1. Describe issues relating to the onset of puberty in American youths.

Adolescence usually begins between 14-17 years of age with some not reaching puberty until 17-20. However, there has been a trend, especially in girls to reach puberty early at age 11-14 over the last century. This has been commonly attributed to improvements in nutrition and health (better nutrition leads to higher body fat leading to puberty). However, there is increasing attention to other factors such as environmental toxins and chemicals (hair spray ingredients) which may be taking a part in this trend.

Puberty results in the development of secondary sex characteristics and increased body size. Most observable changes occur over a 4 year time span with girls beginning 12-18 months earlier than boys. Early puberty has been associated with improved academic and social function in boys but poor body image, increase risk for eating disorders and behavior problems for girls (substance abuse, etc.).

2. List the major outcomes of the identity crisis as described by Erikson.

Erikson saw adolescence as a time of identity crisis between identity vs. role confusion (see Theories of Development. Success in this crisis results in development of fidelity to an ideology. Failure to succeed in this crisis results in role confusion where a coherent identity cannot be achieved and borderline personality disorder occurs.

Identity achievement is the best outcome of this crisis. It involves reasonably firm commitment to an ideology. This occurs when a person experiences the crisis and comes out with a commitment to a political, social, occupation, or value system and a clear, consistent personality. Individuals with identity achievement function better under stress, get better grades, and have higher self-esteem.

Identity diffusion is the worst outcome where no crisis occurs and no commitment is made. An individual with identity diffusion is unpredictable.

Moratorium is a phase during which an identity crisis is currently active but no commitment has yet been made. Individuals in moratorium are philosophically concerned, rebellious, and non-conforming.

Identity foreclosure is when a commitment has been made without a crisis. Typically, these individuals simply accept the mandates of society or their parents without much exploration of alternatives. These individuals are highly conventional and moralistic.

3. Discuss general issues related to self-concept and self-esteem in adolescents.

Adolescents develop a self-concept with the capacity of perceiving their adequacies in multiple dimensions and in abstract terms. They also develop alternative “possible selves” that are contrasted with their real selves. The conception of this “hypothetical version” of self can cause disruption of their self system and loss of self esteem if the distance between the possible self and the real self is too great. Middle adolescent girls feel the greatest fall in self esteem, especially among Whites and Latinas.

4. Discuss general issues related to sexuality in adolescents.

The average age of first sexual activity is 16 years and the number of teens engaging in sex is increasing. Unfortunately, only 1/3 of sexually active teens use contraceptives, often because of lack of access. The rate of teen pregnancy in the United States is higher than any other western industrialized country, possibly due to influences such as the sexualization of media.

Evidence for prenatal hormone patterns determining sexual orientation has received some attention. However, twin studies suggest environmental factors are also implicated. Currently, there is also a casual factor in homosexuality with more experimentation than in the past. As a result, it is important not to foreclose teens to claim they are homosexual because their identification to that lifestyle may not yet be fixed.

Homosexual contacts are most frequent before age 15 and occur usually during middle adolescence. However, 50-60% of those who have homosexual contact identify as heterosexual later in life. There is also a Big Brother theory that the more older brothers an individual has, the most likely that individual will become gay. The theory is that the mother’s immune system attacks the Y chromosome with increasing vigor with each pregnancy.

During adolescence, friendships become more intense and change in quality. Adolescents develop stronger concern regarding reciprocity, loyalty, sharing, and emotional intimacy, especially in girls. Girls develop exclusive same-sex friendships while boys develop less intense, exclusive relationships. Peer influences on behavior appear to come from the closest friends rather than the larger group of peers and the influences are reciprocal. During adolescence, parental influences are reduced as more leisure time is spent with friends and less with parents.

5. Describe the major cognitive changes that take place during adolescence.

Empathy develops significantly during adolescence as responsiveness to emotional experiences of others help maintain important quality of relationships. Moral judgement also increases during adolescence, changing from a rigid acceptance of rules to a more flexible understanding of rules and their relationship to what is best for society at large.

Cognative changes that coincide with a brain growth sprut between age 13 and 15 also occur, qualitatively altering the neural network of adolescents and corresponding with advances in self reflection and abstract thinking. According the Piaget, adolescents enter a formal operational thinking stage with the ability to generate and explore hypotheses and develop higher-order abstractions. Adolescents begin thinking in less concrete concepts and more in relative terms.

Heightened self-reflectiveness results in self-consciousness and promotes egocentricism. Adolescents often develop a personal fable where they have an inflated opinion of self importance and uniqueness, thinking they are special. Also developing out of gains in perspective-taking and increased empathy is the emergence of the imaginary audience which causes adolescents to believe themselves to be the focus of everybody’s attention and concern.

Adolescents also develop a higher working memory, allowing them to hold multiple dimensions on a topic simultaneously to generate multiple alternative solutions. Metacognative skills (thinking about thinking) also develops, allowing adolescents to be able to monitor their own thinking for inconsistencies.

6. Provide examples of psychiatric disorders and other problems that may begin or worsen in adolescence.

About 20% of individuals under 18 suffer from developmental, emotional, or behavioral difficulties but rarely seek help. Substance abuse increases as well as psychiotic disorders.

Eating disorders are more likely to occur in females early in puberty with poor body image and family values idealizing thinness. Anorexia is associated with perfectionism, overprotective/controlling mother, emotionally distant fathers, as well as genetic components. Bulimia nervosa (“you can read minds?”) can associated with disengaged parenting, impulsivity, shoplifting, and substance abuse, though there is some overlap with perfectionism and anorexia.

Adolescents usually have increased activities and neural sensitivity to light which results in later bedtimes and sleep deprivation during the week. This can cause poor performance on cognitive tasks in the morning, depressed mood, and high-risk behaviors.

Depression can manifest as an irritable mood or flatness/emptiness rather than depressed mood per se. Depression can precipitate from social impairments such as academic failure, poor family/peer relationships, and isolation. Somatic symptoms can arise, including insomnia, loss of appetite, psychomotor retardation or agitation. Negative thoughts about self, the world, and the future can results in very low self-esteem, especially among girls for whom low self esteem is so common, it is labeled as normative.

Higher pubertal hormone levels are only weekly associated with moodiness. However, teens tend to be hypersensitive to and report more perceived negative life events. These negative life events coupled with heightened stress reactivity due to neurotransmitter changes (DA, 5HT, ACh) during adolescence can cause more intense mood swings.

Adolescent drug use of every drug except cocaine is on the rise. 32% of high school students binge drink. Violence and aggressive behavior is also on the rise and occurs so often that it is almost normative for adolescents, especially among males. Acting out tends are often depressed.

7. Describe the role of primary physician in detection and treatment of adolescent mental health problems.

Feelings of hopelessness and negativeness can often lead to suicide, which is the 3rd leading cause of death for adolescents, after accidents and homocides. Adolescents tend to overuse avoidant coping strategies to deal with negative affective experiences rather than approach orient strategies like directly solving the problem or seeking help/guidance from others. Typical adolescents speak to parents (60%) and friends (75%) about their problems. However, disturbed adolescents speak to parents <35% of the time and only 1/3 ever seek help from mental health professionals (2/3 never seek professional help). This can be due to stigma of mental illness, perception that nothing is wrong (“just a phase”) or lack of access.

70% of adolescents visit a primary care physician in an average year. Primary care doctors are critical to obtaining specialist care such as mental health services but only half of physicians always ask about their patient’s mental health. Only 1/3 of adolescents with mental illness see a mental health service provider.