Adolescent Health Care: A Practical Guide

Chapter 75

Common Concerns of Adolescents and Their Parents

Mari Radzik

Sara Sherer

Lawrence S. Neinstein

During the adolescent years, adolescents and their families face a myriad of issues and concerns. As stated earlier in this book, what seems important to the adolescent may not be of concern to his or her parents and vice versa. Often the issues that concern adolescents resolve on their own, may be helped by friends or family, or never come to the attention of a health care provider. In cases where the physician is involved, he or she may be asked to answer questions such as, “Am I normal?”, “Is my adolescent normal?”, or “What can I do about this problem?” Occasionally, the issue becomes severe enough to create family disruption. In the extreme case, these problems may lead to acting-out behaviors such as truancy, juvenile delinquency, substance abuse, or suicide.

What is normal adolescent behavior? Chapter 2 deals with normal psychosocial development in the adolescent. This chapter emphasizes common psychosocial concerns to which parents and health care providers should be especially sensitive. Unfortunately, there are no clear-cut answers to what is normal adolescent behavior. In an attempt to understand normal behavior and to build an alliance with the adolescent, it is often helpful for the health care provider to remember his or her own adolescence in order to keep things in perspective. Health care providers should consider the following issues when assessing the concerns of the adolescent or his/her family:

  1. The severity of the problem: Is this behavior usual for the adolescent or is there a marked change?
  2. The chronicity of the problem: Has the problem been present for days, months, or years?
  3. Emotional development: Is the adolescent's behavior consistent with his/her developmental stage with respect to independence, body image, peers, school and identity?
  4. Daily functioning: Are the problems severe enough to interfere with the daily functioning of the adolescent in areas such as school and social activities?
  5. Family functioning: Health care providers must try to understand the adolescent's behavior within the social context of their immediate world, especially their relationship with their caregivers. It is important to develop an understanding of the parenting style. Authoritative parents provide a warm, firm, and involved family climate with consistent and developmentally appropriate limit setting (Baumrind, 1991). Research has shown that this particular parenting style is associated with increased adolescent competence and psychological well-being (Steinberg, 2000). Therefore, a clear understanding of both the adolescent's acting-out behavior and the nature of his or her relationship with the parent(s) will help the health care provider determine whether an intervention is necessary.

Any concern of an adolescent or parent deserves an assessment. Although some general and routine medical concerns can be handled by discussion and reassurance, other issues such as family conflicts, psychosomatic illnesses, or depression may require several sessions with the adolescent and family. When the problem involves severe or chronic disorders or high-risk violent or self-injurious behavior, then a referral to a health care provider is usually indicated. Indications for considering a referral include the following:

  1. Suicidal or self-injurious behavior
  2. Mental health disorders such as mood or anxiety disorders
  3. Substance abuse
  4. Psychotic or other severe psychiatric symptoms
  5. Developmental delay or learning disabilities
  6. Behavioral problems that have either been present since childhood or have recently become apparent
  7. Problems that have persisted despite extensive interventions by the primary caregiver
  8. Problems believed to be beyond the skills of the health care provider
  9. A problem is present but the health care provider is unsure what it is (e.g., the adolescent with no friends who is socially withdrawn)
  10. Severe life stressors or changes in the family such as death, divorce, or suicide of parent or sibling
  11. A dramatic change in school behavior and/or performance
  12. Runaway behavior
  13. Frequent fighting among peers and/or family
  14. Acute or chronic illness

Types of behaviors that may indicate common adolescent behavior, a trouble sign, or a problem behavior are shown in Table 75.1.

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TABLE 75.1
Common Adolescent Behaviors, Trouble Signs, and Problem Behaviors

Not of Significant Concern

Trouble Sign

Problem Behavior

Adapted from Steinberg L, Levine, A. You and your adolescent: a parents' guide for ages 10–20. New York: Harper & Row; 1990.

One or two minor nonviolent violations of the law or school regulations

Repeated violations of the law or school regulations

Any violent act or crime

 

Sexual activity in the context of a loving relationship

Sexual provocativeness

Sexual promiscuity

 

Leaving home for a day and in particular running away to a familiar home, once

Running away more than once in 3 months

Running away to the streets

 

Skipping school or missing a class, once

Skipping school more than once in 3 months

Chronic absenteeism from school

 

Occasional experimentation with alcohol and drugs

Regular use of drugs and alcohol

Addiction to drugs or drug dealing

 

Occasional arguing with parents and other adults

Aggressive outbursts

Oppositionalism leading to violence at home or suspension from school

 

Referrals

When the health care provider decides that a referral to a mental health care provider is necessary, several considerations are important. They include:

  1. Are the adolescent and parents motivated to seek treatment? Without motivation, compliance is extremely poor.
  2. Do the adolescent and family understand the reason for the referral?
  3. Is the referral appropriate for the problem? Many options exist for referrals for psychosocial problems, including social workers, family therapists, psychologists, psychiatrists, and vocational counselors. In addition, there are specialized youth programs (Big Brothers/Big Sisters, YMCA), residential programs, and vocational programs (Job Corps) that can provide support.

Several interventions may help in making the referral. They include:

  1. The health care provider should reassure the adolescent that the primary health care provider will continue to follow up the adolescent and be involved in his or her care.
  2. The health care provider should explain that as part of the total evaluation and treatment of the adolescent's problem, a psychological or psychiatric evaluation is important. It has been shown that screening for mental disorders is not routinely part of the primary care of adolescents (Wren, et al., 2003). Despite this, a routine and practical evaluation for mental disorders is recommended as it will improve the care of the adolescent. If the adolescent and family feel strongly that the problem has an organic etiology, even after a negative medical evaluation, the health care provider can explain that a psychological evaluation is an important part of the diagnostic work-up. The health care provider can describe that such a comprehensive assessment is necessary because physical illnesses can lead to psychological problems and that patients with organic disease often have coexistent psychological disturbances. Psychological support or treatment can often help the adolescent cope with the symptoms.
  3. The health care provider should explain his or her concerns to the adolescent and family. As part of this explanation, the health care provider can ask the adolescent whether he or she thinks that “things could be better?” If the adolescent answers “yes”, the health care provider can review how counseling may be one way to help the adolescent and the family.
  4. The health care provider should reassure the adolescent that often counseling will be arranged for a limited period of time. If the counseling does not work out, the adolescent or family can stop it.
  5. The adolescent should be aware that seeing a psychologist or psychiatrist does not mean that they are “crazy”. Counseling should be described as an opportunity to help the adolescent feel better, to build coping skills, and to enhance family or interpersonal relations.
  6. It is necessary for the health care provider and the parents to distinguish the adolescent from his or her behavior. They must convey acceptance of the adolescent even if they believe the adolescent's behavior to be negative or unhealthy.

Concerns of Adolescents

Common concerns of adolescents include:

  1. Parental conflicts: Rules (e.g., curfew, driving), privacy, expectations, and peer relationships.
  2. Peers: Interpersonal concerns regarding friendships, relationships, and sexuality.
  3. Identity: Who am I? Concerns surrounding body image, sexual and gender identity, culture, and ethnicity.
  4. School: Popularity, academic pressures, teachers, and adjustment to a new school.
  5. Sibling/family conflicts: Blended and cross-generational differences.
  6. Social situations: Social connectivity, whether isolated or gregarious.
  7. Depression: Moderate or severe.

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  1. Medical concerns: Menstrual disorders, body image issues such as short stature, acne, and weight disorders.
  2. Psychosomatic problems: Headaches, stomach pains, and insomnia.
  3. Safety concerns: Violence in the environment, community, home, school, and in relationships.
  4. Prospects for the future: Economic realities, employment, education, relationship building, and establishing a solid sense of self.

Concerns of Parents

Common concerns of parents with regard to their adolescent son or daughter include:

  1. Adolescent acting-out behaviors: Mild acting-out behaviors are common in early and middle adolescence. Marked acting-out behaviors however, may be an indication of an emotional or family dysfunction.
  2. Risk-taking behaviors: Risk-taking is a common part of the early and middle adolescent process. Life-threatening, risk-taking behavior requires family interventions for the purposes of educating, limit setting, and evaluation of any associated unmet needs of the adolescent and his or her family.
  3. Emotional lability: Assessment of the severity, including detailed description of the moods and changes, is required to determine if a mood disorder is the underlying cause.
  4. Drug and alcohol use: Evaluation of the type and degree of drug use is required. The use of steroidal drugs for sports performance should also be addressed because the use of anabolic steroid use can be found among athletes (Goldberg, et al., 2000). Furthermore, determination of complimentary and alternative medication use should also be explored.
  5. Academic problems: Evaluation of the type and severity of the problem is required. Parents should be encouraged to follow-up with their adolescent's school for any available services that may help him or her. The use of video games and Internet should be monitored as it may often interfere with academic success and expose adolescents to experiences or values that may not be developmentally appropriate (Bremer, 2005; Greenfield, 2004).
  6. Sexual activity and identity: Parents should be encouraged to express their concerns. Issues of confidentiality between the adolescent and the health care provider should be explained to the parents. When adolescents know that private and personal information about them will be protected and held in confidence, they are more likely to trust their health care provider and discuss their problems openly. Sexual identity can often be an area of tension in the family, particularly when the adolescent expresses thoughts or behaviors that they may be bisexual, homosexual or transgendered. The parent(s) may reject the adolescent's new sexual identity and may require appropriate resources to help them better understand these issues. Adolescents and their parents should be encouraged to discuss issues of sexuality, sexual identity, and sexual activity whenever possible. Parents often have questions and concerns about limit setting such as, “What is adequate supervision at parties?” “Should I allow my son or daughter to spend time alone in the house or in a room with a girlfriend or boyfriend?” and “What degree and type of sexual activity is normal?” Health care providers should be prepared to help parents explore these issues.
  7. Eating disorders: An evaluation of changes in weight, attitudes toward body image, eating habits and behaviors, psychological and emotional health, family functioning, and self-esteem should be undertaken.
  8. Safety issues: Violence in the environment or safety while driving (i.e., adolescent or other motorists driving under the influence). The novice adolescent driver is a key stressor for parents and one that brings up many issues of limit setting and sharing of responsibilities.
  9. Peer influences: Parents should be aware of the importance of peer influences and should monitor behaviors and activities while understanding that youth need to choose their own friends.
  10. Psychosomatic problems: Medical evaluation should include an exploration of any sources of stress that the adolescent may be attempting to cope with psychosomatically.
  11. “Wasting time” by the adolescent, especially daydreaming: Parents should be reassured that this is usually a normal part of adolescent development. However, parents should monitor to help redirect youth who may need more direction in their activities.

Conclusion

Adolescence is an exciting period of transition and change. It is important to remember the many competencies, strengths, and energy that youth possess. That notwithstanding, health care providers may be confronted by parents and caregivers who struggle with challenging adolescent issues. Parents and caregivers should be encouraged to focus on the positive aspects of adolescence while following up with appropriate resources when needed. Respectful, consistent, and caring parents and caregivers can facilitate a positive transition for their teenager as the move through adolescence toward adulthood.

Web Sites

http://www.aacap.org/. Questions and answers from the American Academy on Child and Adolescent Psychiatry.

http://www.aamft.org. The American Association of Marriage and Family Therapists Web site.

http://www.adolescenthealth.org. Society of Adolescent Medicine.

http://www.cpc.unc.edu/projects/addhealth. The National Longitudinal Study of Adolescent Health. Beginning in 1994, surveyed key issues of adolescents such as physical health, mental health, and risk behaviors.

http://www.apa.org. The American Psychological Association.

http://www.indiana.edu/%7Ecafs/resources.html. ADOL: Adolescence Directory On-Line is an electronic guide to information on adolescent issues. Service of the Center for Adolescent Studies at Indiana University.

http://www.NationalEatingDisorders.org. National Eating Disorders Association, largest non-profit organization.

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http://www.ncfy.com. Supporting Your Adolescent: Tips for Parents, Prepared by the National Clearinghouse on Families & Youth.

http://www.npin.org. The National Parent Information Network.

http://www.pflag.org/. National organization supporting parents of gay, lesbian, bisexual and transgendered persons.

http://www.tnpc.com. Articles on parenting teens from the National Parenting Center, many by Kathleen McCoy and Charles Wibbelsman, M.D., from Teen Body Book.

http://www.4woman.gov/BodyImage. The National Woman's Health Information Center.

References and Additional Readings

Alessi G. The family and parenting in the 21st century. Adolesc Med 2000;11:35.

Arnett JJ. Adolescent storm and stress, reconsidered. Am Psychol 1999;54:317.

Baumrind D. Parenting style and adolescent development. In: Brook-Gunn J, Lerner R, Peterson AC, eds. The encyclopedia of adolescence. New York: Garland; 1991.

Bremer J. The internet and children: advantages and disadvantages. Adolesc Psychiatr Clin N Am 2005;14(3):405.

Glascow KL, Dornbusch SM, Troyer L, et al. Parenting styles, adolescents' attributions, and educational outcomes in nine heterogeneous high schools. Child Dev 1997;68: 507.

Goldberg L, MacKinnon DP, Elliot DL, et al. The adolescents training and learning to avoid steroids program. Arch Pediatr Adolesc Med 2000;154:332.

Greenfield PM. Developmental considerations for determining appropriate internet use guidelines for children and adolescents. Appl Dev Psychol 2004;25:751.

Steinberg L. We know some things: parent-adolescent relations in retrospect and prospect. J Res Adolesc 2000; 11(1):1.

Steinberg L, Levine A. You and your adolescent: a parent's guide for ages 10–20. New York: Harper & Row; 1990.

Wren FJ, Scholle SH, Heo J, et al. Pediatric mood and anxiety syndromes in primary care: who gets identified? Int J Psychiatry Med 2003:33(1):1.