Adolescent Psychological Development

After reading this article, readers should be able to: Adolescent patients present a unique set of challenges to pediatricians. A polite, compliant child can appear to transform into a surly, rebellious teen before a doctor's eyes. Adolescence can be a tumultuous time, even when it is unfolding in a healthy manner. For this reason, and because there is so much individual variation in adolescent development, it can be particularly challenging to determine what is “normal” in adolescent development. Although previously believed to be uniformly a time of turmoil, this view has not been substantiated by large-scale studies. (1) Most teenagers progress through this period of life with few obvious behavioral problems. However, a sound and trusting doctor-patient relationship is required to appreciate the inner struggles many adolescents endure. A working understanding of the developmental tasks of adolescence and the processes through which they are achieved provides the best tool for a pediatrician in evaluating an adolescent's development.Any discussion of adolescent development should include a definition of adolescence itself. Determining the exact onset and conclusion of adolescent development can be difficult, with complex biologic, psychological, and social paradigms all playing roles. Cultural factors also must be considered in determining the developmental norms of adolescence. Normal development from one cultural perspective may appear aberrant when viewed through the lens of another culture, and in an increasingly multicultural society, such considerations are especially important. For example, an Asian youth who begins to question his parents’ values may be viewed very differently by Western versus Eastern cultures. Although the West may view this move as a healthy and normal emotional development, the youth's parents might consider it to be pathologic and dangerous. Cultural differences such as this are generalizations, but keeping these potential differences in mind is extremely important to any clinical consideration of adolescent populations.Given individual and cultural variability, the most useful definition of adolescence is not by age norms but by the developmental tasks that are achieved during this stage (TableT1). Developmental processes often are separated into distinct domains, such as physical, cognitive, psychological, and moral development. Although this article follows the same approach, it is important to note that such domains are in constant flux, interact with each other, and do not occur in isolation. For example, the physical changes associated with puberty and their timing have a profound impact on the social and emotional functioning of the adolescent. In addition, the boundaries between developmental domains are not always distinct. For example, physical changes in the brain during adolescence correspond to the development of new cognitive capabilities that, in turn, are involved in shifts in emotional regulation and processing.From a biologic perspective, the beginning of adolescence is marked by the onset of puberty. The physical changes of puberty are triggered by increased pituitary sensitivity to gonadotropin-releasing hormone, leading to increased release of gonadal androgens and estrogens. Hormonal changes bring about a process of rapid physical changes in height, weight, body shape, and genital development.For girls in the United States, puberty typically begins between the ages of 8 and 13 years with the development of breast buds. Subsequent sexual development includes additional development of the breasts; enlargement of ovaries, uterus, labia, and clitoris; and thickening of the vaginal mucosa. Tanner described five distinct stages of sexual maturation in girls based on breast development and appearance and distribution of pubic hair. (2) Menarche typically follows 2 to 21/2 years after breast bud development, around a mean age of 13 years in the United States.On average, boys lag behind girls in most of the noticeable physical changes of adolescence. Testicular enlargement, the first sign of puberty in boys, typically begins around 12 years of age and is followed by development of pubic hair and growth of the penis. Tanner's five stages of sexual maturation in boys are based on the appearance of the pubic hair, penis, and testes. (3)For both boys and girls, a period of rapid growth in height and weight follows the onset of puberty. Growth tends to occur distally in the hands and feet before moving proximally to the arms and legs and finally to the trunk. Linear growth can outpace increased muscle mass and can occur unevenly, contributing to a period of awkwardness experienced by many adolescents. On average, girls reach their peak growth velocity around 12 years of age, about 2 years before boys.The age of onset of puberty and the rapidity with which the changes unfold vary substantially. Several identifiable factors appear to influence the timing of puberty, including health, nutritional status, and ethnicity. For example, on average, African American girls enter puberty slightly earlier than white girls. (4) In the United States, evidence suggests that sexual maturation in girls occurs earlier than it did 30 years ago. Rates of precocious puberty in girls, defined as the appearance of secondary sex characteristics before age 8 years or the onset of menarche before age 9 years, also appear to be rising. This finding may be due, in part, to rising rates of obesity. Obesity has been shown to correlate with earlier pubertal onset in girls, but with delayed onset in boys. (4)Variations in the timing of puberty can have a significant psychological impact on adolescents whose development deviates from the mean. The impact differs with sex. Early-developing males tend to have greater self-confidence and a greater likelihood of academic, social, and athletic success than their peers, particularly when compared with late-developing males. (5) Conversely, early pubertal development in girls appears to be related to lower self-esteem and more concerns about body image. (5) However, unlike boys, late-developing girls, on average, do not appear to have significant difficulties with self-esteem. Even when these transformations unfold on schedule, the physical changes of adolescence have a major influence on the psychological functioning of an individual. Thus, regardless of the timing, it is important to remain sensitive to how physical development may be affecting the self-esteem and emotional life of every adolescent patient.Adequate sleep is essential to support healthy physical development during adolescence. Adolescents are believed to require about 9 to 91/2 hours of sleep per night. Although this interval is not increased significantly over the needs of preadolescents, several factors may contribute to inadequate sleep in many adolescents. During puberty, hormonal changes, including changes in melatonin secretion, cause a relative sleep phase delay, with a natural tendency toward later onset of sleep and later waking times. Such biologic changes come at a time of accelerating academic and social demands that may crowd out time for sleep. The healthy drive to connect with a peer group may come into conflict with the adolescent's need for sleep. Although this problem is not new, it is more challenging than ever with the variety of means of communication now open to adolescents, including instant messaging, internet sites, online video games, podcasts, cellular phones, and more. As adolescents increasingly engage in these activities in the privacy of their rooms, many parents may not be aware of the amount of time their children are spending online instead of in bed. In addition to fatigue and difficulties focusing in class, inadequate sleep during adolescence may increase the risk of health problems such as obesity.Erik Erikson is the most influential theorist of emotional development. He conceptualized development as a series of crises during which individuals must negotiate difficult, often conflicting tasks to maintain a developmental trajectory, which he termed the epigenetic model of development. He characterized developmental challenges as binary crises that force the individual to choose a more desirable emotional stance. (6) For example, the developmental task assigned to infancy is described as trust versus mistrust, suggesting that if infants do not learn to trust the world to care for them, they will develop a suspicious and paranoid stance when moving along the developmental trajectory. Erikson looked at adolescence as a period of identity formation and separation from adult caretakers. He refers to this stage as a choice between ego identity formation and role diffusion, making the case that if adolescents do not form a coherent sense of self and values, they will lack a consistent sense of identity as they progress into adulthood. Theorists such as Blos have described adolescence similarly as a second separation from adult caretakers, noting that the first separation occurs when the younger child attains the motor and cognitive ability to move away from the parents’ constant watch. (7)There is, however, some question as to whether Erikson's conceptualizations accurately characterize early adolescence. Theorists such as Noam have argued that early adolescence is less concerned with identity formation and more focused on the development of group cohesion. (8) Noam has called this theory the psychology of belonging, and he notes that the middle school child who places a high priority on popularity is in the midst of a normal developmental stage. In this sense, proud membership within groups sets the stage for later confidence to move throughout different groups. Thus, according to this model, healthy early adolescence is characterized by identity with specific group values and norms, whereas healthy later adolescence is characterized by increasing comfort with one's capacity to choose among many different groups and to endorse selectively the values that have particular relevance to the individual.These concepts have important clinical ramifications. Younger adolescents are more susceptible to peer pressure as a means of identifying with the group imposing the pressure. Any attempt to counsel younger adolescents must take these considerations into account. Older adolescents, on the other hand, generally respond more readily to challenges to resist peer pressure for the sake of forming their own unique sense of identity.As adolescents are attempting to solidify their identities and develop increasing autonomy from parents, they occasionally regress and become more dependent, clinging, and in need for soothing caretaking. Development at all stages is not a linear process. Although they may appear aloof, independent, and impervious to adult guidance, adolescents are influenced strongly by the values and attitudes of parents and other trusted authorities. Parents should appreciate that despite attempts at separation, adolescents care deeply about the ideals expressed by close authoritative role models. Therefore, it is extremely important during this developmental period for adults to open lines of communication and be aware of the values and behaviors they are demonstrating to their youth. Teenagers ultimately are likely to accept and promulgate parental values, although they often arrive at them after going through periods of rebellion and rejection.During the process of separation from parents, adolescents often look to other adults in their lives to serve as role models, sometimes to their parents’ chagrin. Teachers, coaches, and friends’ parents frequently serve in this capacity. It is not unusual, particularly during early adolescence, for a teen to romanticize one of these relationships and develop a “crush” on an idealized adult authority figure. In the end, healthy relationships with adults propel adolescent psychological development by facilitating identity formation and separation from parents.The development of a healthy and stable self-image is one of the major goals of psychological development in adolescence. Poor self-image correlates with many of the major problems that can emerge during adolescence, including difficulties in peer and family relationships, depression, unsafe sex, risky or “acting out” behaviors, poor school performance, and substance abuse. Parents and other authority figures can help foster a positive self-image not only through the example that they set in their own lives, but also through demonstrating acceptance of the adolescent. It is important for the development of a positive self-image by their children for parents to take notice of the positive qualities that they admire in their adolescent children and to express praise for such qualities.Pediatricians should be aware that physical illness can have a tremendous impact on self-esteem for many adolescents. This is true both for illnesses that have a visible impact on the patient's appearance, such as a deformity, as well as for less visible conditions, such as diabetes. At a time when group cohesion is of utmost importance, a medical illness can make an adolescent feel flawed or alienated from his or her peers. Additionally, illness can lead to greater dependence on parents when the adolescent is struggling to develop a sense of independence. Although many teens who have medical problems are able to cope with these challenges by using their own internal resources and existing supports of family and friends, it is important for the pediatrician to assess how an adolescent patient is coping with medical illness and refer for additional evaluation when concerns arise. Support groups and similar programs, such as diabetes camps, can help teens reduce the sense of isolation that illness can bring. Psychotherapy often can help adolescents who have significant difficulties coping with illness find their way back to a healthy developmental trajectory.Another important psychological aspect of adolescent development involves impulsivity and risk taking. Although teenagers are advancing in maturity, younger adolescents, particularly, have a sense of grandiosity and invulnerability. This sense often is coupled with a limited capacity to grasp fully the potential ramifications of risky behavior or to conceive of long-term health risks of the lifestyle choices they make. The adolescent's newfound physical maturity, sexual drive, intellectual advances, earning potential, and mobility may lead to trouble, even in the healthiest, most well-adjusted youth. Experimentation and risk-taking behaviors may include sexual behavior, use of alcohol and substances, and thoughtless behavior, such as going to dangerous neighborhoods late at night. Much of this behavior may have a neurologic basis as the brain develops through this period. Thus, adolescents require clear expectations and firm, caring limits from parents and pediatricians. 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