Adolescence
Robert A. King
We are born, so to speak, twice over. Born in existence and born into life; born a human being and born a man.
—Rousseau, Emile
Adolescence in contemporary Western industrial society is shaped and defined by the interplay of complex biological, cultural, economic, and historical forces. This lengthy transitional state, which may last a decade or more, is a distinctive period in which a youngster is no longer a child nor yet fully adult, but partakes of some of the challenges, privileges, and expectations of both epochs.
Adolescence is a period of paradoxes, as youngsters reach physical and sexual maturity well before they are fully cognitively and emotionally mature. On one hand, a secular trend toward earlier puberty over the past century and half means that defining maturational changes often begin by age 9–12, and that by 13 years of age many youngsters are potentially fertile and sexually attuned, if not yet fully active. On the other hand, the educational demands of a complex modern economy have prolonged formal education and raised the age of mandatory school attendance to approximately 16 years, whereas social welfare concerns have abolished child labor and legally restricted adolescent employment, thus postponing entry into the world of work. [Some measure of this shift may be seen in the contrast between 1900, when many Americans still lived on family farms, and only 10% of 14- to 17-year-olds attended high school, and the present 95% high school attendance rate (1).]
As a result, full economic emancipation usually is not possible until the later teens, at the earliest, and in the case of young people pursuing college or postgraduate education, often not until the middle to late 20s.
In the United States, the legal status of adolescents is a confusing mixture of privileges and strictures that attempts to balance the need for control and protection with the incremental granting of autonomy (2). For example, a 14-year-old may fly a plane, but not legally drive a car, whereas a 17-year-old may serve in the army, but not vote until 18 years of age, when he or she still is not legally allowed to drink. In many jurisdictions, a 14-year-old may legally obtain an abortion without her parents’ knowledge or consent but needs her parents’ permission to be absent from school to do so.
Despite the restrictions on their full-time employment, young adolescent consumers are a potent economic force, controlling billions of dollars in disposable income annually. Teenagers, hence, comprise an eagerly sought-after demographic target for marketers, advertisers, and the broadcast, print, and electronic media. In turn, to attract and hold these young viewers and readers, media programming directed to them increasingly emphasizes sex and violence as prominent themes; sexual themes are estimated to make up approximately one-third of the content of prime time shows popular with teens (3).
Winnicott once remarked aphoristically, “There is no such thing as a baby,” meaning that the baby could not be considered apart from its relationship with its mother. Although adolescence is the epoch par excellence of individuation and autonomy striving, it is similarly impossible to have a full understanding of adolescent development apart from its specific biological, family, community, cultural, and historical contexts (4). Thus, while recent theoretical perspectives on adolescence acknowledge the development of independence and autonomy from parents, there is now an increased awareness of the complementary dynamic of the adolescent’s developing capacity for interdependence and the ability to form and sustain mutually supportive relationships outside the family. Paralleling this relational perspective is an increased emphasis on the ecological perspective, which sees individual adolescents and their relationships as embedded in the interconnected contexts of family, school, neighborhood, and culture (5).
The interactions among these factors are complex and multidirectional. Not only are adolescents influenced by their families, but they reshape their families’ dynamics as they grow. Although important aspects of adolescents’ development are genetically and biologically determined, the effects of these determinants may be mediated or influenced by psychosocial factors. For example, family factors influence not only the impact of the timing of puberty but may actually affect the timing of puberty itself, with earlier and more rapid maturation in adolescents raised in more conflictual, less supportive homes (6,7,8). Behavioral genetics studies that have revealed the importance of nonshared environmental factors suggest that adolescent siblings evoke different interactional and social environments even within the same family (9).
It is important to bear in mind the great diversity of social and family contexts in which today’s adolescents grow up (10,11). In the United States, despite some commonalities, the experiences of adolescent who are immigrants, gay or lesbian, or growing up in poverty, foster care, single-parent, or other nontraditional family structures differ in important ways from the general patterns presented later in this chapter. Even greater differences exist between the majority culture of the West and more traditional societies, with less emphasis on individual autonomy and fewer expectations that adolescence should be a period of vocational choice or attaining full independence from families (12). Some anthropologic studies have concluded that in such preindustrial societies, there may be less adolescent turmoil and conflict with parents (13,14).
One important research question concerns the impact on adolescence as the processes of modernization (demographic shift to longer life span, smaller families, urbanization, shift from agrarian to manufacturing and service economies,) and globalization (with development of an “information society”) expose more and more teenagers in such societies to the same media and cultural influences as in the West (11,12,13). As 85% of the world’s adolescents, age 10 to 19 years old, live in developing countries, where they comprise one-third of the national populations, these influences will play a fateful role in shaping the coming century’s culture, politics, and economy (15).
One facet of globalization transforming important aspects of adolescence is the near-ubiquitous availability, at least in the industrialized world, of various electronic media, such
as TV, video games, cellular telephones, and the Internet (including instant messaging, e-mail, downloading music and videos, and social networking sites, such as Facebook and MySpace). At least ¾ of American teens instant message and as many as 1/3 maintain blogs (16). The Youth Risk Behavior Survey (17) found that one-fifth of high school students reported 3 or more hours a day spent on an average school day playing video or computer games or using a computer for something other than schoolwork. A recent Kaiser Family Foundation Study (18) documented the relative amounts of time youngsters, age 8–18 years old, spent daily on these activities, compared with nonmedia activities (see Table 3.1.4.1; note that the times are not mutually exclusive; for example a youngster may talk on the phone while watching TV. Indeed, about 25% of youngsters reported multitasking (using more than one medium at the same time)). Over and above the sheer number of hours spent on these various media and their impact on youngsters’ attention and cognitive style, youngsters are now exposed, for good or ill, and often without much adult supervision, to a plethora of global influences and virtual subcommunities, ranging from pornography to fellow aficionados of various cultural, athletic, or intellectual interests. Many adolescents now live much of their lives in an on-line social context; how this will influence their emotional and social development remains a vast experiment in progress (16).
as TV, video games, cellular telephones, and the Internet (including instant messaging, e-mail, downloading music and videos, and social networking sites, such as Facebook and MySpace). At least ¾ of American teens instant message and as many as 1/3 maintain blogs (16). The Youth Risk Behavior Survey (17) found that one-fifth of high school students reported 3 or more hours a day spent on an average school day playing video or computer games or using a computer for something other than schoolwork. A recent Kaiser Family Foundation Study (18) documented the relative amounts of time youngsters, age 8–18 years old, spent daily on these activities, compared with nonmedia activities (see Table 3.1.4.1; note that the times are not mutually exclusive; for example a youngster may talk on the phone while watching TV. Indeed, about 25% of youngsters reported multitasking (using more than one medium at the same time)). Over and above the sheer number of hours spent on these various media and their impact on youngsters’ attention and cognitive style, youngsters are now exposed, for good or ill, and often without much adult supervision, to a plethora of global influences and virtual subcommunities, ranging from pornography to fellow aficionados of various cultural, athletic, or intellectual interests. Many adolescents now live much of their lives in an on-line social context; how this will influence their emotional and social development remains a vast experiment in progress (16).
TABLE 3.1.4.1 TIME SPENT BY YOUTH 8–18 Y.O. WITH MEDIA AND SELECTED NONMEDIA ACTIVITIES IN A TYPICAL DAY | ||||||||||||||||||||||||||||||||
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Physical Changes at Adolescence
The term puberty (from the Latin pubertas, meaning age of manhood) is used to refer to the physiologic and morphologic changes that mark the transition from childhood to adulthood.
Hormonally Mediated Changes
The most visibly dramatic aspects of adolescence relate to the hormonally mediated changes of puberty: the development of primary and secondary sexual characteristics; marked growth in stature, muscle mass, and strength; and increased sebaceous gland activity. These changes are the result of three different sets of hormonal changes: 1) adrenarche, 2) gonadarche, and 3) increased growth hormone secretion.
Adrenarche, the steady increase in adrenally produced androgens, begins as early as 6 to 8 years of age, leading to increased skeletal growth and the beginning appearance of body hair even before the surge of gonadal hormones associated with puberty proper.
Puberty proper is marked by gonadarche, in which the pulsatile release of gonadotropin-releasing hormone produces increased pituitary release of follicle-stimulating hormone and luteinizing hormone that in turn drive the production of gonadal hormones (primarily testosterone in boys, estrogen in girls). Together with these gonadal hormones, increased release of growth hormone stimulates the pubertal growth spurt.
The triggers for this activation of the pituitary–gonadal axis are unclear, but have been speculated to include leptin (serving as a metabolic signal of adequate body weight/composition), neurotransmitter-mediated attenuation of inhibitory tone or increased excitatory tone at the level of the hypothalamic gonadostat, and altered hypothalamus–amygdala interactions (19,20).
The process of puberty takes approximately 4 to 5 years from start to finish, with girls (in the industrialized world) beginning the process on average at 9 to 11 years of age, approximately 2 years earlier than the average onset for boys. The various stages of this process, as indicated by pubic hair, breast development, height spurt, and menarche in girls, and pubic hair, penile and testicular growth, and height spurt in boys, have been classified by Tanner (21) into stages I through V. Although Tanner staging of a child’s pubertal development is done most accurately by direct physical examination, alternative methods include the self-report Pubertal Development Questionnaire, or asking youngsters to identify their stage of development using a set of standard, gender-specific photographs (7).
The first harbinger of impending puberty usually is acceleration in linear growth, as much as 10 cm per year, which usually precedes increases in muscle mass and strength, thereby producing the gangly appearance of many early adolescents.
For girls, the initial stages of puberty are the beginnings of breast development [mean age 8.9 years (Standard deviation [SD], 1.9) for African-American girls and 10.0 years (SD, 1.8) for white girls] and the appearance of pubic hair [mean age 8.8 years (SD, 2.0) and 10.5 years (SD 1.7), respectively] (22).
The clearest marker of puberty in girls is the onset of menses, or menarche. Girls’ periods initially remain irregular for some time, and despite the high rates of early teen pregnancy, ovulation and full fertility may require 2 years to develop. Most modern girls have been well prepared for menarche by health classes, peers, and mothers, and news of who has (or has not) yet begun her periods is the topic of excited exchanges of confidences among middle school girls.
A critical body weight and fat/muscle ratio appears to be a necessary condition for menarche; hence, girls who train intensively for athletics or dance or who are anorectic may have delayed menarche. Probably related to the permissive role of adequate nutrition and body weight, there has been a steady secular decrease in the age of menarche since the Industrial Revolution, at the rate of approximately 2.3 months per decade. Currently, the average age of menarche is 12.9 years (SD, 1.2) in white girls and 12.2 years (SD, 1.2) in African American girls (22). (As in preindustrial Europe, the age of menarche remains approximately 17 years in many developing countries). In recent years, there has been controversy about the appropriate norms for deciding at what age female pubertal
development should be considered premature, because one large study found that by 7 to 8 years of age, 5% of white girls and 15.4% of African-American girls were at Tanner stage II or greater for breast development and 2.8% and 17.7%, respectively, were at Tanner II stage or greater for pubic hair. Further study is needed as to whether this represents an increased prevalence of very early puberty in girls, and if so, what its implications are regarding potential causes and indications for suppressive treatment (23,24).
development should be considered premature, because one large study found that by 7 to 8 years of age, 5% of white girls and 15.4% of African-American girls were at Tanner stage II or greater for breast development and 2.8% and 17.7%, respectively, were at Tanner II stage or greater for pubic hair. Further study is needed as to whether this represents an increased prevalence of very early puberty in girls, and if so, what its implications are regarding potential causes and indications for suppressive treatment (23,24).
In boys, growth of the penis and testes and beginning spermatogenesis occur in early and middle adolescence. In contrast to menarche, however, “semenarche” or the beginning of ejaculation, whether by masturbation or spontaneous nocturnal emissions, usually remains a very private matter among Western boys (25).
Detailed longitudinal studies reveal considerable variation in the onset and progress of the various stages of puberty, both within and between genders. Thus, peak growth velocity in girls occurs approximately 2 years earlier than in boys, whereas pubic hair appearance often is only approximately 9 months earlier.
Much research has examined the question of the developmental impact on adjustment of early versus late maturation in boys and girls (19,26,27). In general, these studies show that, for boys, early maturation is advantageous in terms of popularity, self-esteem, and intellectual abilities, but does confer some increased risk for delinquent or problem behaviors, perhaps because of friendships with older peers (8). For girls, the picture is more complex, with early maturing girls tending to have more adjustment difficulties (including lower self-image and greater vulnerability to depression, anxiety, and eating disorders), to engage in more risky behaviors, and to experience early sexual intercourse. The impact of early versus late maturation in girls, however, also depends on social context variables such as social class, pubertal status of peers, cultural norms, and timing of concomitant changes (e.g., school transition), as well as prepubertal adjustment (8,19,28).
For many decades, an emphasis on the psychological effects of pubertal hormonal changes dominated discussions of the psychobiology of adolescence—what might be termed the “raging hormones” theory of adolescent psychology. However, only limited and equivocal associations have been found between various forms of adolescent psychopathology and gonadal hormonal levels (29,30), with hormonal levels accounting for only a very small proportion of the variance in negative affects, compared with the influence of social factors.
Neurobiological Changes in Adolescence
Recent research has underlined the magnitude of neurobiological changes in the adolescent brain, especially in the forebrain and mesocortical and limbic regions (31,32). To what extent these are influenced by or dependent on prenatal or pubertal hormonal factors is not clear.
One of the most dramatic changes in adolescent brain reorganization is a massive elimination or “pruning” of cortical synapses, with an estimated loss of up to 30,000 synapses per second during adolescence (33,34). The resulting loss of approximately half of the cortical synaptic connections present before puberty is believed to affect preferentially excitatory synapses and is accompanied by declines in brain glucose metabolism, oxygen utilization, and blood flow; decreased overall electroencephalographic amplitude; and more complex and focal patterns of brain activation. The neuropsychological and neurochemical consequences of this synaptic remodeling are especially prominent in the prefrontal cortex, with loss of excitatory glutamatergic inputs, but also marked changes in dopaminergic input.
Longitudinal magnetic resonance imaging studies find a rostrocaudal wave of growth in the corpus callosum during childhood, with growth rates in the fibers connecting the temporoparietal cortical association and language areas peaking in early adolescence and then declining (perhaps paralleling the ending of the critical period for second-language acquisition). Cortical volume changes varied by region, with enlargement in the temporoparietal regions, but up to 50% loss in the subcortical gray matter of the head of the caudate (35). A longitudinal MRI study of youngsters 7–19 years of age found that intelligence was associated with the trajectory of cortical development, especially in the frontal regions. More intelligent children had a “particularly plastic cortex, with an initial acceleration and prolonged phase of cortical increase [peaking at about age 11 years], which yields to an equally vigorous cortical thinning by early adolescence” (32).
The full extent and significance of these changes in brain architecture and functioning are not yet clear (20,32,35). It seems likely, however, that they are reflected in the adolescent’s burgeoning intellectual capacities, as well as a shift in various motivational, attentional, and emotional realms. For example, various neuropsychological tasks of executive functioning and inhibition that are believed to involve prefrontal cortical functioning continue to improve through adolescence (36).
Studies of schizophrenia, mood disorders, and other conditions have shed light on the pathogenic potential of these adolescent brain developments (see extensive review by Spear (20)). For example, the neurodevelopmental theory of schizophrenia (37) draws on the observation that although the infectious, neuromigratory, and nutritional insults predisposing to the disorder occur prenatally (usually in the second trimester), overt schizophrenic symptoms typically do not appear until late adolescence. Drawing on various animal models, Weinberger (37) and colleagues suggest that the behavioral effects of early lesions remain largely silent until unmasked by abnormalities in the usual late-adolescent maturational changes in the prefrontal cortex, hippocampus, or other limbic regions; these maturational changes are hypothesized to lead to the overt symptoms of schizophrenia, perhaps because of increased sensitivity to normative adolescent stressors. The normal adolescent maturation of the dorsolateral prefrontal cortex and working memory capacity is in part related to developmental changes in GABAergic neurons and their synapses, which are essential for the fine tuning of inhibitory control. Evidence from a variety of sources suggests that these developmental changes in GABAergic neurons are disrupted in schizophrenia (38).
The normative pubertal maturational changes in neuronal connectivity and functioning may interact with specific genetic vulnerabilities to influence the development of psychopathology. For example, Gothelf et al. (39) showed that over the course of adolescence in velo-cardio-facial syndrome (22q11.2 deletion syndrome), youngsters with the low-activity allelic form of catechol-O-methyltransferase (COMT) were at increased risk of decline in prefrontal cortical volume and cognitive functioning, as well as development of psychosis, compared to subjects with the high-activity allelic form. (It is of interest that the propensity of adolescent marijuana use to produce psychosis is also moderated by these same COMT polymorphisms (40)).
Other Biological Changes
Along with puberty come changes in appetite and sleep patterns.
Across species, the adolescence-associated growth spurt results in more time spent feeding and foraging for food. Most families with teenagers can attest to their youngsters’ elevated
metabolic rate and what has been termed developmental hyperphagia (20,41).
metabolic rate and what has been termed developmental hyperphagia (20,41).
Adolescence also sees a shift in sleep patterns, with a sleep phase delay or tendency to fall asleep later and wake up later (42). On average, 10- to 12-year-old children sleep approximately 9.3 hours a night and awaken spontaneously. In contrast, the mean length of sleep for high school students is 7.5 hours per night, with one-fourth of students sleeping 6.5 hours or less per night. Laboratory studies, however, suggest that the actual average sleep need for high school students is closer to 10 hours per night (43).
Part of this phase shift appears to be biological; later night-onset and later morning-termination of melatonin secretion make it difficult for the adolescent to go to sleep earlier or to wake up alert in time for school, which, deleteriously for many teenagers, may begin as early as 7:20 AM. This shift in sleep patterns also has a psychosocial component. Adolescents are given greater autonomy by their parents in controlling their own bedtimes, whereas the expansion of social contacts outside the home and increased social stimulation (in the form of phone, instant messaging, and e-mail) keep the teenager up later.
As a result of both these environmental and neurobiological factors, many adolescents suffer from “too little sleep at the wrong circadian phase,”(43) especially on school days, with consequent difficulty getting up, frequent daytime drowsiness, and impaired alertness and cognitive functioning. Such adolescents are also at increased risk of learning difficulties, impaired academic performance, depressed mood, and accident-proneness.
Cognitive Changes in Adolescence
Adolescence is marked by dramatic quantitative and qualitative growth in cognitive abilities (44). Although not a universal achievement, adolescence marks the attainment for many youngsters of what Piaget termed the stage of formal operations, with the ability to construct “contrary-to-fact” propositions and a growth in hypothetico-deductive problemsolving ability and understanding of propositional logic and probability (45). Along with a greater capacity for abstraction, adolescence often sees the flowering of passionate intellectual and aesthetic interests, with impressive achievements in areas such as music, mathematics, computer science, or physics. Interestingly, adolescent works of genius are more commonly in these abstract areas than in those involving the empirical sciences or the humanities.
Although the validity of Piaget’s views have been debated, there is a general consensus that adolescents’ cognitive abilities are characterized by growing complexity, the ability to think about possibilities, and increased speed and efficiency of information processing.
These cognitive changes also have their counterpart in the adolescent’s social cognition and moral development (46). The development of formal operational thinking permits a growth in social perspective-taking and a decline in childhood egocentrism; it enables the adolescent to contemplate better what a social situation might look like from another person’s point of view. As described by Kohlberg (47), moral reasoning becomes more complex and expands to include orientation to interpersonal relationships, maintenance of social order, notions of social contract and general rights, and, finally, reference to universal ethical principles. (Gilligan (48) has criticized Kohlberg’s purportedly universal hierarchy of stages of moral reasoning as male-oriented in its emphasis on rules and universal principles and “moral logic of justice,” in contrast to what she sees as the more interpersonal and nurturant bases of women’s values in the “moral logic of care.”)
Despite greater cognitive abilities, however, adolescents do not always use these capacities for sound decisionmaking, in part, perhaps, because their cognitive performance in real-life situations (as opposed to optimal test conditions) is more vulnerable to disruption by strong affects, everyday stresses, and peer influences (46,49,50,51,52).
On a practical level, the adolescent develops a more mature time sense, a greater awareness of the finality of death, and, along with wider knowledge of the outside world, a keener sense of the diversity and relativity of moral codes. This moral awakening may be accompanied by an intensified interest in and sophistication about politics, ideology, or religion. This wider vision, as most eloquently described in the work of Erik Erikson (53), provides both opportunities and hazards. Along with a penchant for philosophical musings, the adolescent may experience a sense of moral confusion and at least transient feelings of anomie. The anxieties of what Seltzer (54) has termed frameworklessness may lead some adolescents to a fanatical embrace of some ideology or religion on one hand or a posture of nihilism on the other.
Psychological Tasks of Adolescence
The physical, neurobiological, and cognitive changes described previously herald dramatic shifts in the adolescent’s relationship to his or her own body, appetites, parents, peers, and self-image. In this next section, we turn to the psychological tasks of adaptation these shifts impose on the developing teenager (Table 3.1.4.2).
Coping with a Changing Body Image
Save for pregnancy or devastating illness, no other epoch sees such dramatic changes in the body and its self-representation as does adolescence. Although often welcome, these changes also are unsettling. Body and facial hair begins to grow. Menstrual discharges, erections, or ejaculation can occur at unexpected and embarrassing times. Acne and body odors make their appearance and are a source of anxiety. Boys’ voices may break unexpectedly as they deepen. Changes in the distribution of fat and muscle alter body outlines. Not only must girls deal with breast development, but, to their embarrassment, many boys develop gynecomastia.
Adolescents compare their development carefully with that of their peers and are acutely aware of their self-perceived imperfections. Much time is spent brooding in front of the mirror, examining every potential blemish and trying to catch
a glimpse of the self. A single pimple may seem to loom as large as the Matterhorn, its stigma increased by the sense that it is as glaringly obvious to everyone else as it is to the adolescent.
a glimpse of the self. A single pimple may seem to loom as large as the Matterhorn, its stigma increased by the sense that it is as glaringly obvious to everyone else as it is to the adolescent.
TABLE 3.1.4.2 GROWTH TASKS BY DEVELOPMENTAL PHASE | ||
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In Western society, girls in particular are very preoccupied with the body image ideal of thinness held up to them by the media (55). Girls’ levels of satisfaction with their bodies and physical appearance decline as they pass through adolescence. This is especially problematic for girls who are earlier maturing. The National Health Examination Survey (56) found that most adolescent boys with body weights less than the top 10th percentile were satisfied with their weight; in contrast, even among girls whose weight was in the 50th percentile, 25% of lower socioeconomic group girls and over 40% of high socioeconomic group girls wanted to be thinner. The Youth Risk Behavior Survey (17) found that although 32% of high school boys and 25% of girls were overweight or at risk of being overweight (defined as having a body mass index equal to or greater than the 85th percentile for age and sex), only 25% of boys thought they were overweight, compared with 38% of girls; furthermore, only 30% of boys were trying to lose weight during the preceding 30 days, compared with 62% of girls. Compared with black girls, a higher proportion of white and Hispanic girls considered themselves overweight or were trying to lose weight.
Pathologic eating behaviors are common in adolescent girls. For example, a survey of two private girls’ secondary schools found that 18% of the girls reported at least one major symptom of an eating disorder: 8% to 15% thought about food all the time, 6% to 12% induced vomiting to control their weight, over 2% used laxatives for weight control, and 7% often fasted or starved to lose weight (57). The most recent Youth Risk Behavior Survey (17) found that 4.5% of high school students report vomiting or taking laxatives within the past month to lose or control weight; the prevalence was higher among girls (6.2%) than boys (2.8%), with white and Hispanic girls reporting a higher prevalence (6.7 and 6.8% respectively) than black females (4.0%). These endemically high levels of body dissatisfaction and pathologic eating attitudes and behaviors provide a large reservoir of vulnerable adolescent girls from whose ranks those with frank bulimia and anorexia are recruited.
More research is needed, however, to understand better the cultural factors that influence the wide variations in the prevalence of disordered eating attitudes and behaviors across different communities and ethnic groups and over time.

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