Adolescence…A Critical Transition
WHO identifies adolescence as the period in human growth and development that occurs after childhood and before adulthood, from ages 10 to19. It represents one of the critical transitions in the life span and is characterized by a tremendous pace in growth and change that is second only to that of infancy. Biological processes drive many aspects of this growth and development, with the onset of puberty marking the passage from childhood to adolescence. The biological determinants of adolescence are fairly universal; however, the duration and defining characteristics of this period may vary across time, cultures, and socioeconomic situations. This period has seen many changes over the past century namely the earlier onset of puberty, later age of marriage, urbanization, global communication, and changing sexual attitudes and behaviors.
Key developmental experiences
The process of adolescence is a period of preparation for adulthood during which time several key developmental experiences occur. Besides physical and sexual maturation, these experiences include movement toward social and economic independence, and development of identity, the acquisition of skills needed to carry out adult relationships and roles, and the capacity for abstract reasoning. While adolescence is a time of tremendous growth and potential, it is also a time of considerable risk during which social contexts exert powerful influences.
Pressures to engage in high risk behaviour
Many adolescents face pressures to use alcohol, cigarettes, or other drugs and to initiate sexual relationships at earlier ages, putting themselves at high risk for intentional and unintentional injuries, unintended pregnancies, and infection from sexually transmitted infections (STIs), including the human immunodeficiency virus (HIV). Many also experience a wide range of adjustment and mental health problems. Behavior patterns that are established during this process, such as drug use or nonuse and sexual risk taking or protection, can have long-lasting positive and negative effects on future health and well-being. As a result, during this process, adults have unique opportunities to influence young people.
Adolescents are different both from young children and from adults. Specifically, adolescents are not fully capable of understanding complex concepts, or the relationship between behavior and consequences, or the degree of control they have or can have over health decision making including that related to sexual behaviour. This inability may make them particularly vulnerable to sexual exploitation and high-risk behaviours. Laws, customs, and practices may also affect adolescents differently than adults. For example, laws and policies often restrict access by adolescents to reproductive health information and services, especially when they are unmarried. In addition, even when services do exist, provider attitudes about adolescents having sex often pose a significant barrier to use of those services.
Family and community are key supports
Adolescents depend on their families, their, communities, schools, health services and their workplaces to learn a wide range of important skills that can help them to cope with the pressures they face and make the transition from childhood to adulthood successfully. Parents, members of the community, service providers, and social institutions have the responsibility to both promote adolescent development and adjustment and to intervene effectively when problems arise.
Social and Emotional Challenges in Adolescence
Most teenagers have concerns about being accepted by their peers, but many teens with ADHD have come to expect some social rejection due to their difficulties with controlling their behavior and understanding others’ social signals. Social issues encountered in childhood can become worse in adolescence, with the intensity of any rejection or bullying increasing during the teenage years. This rejection can negatively affect both academic performance and emotional health—and can be, in fact, much more troubling to him than making poor grades in school. He also may appear emotionally immature compared with classmates, and sometimes he’ll be more comfortable interacting with younger peers or when spending time with adults who may show greater acceptance of his immature actions.
As with academic challenges, however, difficulties with social interaction can often be helped by having adolescents learn specific skills. You learned a number of ways to teach younger children how to interact positively with others, including role modeling, role-playing, analyzing interaction, and practicing new techniques. Now, in adolescence, your child is likely to experience new motivation to improve his social life, and advice about social issues is now more often sought from peers than from parents.
Teenagers with ADHD can certainly have the close friendships that are important for their happiness and self-esteem. A teenager’s targeted efforts to increase the accuracy of his social perceptions and monitor his social interactions may make this easier for him. As he develops friendships, support this by allowing his friends to hang out in your home and help to provide the kind of supportive environment that facilitates all friendships. Observe how the friends relate to one another, and provide tactful feedback later if you feel that it will be received in a positive and constructive manner. Teenagers with ADHD need to be increasingly aware that friendships take organizational skills too—returning phone calls, arriving at meeting places on time, and following through on plans.
It is important for your teenager to learn how to resolve conflict without resorting to physical fights, and how to avoid becoming the target of others’ aggression. Again, resolving conflict can be a difficult teenage task if his impulsiveness causes him to strike out when he gets upset. An important step in avoiding this problem is to identify his own anger cues and to brainstorm in advance about the kinds of positive solutions he can apply to future conflicts.
If this is an issue with your teenager, through discussions with you and peers; post-conflict analysis; and sessions with a counselor, therapist, or social-skills instructor, he can learn to “talk himself down” when he finds himself in a frustrating clash of wills (“I’m going to take three deep breaths and think about my best choice in this situation before lashing out.”). He can also practice conflict-prevention techniques, such as providing an alternative (“How about if we go bowling first and then see a movie?”), adding provisions (“OK, you can drive, but then I get to decide on the restaurant.”), or changing the subject (“I’m starving. You want to get some pizza?”).
Once your child has learned a few of these specific techniques, he may be surprised at how effective they are in helping him avoid the crises that used to disrupt his social life. If you are seeking counseling in this area, the most proven approach is through cognitive-behavioral therapy—this is a type of talk therapy that views behavioral issues as related to the interaction of thoughts, behaviors, and emotions. In cognitive-behavioral therapy, the therapist and adolescent will work on identifying and directly changing behaviors that are problematic.
Working on Social Skills
As with other learning processes, your teenager can hone his social skills and interaction by
- Developing a list of specific target behaviors to work on
- Outlining a step-by-step plan to address each one
- Receiving consistent, tactful feedback from you, his peers, and his teachers
- Learning such techniques as identifying cues that set off his anger, analysis of others’ social interaction, social role-playing, etc
- Getting training in anger management or social skills, or treatment in individual or group therapy, when appropriate
- Receiving treatment for any coexisting conditions that may affect his social interaction
- Getting positive feedback for improvement in targeted social skills
- Staying involved in rewarding prosocial activities
That said, it is also true that many people with ADHD continue to have trouble with certain social interactions throughout adolescence and into adulthood. Whether or not this is the case with your teenager, make it clear that you support him no matter what. Nothing will be more difficult for him than overcoming social rejection. It will mean a lot to your teenager to know that you will always be in his corner. Keep in mind that even teenagers who are socially unhappy in high school go on to find rewarding friendships in college or work situations.
Your Teenager’s Emotional Development
It is easy to see how academic, social, and family strains can create a heavy emotional burden for adolescents with ADHD. Low self-esteem caused by academic failure and social rejection can lead to depression, defensiveness, pessimism about the future, hostility, and physical aggression. Combined with ADHD-related impulsiveness, it can pave the way for unsafe sexual activity; alcohol, tobacco, or drug abuse; and other high-risk behavior.
Take a moment to consider your teenager’s emotional state. Does he spend nearly all of his time alone in his room? Does he seem sad nearly all the time, or irritable? Is his anger starting to get out of hand? Has he been suspended from school more than once this year, or are you receiving reports of inappropriate behavior? If so, discuss these issues with your adolescent and bring them up at follow-up sessions with his pediatrician. Anxiety and depressive disorders should be thought of any time an adolescent’s social, academic, or behavioral functioning starts to deteriorate without an obvious explanation.
In teenage years depression and anxiety increase significantly in individuals with ADHD. Whereas in childhood the number of boys and girls who experience depression are about equal, in adolescence the number of girls outnumber boys by 2 to 1. The sooner an adolescent’s depression, anxiety, anger, substance use, etc, is recognized, the greater the chances that the situation can be resolved before worse problems develop.
Adolescence is a time when all teenagers are prone to testing limits and engaging in risk taking. Adolescents with ADHD and an impulsive style are especially prone to taking risks. Surveys have shown that teenagers with ADHD can have an earlier age of first intercourse, more partners, less use of birth control, and more sexually transmitted infections and teenage pregnancy than their peers. Education about these issues in the preteen years and continuing guidance now can really pay off.
Driving can be a particular area of concern as well. Teenage drivers with ADHD have been reported to be 8 times more likely to lose their license, 4 times more likely to be involved in a collision, 3 times more likely to sustain a serious injury, and 2 to 4 times more likely to receive a moving violation. As a parent, you may want to consider this area carefully, make sure that your adolescent is at a maturity level appropriate for driving, and set appropriate limits if necessary. Some parents restrict the time of day when their adolescent with ADHD can drive and make driving contingent on responsible driving behavior.
It is a known fact that teenage driving accidents go up progressively with the number of people in the car. Parents may put limits on how many teenagers can travel in the car when your teenager is behind the wheel, particularly in the first year or two of driving. Discuss safe driving at home. Where medication is found helpful in cutting down on impulsivity, it makes sense to have a rule that teenagers who respond well to medication make sure that their medication schedule includes driving times.
Finally, as with any teenager it makes ultimate sense to have a “parent taxi” understanding. Even if use of alcohol or drugs is never condoned by parents, develop an understanding that it is always safe for your teenager to call you and ask you to pick them up if they are even minimally impaired from these substances.
Adolescent Behavior Problems
Many adolescents today have problems and are getting into trouble. After all, there are a lot of pressures for kids to deal with among friends and family. For some youth, pressures include poverty, violence, parental problems, and gangs. Kids may also be concerned about significant issues such as religion, gender roles, values, or ethnicity. Some children are having difficulty dealing with past traumas they have experienced, like abuse. Parents and their teenagers are struggling between the youth’s wanting independence while still needing parental guidance. Sometimes all these conflicts result in behavior problems.
Any number of isolated behavior problems can represent adolescent problems and delinquency-shoplifting, truancy, a fight in school, drug or alcohol ingestion. Sometimes, kids can’t easily explain why they act the way they do. They may be just as confused about it as the adults, or they simply see delinquent behaviors as appropriate ways to deal with what they experience. Parents and loved ones may feel scared, angry, frustrated, or hopeless. They may feel guilty and wonder where they went wrong. All these feelings are normal, but it is important to understand that there is help available to troubled kids and their families.
How do you know when to seek help?
What are the signs of trouble? Many adolescents get into trouble sometimes. A big question for parents (whether they be “traditional,” single, step, or grand-parents), though, is how to know when a youth is headed for more serious problems, or when bad behavior is just “a kid being a kid.” Try to focus on patterns rather than an isolated event. In other words, does the behavior happen repeatedly despite efforts to change it?
The patterns signaling the need for help include not only deviant behaviors by the adolescent, but also the presence of other problems in the family or tensions at home. For example, problems in the parents’ marriage or frequent fighting or hostility among the family members can also be involved in the youth’s behavior problems. The problem behaviors and other family issues can interact and feed off each other, so that it is hard to tell where it started.
Of course, there are also some obvious signs that indicate the need for immediate and effective intervention, including violence against other persons or animals, or when peers are involved in destructive processes (crime, truancy, drugs). Or, a parent may simply have an instinctive feeling that something serious is happening. An important first step to find out what is going on is to try to talk to the adolescent and other family members about what is happening, possible reasons, and potential solutions. Others who know the adolescent and family, like teachers or caregivers, may also be able to provide information about the youth’s mood or behaviors outside of the home to help assess the severity of the problem.
Many factors put youth and families at risk for juvenile delinquency, though they do not necessarily cause delinquency. Such factors include youth attention and hyperactivity problems and learning disorders, volatile temperament, and even the early onset of puberty and sexual development. All these factors affect the way an adolescent feels and acts and also how peers, family, and society view the adolescent. Similarly, parental problems, such as depression, substance abuse, and domestic violence can interact negatively with a youth’s developing path of delinquency. Rather than causing delinquency, factors such as these tend to place youth at increased risk, intensify the downward spiral, and in turn add to the difficulty in changing these processes for the better.
What kinds of treatments will work?
Once you have determined that you and your loved ones need help, there are many kinds of treatment that you should explore. First, there are popular group-based, residential, and “life-experiential” options, like survival camps, boot camps, and “scared straight” programs, which have had some limited success. Research indicates that the most effective treatments, even with very difficult youth, are programs and treatments that are family-based and multisystemic. That means treatment that involves the adolescent and his or her family, and that also addresses other aspects of their lives, such as the school system, the neighborhood, peers, juvenile justice system, and even employers. In other words, it is treatment that focuses on all the parts of the youth’s life that shape how he or she views the world, emphasizing family and parental support.
Treatments that focus on the family can also be useful in helping adults develop their parenting skills, deal with stress, and work on marital relationships. Many parent aids have demonstrated promising positive results. Professionals, such as family therapists, are there to help the adolescent and family gain understanding of the relationship dynamics and background issues that may be influencing the problem, and come up with solutions.By Dr. Cameron-Xavier, M.D. WWC CEO & President