Yolanda N. Evans1
Department of Pediatrics, Seattle Children’s Hospital/University of Washington, 4540 Sand Point Way NE, Suite 200, Seattle, WA 98105, USA
Yolanda N. Evans
Psychosocial developmentPubertyHigh-risk behaviorAdolescent developmentDeviations from normal adolescent development
Adolescence is an intense period of transition. The experience is one that many adults tend to move past without looking back. There is the awkwardness of a maturing body that may feel foreign and betraying as it morphs from looking like a child into that of an adult. At the same time the maturing brain begins to grasp abstract concepts while simultaneously seeking out behaviors that yield high rewards. With all of this change occurring, it can be challenging to distinguish normal from the deviations of adolescent development. Our culture is often avoidant, afraid of, or shows little patience for children going through adolescence. As adults, we interact with adolescents hoping for mature responses, but may find that their actions are often different than those expected of adults. Why do teens act this way? During adolescence, behavior often occurs because there is a consequence that is of benefit to the youth . Though the medical community emphasizes the harm that can come from deviations from normal adolescent development , it may be challenging to engage the youth in behavior change if they are receiving social benefits. The neuropsychological changes that occur during adolescent development have become better understood over the past decade. The limbic system of the brain, which controls rewards and emotions, matures faster than the prefrontal cortex, the logic center of the brain. This reward center maturation may translate into ongoing harmful behaviors if the stimulus to continue a behavior, and thus receive a reward, is great enough. While the neurologic and cognitive changes take longer to mature, the physical maturity can contribute to adult-like behaviors in the form of both peer and sexual relationships.
A key part of the transition from childhood to adulthood is the development of identity. This formation of identity includes the maturation of intellect, morality, ethnicity, spirituality, and sexuality. The three stages of adolescent development are an outline of the journey to discovering identity .
Early Adolescence : Ages 10–14 Years
During the early stage of adolescence, youth begin to exhibit separation from the family. This is the time when it is normal for children to be embarrassed being seen with their parents in public, and they may ask to go out with peers unaccompanied. They are preoccupied with their own body as the physical changes of puberty are underway. Youth begin to identify with their ethnic background, and cultural biases regarding gender, size, religion, ability, and race may lead to preferential interactions with like-minded peers. While youth in this stage have concrete thinking, they are gaining the ability to perceive and truly understand the consequences of their actions. However, this understanding of consequence may be ignored if the reward from risky behavior is great enough. It is during this stage that adolescents may begin to experiment with behaviors, such as substance use. Some youth may initiate sexual activity, but the majority of teens are just beginning to find themselves attracted to another individual in a sexual way .
Middle Adolescence : Ages 14–17 Years
During middle adolescence, the physical changes of puberty are ending. Romantic relationships intensify as sexual maturity is achieved. This is the peek of conflict with family as the individual struggles to develop a sense of self. Normal conflict with family can appear in a variety of ways. For some adolescents, they challenge the authority of their parents by defying set rules such as curfew or household chore completion. Others take on political stances that are the opposite of the family. The teen wants to be seen as an autonomous being, yet this is the peek of conforming to peers. Risky behavior heightens, such as substance use, sexual activity, violence, and driving. Though teens push away from family, this is often the time when parental guidance is most needed as the rates of suicide, homicide, sexually transmitted infections, and substance use all increase with this age group .
Late Adolescence : Ages 17 and Older
Late adolescence is the developmental stage where identity is beginning to solidify. This age group is less reliant on peer acceptance and may resume seeking counsel from family regarding values. This is the time when education and vocational goals are explored, which provides the developing youth the opportunity to practice autonomy as they make decisions that will shape their future employment and earning potential. Adolescents transition from high school to the pursuit of university or college studies. They may opt to join the military or look at a vocational training program. Romantic relationships also change during this stage. Instead of intense feelings of desire and attachment, older adolescents are beginning to understand the need for mutual support, trust, and intimacy in order to allow relationships to thrive.
The normal stages of adolescence and development of self identity occur over a relatively short time period and when coupled with rapid changes in physical maturity equate to a potentially tumultuous portion of an individual’s life. Normal adolescents experiment, push limits, and challenge authority; all are required to reach the goal of recognizing the individual’s identity. To aid in this development, society as a whole should encourage pursuit of vocational interests, teach and model healthy romantic relationships , and encourage adolescents through mentorship.
Deviations from Normal Development
Deviations from normal psychosocial development include, but are not limited to, the following: mood disorders such as depression and anxiety , violence , substance abuse [6–8], and risky sexual behavior . The Youth Risk Behavior Surveillance System (YRBSS ) conducted by the US Centers for Disease Control (CDC) was developed in 1990 to look at trends in behavior among teens that contribute to significant morbidity and mortality . The behaviors reported by the YRBSS provide an overview of deviations from normal development in adolescents in the United States. In the survey, adolescents in grades 9–12 were asked questions related to behavior. The most recent survey completed in 2013 addresses adolescent suicidal ideation, violence, substance abuse (including alcohol, marijuana, and tobacco), risky sexual activity, and unhealthy eating behaviors. The following is a summary of the findings.
Among those who responded, 17 % seriously considered suicide and 8 % attempted suicide in the 12 months prior to the survey.
Violent behaviors were categorized by carrying a weapon (17.9 %), carrying a weapon on school property (5.2 %), being in a physical fight (24.7 %), being bullied on school property (19.6 %), being bullied electronically (14.8 %), and being physically forced to have sexual intercourse (7.3 %).
Substance abuse was asked in a variety of ways. Sixty-six percent reported having at least one alcoholic drink in their lifetime, and 20.8 % had at least five drinks in a row during the 30 days prior to the survey. Marijuana use has increased with 31.3 % having used in 1991 versus 40.7 % ever used in 2013. Of those surveyed, 23.4 % reported current use of marijuana.
Since 2001, there has been no change in the percentage of youth who reported sexual activity. In 2013, 46.8 % reported that they had ever had sex, 15 % having had more than five lifetime partners, 34 % reporting current sexual activity, 59.1 % used a condom during the last sexual encounter, and 22.4 % had drank alcohol or used drugs before their last sexual encounter.
Breakfast was not eaten by 13.7 % in the week prior to the survey and only 38 % ate breakfast all 7 days prior to the survey. In the 30 days prior to the survey, 13 % did not eat for 24 h in order to lose weight and 4.4 % vomited or took laxatives in order to lose weight.
Contributing Factors to Deviations
Environment and community, family and peer interactions, and individual traits are all factors that can contribute to normal adolescent development. Deviations from normal development in one or more of these factors can lead to psychosocial challenges during puberty. For example, the presence of living in a high-risk neighborhood, having low parental monitoring, and engaging with high-risk peers impacts the probability of a youth engaging in risky behaviors . The following information will discuss variations in each of the above factors and the effect on social characteristics among adolescents.
Adolescence is characterized by the increasing ability to think abstractly and control behavioral impulses while at the same time seek rewards from behavior and novel experiences. The limbic system matures at a faster pace than the prefrontal cortex which is the area in control of abstract thoughts, consideration of consequences, and logic. This maturation of the emotional control without the mature logic center of the brain likely adds to the stereotypical poor impulse control, high-risk behaviors associated with adolescence [11, 12]. The adolescent brain changes are associated with activation of the regions of the brain associated with rewards and attenuation of areas sensitive to aversive stimuli. The pruning and molding that occurs allows the adolescent to ultimately develop into an adult that encounters aversive stimuli and thus avoids the associated risk , but this takes time to mature. Why is it that some teens perform behaviors that can have high rewards and high risks, while others are content to exert autonomy but limit risk taking? Is this difference related to the rate of maturation of the brain, temperament, personality type, or a combination of all three? How might extracurricular activities such as music performance, speaking a second language, or sports participation play a role in deviations from normal psychosocial development?
Temperament and personality type are apparent during childhood and vary little over the course of growth and development [14, 15]. Children who have optimistic thinking styles have been associated with resilience from depression and anxiety . It is reasonable to expect that certain temperaments would be more averse to risk-taking behavior. People who regularly work with teens may benefit from encouraging certain styles of behavior and minimizing others. For example, decreasing or minimizing anxious personality traits (i.e., perfectionism) and maximizing optimism may lead to fewer risk-taking behaviors. Of course, personality type is not the sole factor contributing to behavior. A study exploring white matter integrity in the limbic and prefrontal regions of the brain compared adolescent substance users to nonusers. Early-onset substance use is associated with regular use as an adult . While mid-adolescence is the time when brain changes are at their highest, many high-risk behaviors, such as substance use, peak during emerging adulthood. In the study, those with lower white matter integrity at baseline were associated with a greater chance of initiating substance use by mid-adolescence, and lower white matter predicted future risk-taking behaviors . This combination of brain composition and temperament likely translates into some of the differences in risk-taking behavior observed during the teen years. While both may have genetic contributions, environmental factors likely play a large role in development as well.
Environment and Family
There is no question that the environment in which a youth grows can have profound impacts on health, educational attainment, career, and adult life circumstances. Growing up in a violent community may lead to physical harm as well as external violent behaviors or internal mood disorder. One study of 728 children and families found that for boys, growing up in a violent community with a high-conflict family exacerbated the negative effects of community violence, yet growing up in the violent community with a low-conflict family was protective from negative effects of community violence (depression, anxiety, and risk-taking behaviors). For girls, the family did not moderate the effects of the violent community [5, 18].
Unsupportive environments or changes in environment, whether via immigration or community violence, can affect mood and self-esteem. In the United States, the 2012 Census data found that roughly one fifth of all households spoke a language other than English at home . Acculturation, variation in peer or family expectations from that of the new culture, may lead to adolescents making choices that negatively impact their health. The need to learn a new language, adjust to new cultural norms, and learn new cultural idioms may lead to initial social isolation. Efforts to conform to peers may lead to modified mood in the form of low self-esteem or depression .
In combination with environment, the opposite of supportive parenting can have negative effects on behavior. One study examining a national longitudinal data set of adolescent twin and sibling pairs asked if maltreatment by parents caused conduct problems or if conduct problems led to parents treating them poorly. The findings were more consistent with the latter. Parents tended to react to unwanted behavior in a negative way . Parenting styles that promote autonomy instead of negatively controlling motives have been positively associated with adolescent personal well-being . Thus, the external environment in which a child develops into adolescence in addition to the family environment can shape development.
There is a body of literature on the importance of human relationships for adolescent development and well-being [23, 24]. As children enter adolescence, relationships change and teens begin to exhibit identities that conform to cultural expectations. For males in the USA, this may manifest as masculine ideals, decrease in emotional expression, and increase in individualism. For females, this may appear as a shift toward a more demure exterior. Peer influence plays a significant role in what is viewed as normative and changes in friendships impact behavior. A study using a national longitudinal data set examined the risk behavior of alcohol use and peers in an effort to determine if adolescents would exhibit dangerous behavior (increased alcohol consumption) in order to gain popularity. The study found that alcohol consumption leads to an increase in popularity among white males and females . When adolescents perceive benefits from their actions, they will proceed with the behavior even if it is dangerous. Even in the setting on non-risky behavior, peer presence is impactful during adolescence. A novel study used functional magnetic resonance imaging (fMRI), an imaging study that looks at the blood flow to the brain, to examine teens ages 14–19 years on a card-guessing task that incorporated reward and non-reward tasks. In the setting of completing the task in the presence of same-age peers, teens exhibited greater ventral striatal activation, the part of the brain involved in rewards, than adults (ages 25–35) on the same task . This activation of reward circuitry is evidence for biomechanical impact of the presence on peers for behavioral choices.
Pubertal development encompasses both cognitive and physical changes which can deviate from the norm. Health-risk behaviors generally increase during adolescence and then level off and diminish into adulthood . Adolescent development can be modified by many factors, from peer relationships to environment, and these factors can contribute to either positive (normal) outcomes or negative (deviations) outcomes. Brain development may play a role in deviations from the norm, as some adolescents may indeed be more susceptible to risk-taking behavior, but there are also factors that may be amenable to intervention, such as peer dynamics, parental support, and community. Parental monitoring and parental communication have been associated with promoting less risk taking  and teens may be more susceptible to seeking out immediate rewards when in the presence of peers  Providers who routinely engage in care with adolescence should be aware of the influences on normative behavior and risk taking in order to address deviations from the norm.
Guidelines for Providing Care to Adolescents
Adolescents are less likely than younger children to be seen by a healthcare provider. In early childhood, it is recommended that infants visit a provider multiple times per year for routine well-child care screening. As children age, they are still evaluated by a healthcare provider yearly. These visits offer the healthcare provider the opportunity to provide anticipatory guidance to parents, address concerns about development, and screen for behaviors that may impact health. As children enter adolescence, healthcare utilization plummets, with only about a third receiving one healthcare visit a year .
Confidentiality is a major barrier to youth seeking out healthcare. If the youth does not trust their healthcare provider, they will not come in for visits. In a large study of adolescents using a national data base with over 18,000 respondents, boys with suicide attempt, depression, and suicidal ideation were more likely to report confidentiality concerns as a reason for not seeking healthcare. Girls with depression, history of sexually transmitted infection, nonuse of birth control at their last sexual encounter, and past alcohol use were also more likely to report confidentiality as the rationale for not seeking care . These youth have the risky behaviors that are most likely to threaten normal development.
When healthcare practitioners provide confidential care, the number of topics addressed in the encounter increases , and adolescents are more likely to come in for visits. So how do we accomplish this? First, the healthcare provider must understand the confidentiality laws in their state. All 50 states and the District of Columbia have confidentiality laws in place for minors (under age 18 years) for provision of services related to mental health, substance abuse, and reproductive health. In the patient encounter, an approach that allows the parents to have their concerns heard and addressed, while at the same time allows the youth to have time alone with the provider, can be a challenge. One approach that works well is to split the visit. Initially meet with the youth and parents together. Ask the accompanying adults what their concerns are and what they would like covered during the visit. Let them know that you will spend a few minutes alone with their adolescent as part of your standard practice. After you address the parent concerns, have them step out of the room. When in the room with the adolescent alone, ensure confidentiality, but also let them know the limits to confidentiality laws. An example of how to inform the adolescent about confidentiality is the following:
Provider: “Everything we talk about can remain between you and me, but there are a few exceptions. If I am concerned about your safety, I have to tell someone. This includes if you tell me you have a plan to end your life, if you have a plan to hurt someone else, or if someone has hurt you.”
The provider should take the opportunity to screen for risky behaviors when speaking with the youth in confidence. Your encounter may be the only opportunity for the adolescent to discuss normal and abnormal adolescent development during the teen years. Ask about the home environment, their educational pursuits, activities of interest, and eating patterns. Screen for depression, anxiety, suicidal ideation, and substance use. Inquire about their peers and what activities they enjoy. Screen for sexual debut and sexual identity. If the youth provides an answer outside of the provider’s scope of practice, refer to an appropriate practitioner to address the concern and schedule a follow-up with the youth to ensure the issue has been addressed.
Willoughby T, Good M, Adachi P, Hamza C, Tavernier R. Examining the link between adolescent brain development and risk taking from a social-developmental perspective. Brain Cogn. 2013;83:315–23.CrossRefPubMed
HealthyChildren.org. American Academy of Pediatrics. 2015. https://www.healthychildren.org/English/ages-stages/teen/Pages/Stages-of-Adolescence.aspx. Accessed 15 Oct 2015.
Centers for Disease Control and Prevention. Youth risk behavior survey. 2013. Accessed 14 Sept 2015. http://www.cdc.gov/healthyyouth/data/yrbs/index.htm
Arbeit MR, Johnson S, Champine R, Greenman K, Lerner J, Lerner R. Profiles of problematic behaviors across adolescence: covariations with indicators of positive youth development. J Youth Adolesc. 2014;43(6):971–90.CrossRefPubMed
McKelvey LM, Whiteside-Mansell L, Bradley R, Casey P, Conners-Burrow N, Barrett K. Growing up in violent communities: do family conflict and gender moderate impacts on adolescents’ psychosocial development? J Abnorm Child Psychol. 2011;39(1):95–107.CrossRefPubMed
Griffin KW, Bang H, Botvin GJ. Age of alcohol and marijuana use onset predicts weekly substance use and related psychosocial problems during young adulthood. J Subst Use. 2010;15(3):174–83.CrossRef
Ali MM, Amialchuk A, Nikaj S. Alcohol consumption and social networking ties among adolescents: evidence from add health. Addict Behav. 2014;39(5):918–22.CrossRefPubMed
Dayan J, Bernard A, Oliac B, Mailhes A, Kermarrec S. Adolescent brain development, risk-taking, and vulnerability to addiction. J Physiol Paris. 2010;104(5):279–86.CrossRefPubMed
Samek DR, Iacono W, Keyes M, Epstein M, Bornovalova M, McGue M. The developmental progression of age 14 behavioral disinhibition, early age of sexual initiation, and subsequent sexual risk-taking behavior. J Child Psychol Psychiatry. 2014;55(7):784–92.CrossRefPubMedPubMedCentral
Wang B, Deveaux L, Li X, Marshall S, Chen X, Stanton B. The impact of youth, family, peer, and neighborhood risk factors on developmental trajectories of risk involvement from early through middle adolescence. Soc Sci Med. 2014;106:43–52.CrossRefPubMedPubMedCentral
Geier CF. Adolescent cognitive control and reward processing: implications for risk taking and substance use. Horm Behav. 2013;64(2):333–42.CrossRefPubMed
Luciana M. Adolescent brain development in normality and psychopathology. Dev Psychopathol. 2013;25(4 Pt 2):1325–45.CrossRefPubMedPubMedCentral
Spear LP. Adolescent neurodevelopment. J Adolesc Health. 2013;52(2 Suppl 2):S7–13.CrossRefPubMedPubMedCentral
Neumann C, Wampler M, Taylor J, Blongen D, Iacono W. Stability and invariance of psychopathic traits from late adolescence to young adulthood. J Res Pers. 2011;45(2):145–52.CrossRefPubMedPubMedCentral
Meeus W, Van de Schoot R, Kilmstra T, Branje S. Personality types in adolescence: change and stability and links with adjustment and relationships: a five-wave longitudinal study. Dev Psychol. 2011;47(4):1181–95.CrossRefPubMed
Patton GC, Tollit M, Romaniuk H, Spence S, Sheffield J, Sawyer M. A prospective study of the effects of optimism on adolescent health risks. Pediatrics. 2011;127(2):308–16.CrossRefPubMed
Jacobus J, Thayer R, Trim R, Bava S, Frank L, Tapert S. White matter integrity, substance use, and risk taking in adolescence. Psychol Addict Behav. 2013;27(2):431–42.CrossRefPubMed
Wickrama KA, Noh S. The long arm of community: the influence of childhood community contexts across the early life course. J Youth Adolesc. 2010;39(8):894–910.CrossRefPubMed
USA Quick Facts. United States Census Bureau. 2015. http://quickfacts.census.gov/qfd/states/00000.html. Accessed 14 Sept 2015.
Greene ML, Way N, Pahl K. Trajectories of perceived adult and peer discrimination among Black, Latino, and Asian American adolescent: patterns and psychological correlates. Dev Psychol. 2006;42(2):218–36.CrossRefPubMed
Schulz-Heik RJ, Rhee S, Silvern L, Haberstick B, Hopfer C, Lessem J. The association between conduct problems and maltreatment: testing genetic and environmental mediation. Behav Genet. 2010;40(3):338–48.CrossRefPubMed
Smits I, Soenens B, Vansteenkiste M, Luyckx K, Goosens L. Why do adolescents gather information or stick to parental norms? Examining autonomous and controlled motives behind adolescents’ identity style. J Youth Adolesc. 2010;39(11):1343–56.CrossRefPubMed
Osterman KF. Students’ need for belonging and school community. Rev Educ Res. 2000;70:323–67.CrossRef
Connell JP, Wellborn JG. Competence, autonomy, and relatedness: a motivational analysis of self-system processes. In: Gunnar MR, Sroufe LA, editors. Self processes and development, vol. 23. Hillsdale, NJ: Erlbaum; 1995. p. 43–77.
Smith AR, Steinberg L, Strang N, Chein J. Age differences in the impact of peers on adolescents’ and adults’ neural response to reward. Dev Cogn Neurosci. 2015;11:75–82.CrossRefPubMed
Mahalik JR, Levine Coley R, McPherran Lombardi C, Doyle Lynch A, Markowitz A, Jaffee S. Changes in health risk behaviors for males and females from early adolescence through early adulthood. Health Psychol. 2013;32(6):685–94.CrossRefPubMed
Dever BV, Schulenberg J, Dworkin J, O’Malley P, Kloska D, Bachman J. Predicting risk-taking with and without substance use: the effects of parental monitoring, school bonding, and sports participation. Prev Sci. 2012;13(6):605–15.CrossRefPubMedPubMedCentral
Weigard A, Chein J, Albert D, Smith A, Steinberg J. Effects of anonymous peer observation on adolescents’ preference for immediate rewards. Dev Sci. 2014;17(1):71–8.CrossRefPubMed
Irwin CE, Adams S, Park M, Newacheck P. Preventive Care for Adolescents: few get visits and fewer get services. Pediatrics. 2009;123(4):e565–72.CrossRefPubMed
Lehrer JA, Pantell R, Tebb K, Shafer M. Forgone healthcare among U.S. adolescents: association between risk characteristics and confidentiality concern. J Adolesc Health. 2007;40:218–26.CrossRefPubMed
Gilber AL, Rickert VI, Aalsma MC. Clinical conversations about health: the impact of confidentiality in preventive adolescent care. J Adolesc Health. 2014;55(5):672–7.CrossRef