. 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. 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. Many teens in mid adolescence “try on” different is regulated by growth hormone–releasing factor and images in hopes of finding a “true” self. Teens in mid adolescence growth factor I (IGF-I or somatomedin C) and IGF-II generally begin heterosexual dating patterns. This increased production of adrenal This literature has led to an emphasis on a neuronal ba- androgens is followed by an increasing pulsatile secre. however. In this model. there has been a shift in how biologists child into an adult capable of reproduction. and the growth of chest hair in boys. 1962). a mid–menstrual 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. but is usually the development of breast buds between the may not be definite. A large body of lit- cific changes in the hypothalamic-pituitary-adrenal axis. one’s sexuality. puberty is signaled clini- sponsible adult. For many youngsters. and interaction of all of these hormones result in sexuality or perceived attitudes toward homosexuality the physical changes observed during adolescence. In addition. erature has developed. by other factors. intimate. increased myelination of cortical and subcortical fiber lar Sertoli cells to support the development of sperm. ages of 8 and 10 years. are produced by the liver and influence growth. this may be somatostatin. increasing levels of luteinizing hormone (LH) and to Human adolescent development involves widespread a lesser extent follicle-stimulating hormone (FSH). the process of act trigger that begins pubescence is unknown. Menarche signifies the end of pubertal career or how one will contribute to society as a re. deepen- another person. aromatase converts unisexual peer group. youth in late adolescence ditional enlargement of the genitalia. but rather as a brain event. signs of ­puberty. puberty as related to reproduction. a weight spurt. of 10 and 12 years. The start of pubic hair. The proliferation of pubic hair. and sexual cognitive functions expand with the capacity and capa. and the the testes. The first sign of puberty in girls ing. cells. Later in puberty. there is increased produc. The ex. axillary hair. 2 years earlier than boys. tuitary begins to secrete human growth hormone. The age of . LH stimulates the Leydig cells in the testes to ume of white matter increases linearly as a result of produce testosterone. The pi- comfortable with one’s body and with one’s body im. Hormonal Changes of Puberty Neurologic Maturational Changes The onset of puberty marks the metamorphosis of a In recent years. 1962). androgens to estrogens in the FSH-stimulated granulosa tive establishment of independence from parents. that has focused on the Sometime in late childhood. and later FSH stimulates testicu. tracts. the onset of puberty is viewed not as a ­Gonadotropin-releasing hormone secretion results in gonadal event.

More informa- matter) actually achieve the stage Piaget labeled formal tion is unfolding on a regular basis and is expected to operations.” a process and typically emerge as adults functioning well within that largely explains an adolescent’s continuous growth the range of normal.). Put rapid biologic growth and dramatically expanding life in simpler terms. 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. 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. ing block for successful human development during the Second. or the ability to “think about thoughts. Generally. and it should not on possible strategies. 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. 2. in cognitive skills and the ability to draw on a useful Pertinent to clinical work with teens. In contrast to a Piagetian view. The lack of a sense of self) appropriate stimulation in any of these life contexts. DEVELOPMENTAL DOMAINS More recently. 2005). 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. however. 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. by virtue of essary for the key tasks of adolescence cited earlier. His “stage” changes in gross morphology of gray matter have not theory of human cognitive development was a useful yet been determined. on tion of the adolescent brain is an exciting new topic that the assumption that all adolescents (or adults. 2005). The structural bases of adolescent by the work of the major theorist Piaget. . tion. be largely responsible for helping adolescents success- and various factors that can derail normal development. 2005). however. during adolescence. each domain represents a basic build- ­experiences. 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. during adolescence. perhaps to understand and help teenagers. This area of neuromatura- search in the last 20 years has cast doubt. 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. the formal operational stage Piaget described (Kuhn et al. theorists. cent’s thought processes gradually evolved further. in the mental capacities of adolescents. but many investigators interpret ­rubric for the study and understanding of how a child’s the adolescent reduction in gray matter volume as evi- burgeoning mental skills evolve over time from thought dence for synaptic pruning (Sisk and Zehr. review and reflect velopment or the environment itself. 2001). Chapter 6    Adolescence 67 peak gray matter thickness varies by gender. “How well can I think. Piaget also theorized that a young adoles- fundamental feature of adolescent brain development.. 1977). which go beyond tive-developmental functioning) numerical differences in measurable intelligence (i. fully counterbalance an array of conflicting thoughts These domains each represent essential ingredients nec- and emotions “new” to their experience. Developmental re- ment (Sisk and Zehr. a computational model of cognitive develop- second decade of life. 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. First is metacogni- awkwardly at first. 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. to solve problems mentally through steps from begin- Steroid-dependent organization of neural circuits is a ning to end. the effects of home milieu. these cess or failure of teens as they transition into adulthood. reason and decide?” (cogni. for that is being studied and debated in the field. what should occur in those domains. studies would argue that there is wide variation in in- Most teenagers do well in this transition. we attempt to examine and act to limit or stultify individual cognitive development discuss each of these topics in greater depth. The reality is that most teens manage to steer adolescents hold particular value for clinicians seeking successfully through the maze of adolescence. social development) and general life experience should combine to strengthen 3. and do I like who I am?” (emergence of an adolescent’s increasing mental capacities. might sur- Two concepts regarding cognitive development in mise. and many contemporary parents.e. then more skillfully as they mature.Q. The adolescent dividual capacity to “think” and “process” information years can be a time of elevated emotional vulnerability. while navigating through the a teenager. and eventually solve or resolve be categorized simplistically as just a symptom of being the tasks of everyday life. “Who am I. occurring Cognitive-Developmental Functioning 1 year earlier in girls than in boys and correlating with Before the 1980s. “How well do I interact with others?” (moral and I. also can In the following sections. schooling. Metacognitive processes are thought to opmental domains. 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. or the presence of considerable stress or trauma. as early developmental and the accrual of environmental experience.

Ado. debate continues regarding the relative weight parental only personality differences seem to explain the wide versus peer influence wields on adolescent moral and so. Emergence of Self tive. Verbal. this journey of self-discovery to be reviewed here.” age girls in recent years. and societal/community values. and spatial abilities increase.68 Part I   LIFE STAGES According to the information-processing perspec. States in which gay and lesbian couples are not wel- lescents who do not fare well are the ones health care comed. dysfunctional social relations. but dramatic improvements evolve in the specific the adolescent years is simply due to the fact the issues mental abilities that underlie intelligence. 2006). 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. Too much has been written about their store of knowledge increases (Feldman. cent development in all of its facets. we would expect far fewer problems arising causation. general intelligence remains stable during adoles- One reason psychological issues seem so dramatic during cence. 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. their abstract and hypothetical internal (“Who am I?”) and the external (“What is the thought grows. 1998. of “Industry versus Inferiority” during the preadoles- 1972). 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. sense of identity that derives from an emerging self- ory holds heuristic value for clinicians seeking to under. To this day. including teen. Much research is being done to understand adoles- drug and alcohol abuse. stand a young person’s moral transition from childhood In Eriksonian terms. especially parents. If all adolescents were equally able 1. the the. peer. 1963). ­adolescent development. 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. familial. Developmental cial ­behavior in general.” conventions that derive from an amalgam ality and self-appraisal. Kohlberg’s 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. Steinberg. it is clear that many people. and siblings. Teens who need help on body image and sexual identity acceptance. Self-esteem processes evolve from evaluation that From the 1960s through the late 1970s. there are many communities in varied. however. observed in teenagers. but in ­accepting of one’s body is a major component of competing and concerted ways (Harris. and meaning of life?”). In addition. teachers. often act or behave at odds with their capacity to of eating disorders that is pervasive among many teen- recognize “right from wrong. to a more realistic view during adoles- from poor decision making in teens and young adults. and antiso. chronic risk-taking. the broad variability in adolescent abilities perspectives and allows for multiple-factor causation to employ acquired knowledge and scientific reasoning of events. Biologic grows. Their social experiences appear rich and previous generations. Children generally evolve from a largely egocentric to manipulate easily abstract concepts related to every. but often extends into adult- 2001). memory capacity them. Cultural and societal norms have a major influ- moral development in clinical settings. Becoming comfortable with one’s sexuality and by parents and peers in comparable measure. and as well as adolescent girls to struggle with body image moral growth during adolescence. we find that most issues. is the ence in these areas of development. In beauty is a different cultural norm today than it was other words. A central problem in using Kohlberg’s theory of hood. appraisal based on past and current life experience. Much we would see heightened emotionality in most teens. with the bulk of empirical research tions and poor coping with strong emotions. and macrocultural influences. cence and adulthood that takes into account others’ Similarly. and adolescents are more adept at dividing their and cognitive changes give rise to a re-definition of the attention. 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.” to a more coalesced adolescent social decision making. supporting the view that most adolescents are affected 3. however. It is not unusual for women As we learn more about social. Moral and Social Development in Adolescence 2. Although it is a given that of parental. (Erikson. view of themselves. theory and research seeks to help understand how it is . range in variation adolescents show in negative emo- cial decision making. A growing awareness of other people’s helps to explain the real-life differences in achievement perceptions can be a double-edged sword. 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. in terms of worldview and event day life. in previous centuries and may be influencing the wave agers. and there are many areas of the United personal. heightening the adolescent’s fears of being scrutinized and judged by peers or adults. the child moves from the task through the adolescent years (Kohlberg and Gilligan. These external factors have a strong influence providers and others seek to help. in these areas are often those who have poor academic or work achievement. they know more about the world. emotional. math- are new to the experience of the teens and those around ematical.

His. Chapter 6    Adolescence 69 that adolescents come to think about their internal and tend to perform at lower levels. For example. these laws allow adolescents to be seen for schools. 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. receive lower grades. 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. are educated Studies of academic achievement in the United States about adolescents’ rights to confidentiality and the site’s are illustrative of how the risks of ethnic origins are expectations as to how adolescents should be treated. When asking about sexu- ment issues. of dysfunction in the general population of teens and Second. there are commonly accepted guidelines for suc- development have involved only samples of European. edge or consent. middle. parents living in poverty are prescribing of contraceptives without parental knowl- less likely to be involved in their children’s schooling. 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. American. do you find yourself having sexual thoughts panic. adolescent clinics. “Everyone has sexual thoughts and feelings sometimes. 2001). whereas the number of Asian/Pacific-Islander. most parents understand the explanation . In and health. and their emerging sense students. As with other areas of psychosocial and clinics. the clinician of white youth). Community-based development. Developmental theory and research helps clinicians to see how adolescents come to hold values. 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. social relationships. fewer places to do homework. external world. CLINICAL IMPLICATIONS temporary chapter on adolescence. and person who answered the phone. Clinical sites should ensure (National Association of Social Workers. is not unusual to find out that adolescents are reluctant to use a certain facility not because of the clinician. 2004). but On average. heterosexual youth. mental health problems vary by ethnic group. 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. there are magazines appropriate for teens. 1999). First. and disorders” also may exist. including the frontline staff. In addition. adolescents from about the teen’s activities. ity. 59%. and school-based health clinics. public health ority for all. The sheer numbers of teens found within ality. With you. 2001). and Some research has suggested that “culture-bound attitudes that serve to guide their adult behavior. complete more years of schooling than students from Fourth. For example. Regardless of the medical research. It largely mediated by socioeconomic status (SES). of selves as individuals in a crowded world of others. crowded conditions. 2001). 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. tions may be less threatening. that all staff. 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. African American and Hispanic students these efforts. 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. all clinical sites should be familiar with the lower-SES homes. there are posed of ethnic minorities (Hagen et al. adolescents should be told about confidential- and Delinquency Prevention. Several environmental factors ex. teens judged at elevated risk for psychiatric and health there are chairs big enough for teens in the waiting room. 2000). Although some parents may question On average. most studies of normal adolescent settings. and African-American adolescents will increase about sex with boys or girls or both?” by 75%. and these youth would be overrepre. Changes in the ethnic makeup of American youth dur- ing the past 20 years merit special attention in any con. and how they make meaning of their and score lower on achievement tests. cessful interactions and interventions with teens. drugs or sexuality. attending inadequate most states. and that attitudes toward how all these factors help to set the stage for the discov. At the same time. studies of the setting must be welcoming to the teen. In contrast. a lack of books the treatment of sexually transmitted infections or the and computers. When asking about health disorders and stressful life events increases dra. adolescents and parents must be interviewed overstate the case that most problems occur in “high. problems often contain samples almost exclusively com. score higher on achievement tests.and high-SES students earn because of an unpleasant experience they had with the higher grades. This is one way that the ques- all social classes seem to be at elevated risk for adjust. separately so that the clinician can take a history con- risk” youth in largely urban and poor communities. 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. than Caucasian emotions. achievement differences diminish (Feldman. When socioeconomic status is controlled for. cerning sexuality or drugs or both without the teenager Although it is clear that the risk-likelihood for mental being afraid to answer truthfully. vate physician offices. beliefs. and 19% (Office of Juvenile Justice Third. 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.

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

A commonly to penetrate the most at-risk teen populations before . 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. 1997). Mean alcohol consumption by What does the teen do with peers? teens. 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. 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.S. Truancy? Does the teen feel safe It has been estimated that 12% of adolescents engage at school? in heavy smoking. ­attempts? History of family suicides? rate in identifying the full range of behavioral and emo. There are TREATMENT OVERVIEW: HELPING TODAY’S now many screening instruments to choose from. Similarly. 2005). such as middle-class practices that have find helpful is HEADSS (Table 6-3). Much less likely to be identified. and often medical providers.ucla. and which place the individual child’s ­Decreased affect? symptoms in direct comparison with large samples of Preoccupation with death? Suicidal comparable youth (i. 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. are usually more Assessment_pdf_New/Assess_headss_pdf. The cost and limitations in ability evaluate and diagnose most adolescents. whom? adolescent population (Friedman et al. Accessed August 26. Any failures? Repeated classes? Teens engage in risky behaviors at alarming rates. Employment grades? Favorite subjects? Best subjects? tion (Flaherty. of a screening questionnaire approach for teens is the 1991). tional. ages 11 through 15 years. Chapter 6    Adolescence 71 risk-­taking elders). although equally at risk. 1996) is an example of a disorder-specific instrument that can be adminis- tered and scored in the primary care setting. but are more likely to come to the at- Table 6-3. 2008. 1998). and TEENS AND TOMORROW’S ADULTS questionnaires for a wide range of specific adolescent disorders or behaviors can be used. More recent A Activities What does the teen do for fun? studies in the United States and abroad suggest that some Who are the teen’s peers? of these risky teen behaviors are dramatically increasing Any organized sports? Clubs? Any hobbies? Church attendance? (­Aggleton et al. was estimated to in.edu/assessment/Assessment_Instruments/ of saving time for busy practitioners. goal: to identify and list the range of behavioral. but are useful only in settings that are conducive to such ques. History of recurrent accidents? tional symptoms. behavioral epidemiology has identi.e. and structured interviews Adapted from Headss for Adolescents. A good example used successfully in many clinical settings (Cohen et al. standardized norm-referenced ideation? checklists. Although Use by family members? teen birth rates have consistently decreased since the early Source? How paid for? 1990s. and 3% engage in Future goals or ambitions? frequent use of cocaine (Dryfoos.pdf. which has been ­English-speaking patients and parents. Inventory for Adolescents (Beck. teachers. the United States still has the highest teen birth S Sexuality Orientation? Sexual experience? Number of partners? Masturbation? rates of all developed countries. emo- ond Edition). With family? Does teen have a car? crease 50% in Great Britain during a 10-year period in Does teen use seatbelts? the 1990s. a general approach to measuring symp. 2000). questionnaires. and pro- vide a baseline for monitoring change over time. comprehensive. the Beck Depression presenting problems. Ideally. Essentially all of these methods have the same BASC (Behavior Assessment System for Children. so screening for psychiatric issues Worst? often addresses both problem areas at once. 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. where possible). Similarly. These techniques have the advantage Available at http://chipts. and sexually transmit. Sec. 5% Who does the teen turn to if ­problems? engage in frequent marijuana use.  HEADSS Interview Instrument tention of parents. 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. there should be effective.. thorough during the initial evaluation phase. Some providers Withdrawn? History of past suicide now use screening techniques shown to be more accu. 2004). 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. used psychosocial interview tool that many clinicians tionnaires. 15% engage in heavy drinking. 1990).

social. velopmentally the actual end point is much more open- Psychopharmacologic interventions for troubled ado.72 Part I   LIFE STAGES problems occur have hampered these efforts. agents have a valuable place in the armamentarium of 2005). 1991). the “smoking is cool” skills necessary to care for her child. First. Alcohol abuse. and the added responsibility of raising a child U. 1995). Although psychopharmacologic creased immensely over the last 15 years (Child Trends. however. but been far less than successful. children and teens also represent a contribution to help- lant medications for attention-deficit and disruptive be. risk for behavioral. although clearly often effective and important between teenager and adult. 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. SUMMARY ing events in the United States and the consumption of beer). and Felice. and political resistance to. 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. age. psychological. our attempts to promote the well-being of medications—particularly the burgeoning use of stimu. as traditional psychotherapy. ended—the distinctions between immature and mature. although de- services. The clinician may care health interventions for teens. Many services. Substance use/abuse rates in stunted. Children born to teen mothers are at increased ers (Johnston et al. Because This discussion of substance use/abuse. 1995). with may lead to additional problems for themselves and their minor decreases in some drug types and increases in oth. teens have been relatively stable since 1996. such Western cultures today. and ul- attention at all. time to help the teenaged parent develop the parenting sures or influences to do so (e. 1991). abuse seems to be a problem that has a substantial ba- Proactive. have increased exponentially during the past cult to discern. ers do very well (Horwitz et al. educational. 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. community-based interventions are more sis within the common adolescent experience in many powerful than individually focused interventions. the current symbiotic relationship between televised sport. public emerges during the teen years. and the expanding range and volume of antidepressant medications prescribed to ­ American ADOLESCENTS AS PARENTS teenagers—has given rise to intense social critique and revised federal guidelines regarding psychotropic Although adolescent pregnancy and birth rates have de- medication and youth. 1994) and for continuing the cycle of age youth in the last decade. One cannot presume. most teenagers who give birth choose to keep health care providers who help adolescents.” As adolescence comes to starting with a merging of educational and health-­related a close—chronologically in the early 20s. violence. than average history of learning problems and school stance abuse problems has overlap with internalizing dropout (East and Felice. to a degree. and models that overly rely on the use of psychopharmaco. Many critics of our current programs timately the individual’s 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. In addition. and moral growth. . the young mother and the infant. Rather.S. infants. One popular psychological teen parenting. 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.g. mation in childhood and adolescence.. social. havior disorders. and pregnancy at a young past 50 to 60 years. cognitive. Medical and public health for two patients. 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. substance abuse. provides a segue into some health attempts to make significant strides in prevention final comments. drug use. advertising campaigns of the 1950s and 1960s. most common and vexing “risky behaviors” that clearly major overhaul of health care delivery to teens. perceive no other treatment options viders who are in the unique role of caring for a teen readily available to them. both are at risk for certain problems. lescents. This sudden surge in use of with youth. in particular. 1990. become merged and diffi- treatments. 2006). 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. they must their infants and do not give them up for adoption not replace broader social. one of the of logistical constraints on. Despite this. precedes the “here and now. and some experience and externalizing psychological symptoms and merits postpartum depression (Barnet et al. ing the adults that teens soon become. Health care pro- for whatever reason. As in all clinical and educational work 20 years (see Chapter 90). School or work bled youth who receive no professional mental health failure. and mental (­Donnelly and Voydanoff. this chapter has been focused on of social and psychiatric disorders in adolescence have the period of development identified as adolescence. This leaves a very large proportion of trou. substance cal. 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. 1996). these adolescent girls have a higher Identification and treatment of adolescents with sub. These is- special attention in health care or school settings that see sues alone may make their own adolescent development teenagers (see Chapter 45). of what has come before. however. and the funding that drives both. relationship disasters. and learning problems (East has been described as increasing alarmingly in college. for adolescents.

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