Adolescent Health Care: A Practical Guide
Psychosocial Development in Normal Adolescents
Lawrence S. Neinstein
No brief manual can hope to fully illuminate the complicated psychosocial developmental process of adolescence. This chapter offers an elementary framework from which to approach the study of this developmental process and discusses ways to enhance interactions between health care providers and adolescents.
In terms of physical development, adolescence can be described as the period of life beginning with the appearance of secondary sexual characteristics and terminating with the cessation of somatic growth. In modern Western culture, the behavioral aspects of this developmental period have become equally important. Adolescence is, in fact, a biopsychosocial process that may start before the onset of puberty and last well beyond the termination of growth. The events and problems that arise during this period are often perplexing to parents, health care providers, and adolescents. It is a time in which, for example, a previously obedient, calm child may become emotionally labile and act out.
It is vital that health care providers who provide comprehensive care for adolescents understand the adolescent psychosocial developmental process. Such an understanding is not only beneficial in routine adolescent health care but can also help adolescents and their families through problem periods involving, for example, failure in school, depression, suicidal tendencies, and out-of-control behavior. This chapter examines the phases and tasks of normal adolescent psychosocial growth and development, beginning with some general comments about the process of adolescence.
The Process of Adolescence
First, it is important to keep in mind that no outline of psychosocial development can adequately describe every adolescent. Adolescents are not a homogeneous group, but display wide variability in biological, psychological, and emotional growth. Each adolescent responds to life's demands and opportunities in a unique and personal way. Further, adolescents must meet the challenges that arise from their own high-risk behaviors as well as the many social factors that impact their lives (Atav and Spencer, 2002; Galambos and Leadbeater, 2000; Gutgesell and Payne, 2004; Lerner and Galambos, 1998).
Second, the transition from childhood to adulthood does not occur by a continuous, uniform synchronous process. In fact, biological, social, emotional, and intellectual growth may be totally asynchronous (Steinberg, 2005). In addition, growth may be accented by frequent periods of regression. It must be remembered that all of life, from birth to death, is a constant process of change and that adolescence is not the only challenging period.
Third, whereas adolescence has historically been described as a period of extreme instability or “normal psychosis,” most adolescents survive with no lasting difficulties, and many are unperturbed by the process (Freud, 1958). This ability to cope is a resiliency that is often overlooked, as the behaviors of adolescents are often the primary focus of attention (Olsson et al., 2003). In actuality, approximately 80% of adolescents cope well with the developmental process. Of these 80%, approximately 30% have an easy continual growth process, 40% have periods of stress intermingled with periods of calm, and 30% have tumultuous development marked by bouts of intense storm and stress. In a national survey, approximately 90% of 16-year-old boys and girls reported that they got along well with their mothers and 75% reported getting along well with their fathers (Rutter, 1980). Only one in five families reported difficult parent–child relationships. Overall, intractable and major conflict between parents and their adolescent children is not a “normal” part of adolescence (Steinberg, 1990; Laursen et al., 1998).
Phases and Tasks of Adolescence
Adolescence can be conceptualized by dividing the process into three psychosocial developmental phases:
- Early adolescence: approximate ages 10 to 13, or middle school years
- Middle adolescence: approximate ages 14 to 17, or high school years
- Late adolescence: approximate ages 17 to 21, or college or 4 years of work after high school
These stages overlap among different adolescents. By the end of adolescence, emerging adults (Arnett, 2000) have become emancipated from parents and other adults and have attained a psychosexual identity and sufficient resources from family, education, and community to begin to support themselves in an emotionally, socially, and
financially satisfying way. In addition, they have learned how to appropriately seek support from other individuals when needed.
Several tasks characterize the development of the adolescent and are discussed in the next several sections in conjunction with the various phases of adolescence. These tasks include the following:
- Achieving independence from parents
- Adopting peer codes and lifestyles
- Assigning increased importance to body image and acceptance of one's body image
- Establishing sexual, ego, vocational, and moral identities
Early Adolescence (Approximate Ages 10 to 13)
Early adolescent psychosocial development is heralded by rapid physical changes with the onset of puberty. These physical changes engender self-absorption and initiate the adolescent's struggle for independence. The onset of puberty occurs 1 to 2 years earlier for girls than for boys. Concomitantly, the psychosocial and emotional changes also occur 1 to 2 years earlier in girls. Recent studies have provided evidence for an earlier age at onset of pubertal development in girls.
Early adolescence is characterized by the beginning of the shift from dependence on parents to independent behavior. Common events at this time include:
- Less interest in parental activities and more reluctance to accept parental advice or criticism; occasional rudeness; more realization that the parent is not perfect
- An emotional void created by separation from parents, without the presence of an alternative support group, which can often create behavioral problems (e.g., a decrease in school performance)
- Emotional lability (wide mood and behavior swings)
- Increased ability to express oneself through speech
- Search for new people to love in addition to parents
Body Image Concerns
Rapid physical changes lead the adolescent to be increasingly preoccupied with body image and the question of, “Am I normal?” The early adolescent's concern with body image is characterized by the following four factors:
- Preoccupation with self
- Uncertainty about appearance and attractiveness
- Frequent comparison of own body with those of other adolescents
- Increased interest in sexual anatomy and physiology, including anxieties and questions regarding menstruation or nocturnal emissions, masturbation, and breast or penis size
Peer Group Involvement
With the beginning of movement away from the family, the adolescent becomes more dependent on friends as a source of comfort (Pugh, 1999; Eccles, 1999). The early adolescent's peer group is characterized by the following:
- Solitary friendships with a member of the same sex. This idealized friendship may become intense; boys, for example, may become “comrades-in-arms” with sworn pacts and allegiances and young teenage girls may develop deep crushes on men as well as women.
- Strongly emotional, tender feelings toward peers, which may lead to homosexual exploration, fears, and/or relationships.
- Peer contact primarily with the same sex, with some contact of the opposite sex made in groups of friends.
At the same time that the rapid physical changes occur, the adolescent's cognitive abilities are improving markedly. According to Piaget's (1969) cognitive theory, this corresponds to the evolution from concrete thinking (concrete operational thoughts) to abstract thinking (formal operational thoughts). During this time, the adolescent is expected to achieve academically and to prepare for the future. This period of identity development is characterized by the following:
- Increased ability to reason abstractly. This ability is usually turned inward, leading to increased self-interest and fantasy. For example, the young adolescent may feel himself or herself constantly “onstage.”
- Frequent daydreaming, which is not only normal but also an important component in identity development because it allows adolescents an avenue to explore, enact, problem solve, and recreate important aspects of their lives.
- Setting unrealistic or idealistic (depending on the individual) vocational goals (e.g., musician, airplane pilot, or truck driver).
- Testing authority is common behavior in adolescents as they attempt to better define themselves and is often one cause of tension between the adolescent and his or her family or teachers.
- A need for greater privacy, with diary or journal writing often becoming highly important.
- Emergence of sexual feelings often relieved through masturbation or the telling of dirty jokes. Girls are often ahead at this point in sexual development.
- Development of the adolescent's own value system, leading to additional challenges to family and others.
- Lack of impulse control and need for immediate gratification, which may result in dangerous risk-taking behavior.
- Tendency to magnify one's personal situation (although adolescents often feel that they are continually onstage, conversely, they may also be convinced that they are alone and that their problems are unique).
Middle Adolescence (Approximate Ages 14 to 16)
Middle adolescence is characterized by an increased scope and intensity of feelings and by the rise in importance of peer group values.
Conflicts become more prevalent as the adolescent exhibits less interest in parents and devotes more of his or her time to peers.
Body Image Concerns
Most middle adolescents, having experienced most of their pubertal changes, are less preoccupied with these changes. Although there is greater acceptance and comfort with the body, much time is spent trying to make it more attractive. Clothes and makeup may become all important. Because of the societal emphasis on youthful body image, eating disorders may become established during this developmental phase.
Peer Group Involvement
The powerful role of peer groups is most apparent during middle adolescence (Pugh, 1999; Eccles, 1999). Characteristics of this involvement include the following:
- Intense involvement by the adolescent in his or her peer subculture
- Conformity by the adolescent with peer values, codes, and dress, in an attempt to further separate from family
- Increased involvement in partnering relations manifested by dating activity, sexual experimentation, and intercourse
- Involvement with clubs, team sports, gangs, and other groups
Evidence suggests that friends are the primary source of influence on youths' behavior, but estimates of peer pressure are often overstated (Aseltine, 1995). Adolescents' reactions to peer pressure are extremely varied and peer pressures can also involve a desire to excel in school, sports, or other positive activities.
The abilities to abstract and to reason continue to increase in middle adolescence, along with a new sense of individuality. The middle adolescent's ego development is characterized by the following:
- Increased scope and openness of feelings, with a new ability to examine the feelings of others
- Increased intellectual ability and creativity
- Less idealistic vocational aspirations (adolescents with average and below-average intellectual abilities often realize their limitations at this time and may consequently experience lowered self-esteem and depression)
- A feeling of omnipotence and immortality, leading to risktaking behavior, which is certainly a factor in the high rate of accidents, suicides, drug use, pregnancies, and sexually transmitted diseases that become prevalent at this stage
Late Adolescence (Approximate Ages 17 to 21)
Late adolescence is the final phase of the adolescent's struggle for identity and separation. If all has proceeded well in early and middle adolescence, including the presence of a supportive family and peer group, the adolescent will be well on his or her way to handling the tasks and responsibilities of adulthood. If the previously mentioned tasks have not been completed, then problems such as depression, suicidal tendencies, or other emotional disorders may develop with the increasing independence and responsibilities of young adulthood. A new conceptualization of the period from late adolescence through the twenties (specifically the period from 18–25 years of age) is referred to as the “emergent adult” period (Arnett, 2000). These new young adults have begun to accept responsibility for their behaviors, formulate their own decisions, and make an effort to be financially independent.
For most, late adolescence is a time of reduced restlessness and increased integration. The adolescent has become a separate entity from his or her family and may better appreciate the importance of his or her parents' values. Such an understanding may make it possible for the adolescent to seek and accept parental advice and guidance. However, it is not uncommon for some adolescents to be hesitant to accept the responsibilities of adulthood and to remain dependent on family and peers. Characteristics include the following:
- Firmer identity
- Greater ability to delay gratification
- Better ability to think ideas through and express ideas in words
- More stable interests
- Greater ability to make independent decisions and to compromise
Body Image Concerns
The late adolescent has completed pubertal growth and development, and is typically less concerned with this process, unless an abnormality has occurred.
Peer Group Involvement
Peer group values become less important to late adolescents as they become more comfortable with their own values and identity. More time is spent in a relationship with one person. Such relationships involve less exploitation and experimentation and more sharing. The selection of a partner is based more on mutual understanding and enjoyment than on peer acceptance.
Ego development during the late adolescent phase/stage is characterized by the following:
- The development of a rational and realistic conscience
- The development of a sense of perspective, with the abilities to delay, compromise, and set limits
- The development of practical vocational goals and the beginning of financial independence
- Further refinement of moral, religious, and sexual values
Most adolescents follow the general psychosocial developmental phases as outlined above. An understanding of this general pattern helps health care providers evaluate an adolescent's behavior. Table 2.1 summarizes the developmental tasks for each phase of adolescence.
http://www.My.webmd.com. Web MD Health, search under “growth and development”.
http://www.Connectforkids.org. For adults—parents, grandparents, educators, policy makers and others who want to become more actively involved with youth.
http://www.apahelpcenter.org/. The American Psychological Association's online resource center.
http://www.Generalpediatrics.com. The General Pediatrician's view of the Internet.
http://www.Parent-teen.com. An online magazine for families with teens.
http://www.cpyu.org. Center for Parent Youth Understanding.
http://www.aacap.org/publications/factsfam/develop.htm. American Academy of Child and Adolescent Psychiatry.
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