Adolescence

Most definitions of adolescence attempt to capture the distinct physical, emotional, and social changes that characterize this turbulent, stage of human development. Writing in her diary, young Anne Frank voiced her experience of adolescent angst.

Adolescents experience a full spectrum of emotions: elation and joy, overwhelming loneliness, laughter and fun, seemingly unbearable emotional pain, anger, and frustration and embarrassment. Supreme confidence and a sense of immortality contrasts with moments of hopelessness, which they perceive are an eternity. They experience the closeness of friendships and discover the pleasure of intimacy. They have intense passions, often reinforced and heightened by the mass media, for music, video games, sports, or other interests, which for a week, a month, or a year are all-absorbing.

Adolescents also have remarkable creativity, energy, compassion, and potential. The teenage years are a time of exploration, idealism, and cynicism. They will make some of the most important decisions of their lives. Ideally, they will plan and prepare for their futures, develop positive attitudes and make healthy, safe, behavioral choices.

Stages of adolescent development

The term adolescence defines the psychosocial development that occurs during puberty. However, there is little agreement about the ages at which adolescence begins and ends. This chapter uses the most commonly agreed-upon period of adolescence, 10 to19 years. By age 19, most young people have completed high school; they are experiencing living outside the family home; and they are pursuing divergent paths (e.g., work, college, parenting, or military service) to adulthood. However, the transition to adulthood often continues through the ages of 20 to 24 years, and these years of young adult life are often included as part of a continuum of adolescence. Therefore, the chapter also includes some data related to this age group.

Physical maturation and psychosocial development shape an adolescent’s capacities to think, relate, and act as a future adult. This development affects and is influenced by adolescents’ choices of occupations and the quality of their occupational performance. The end of adolescence is marked by the legal status of adulthood with all its rights and responsibilities. As OT practitioners, we understand development as a maturational process, which we observe in the age-related tasks and occupational performance challenges that adolescents undertake. These developmental tasks include seeking independence from parents, learning and adopting the norms and lifestyles of peer groups, accepting the physical and sexual development of one’s body, and establishing sexual, personal, moral, and occupational identities. If successfully achieved, these developmental tasks result in a sense of well-being, whereas failure leads to further life difficulties.²⁷ However, developmental tasks do not stand alone, and they are best understood when viewed in the context of adolescents’ sociocultural and economic environments.

Physical development and puberty

Physical development is the result of significant biological changes. Adolescents gain approximately 50% of their adult weight and 20% of their adult height during this rapid period of physical growth. This dramatic increase in height, weight, and changes in body proportions occur as the result of a complex regulatory process, involving pituitary gland initiation of the release of growth and sex-related hormones from the thyroid, adrenal glands, and ovaries and testes.¹¹

Due to individual differences, growth varies in onset and duration. The average growth period lasts about 4 years. It can begin as early as when the child is 9 years old, and in some adolescents, it may continue to around age 17. In the United States, the average peak of growth for girls occurs around age 11, and they usually reach their full height 2 years after they begin menstruating. In boys, age 13 is typically the time of peak growth. Skeletal growth and muscle development result in an overall increase in strength and endurance for physical activities. Bones grow; increase in length, width, strength; and change in composition. This skeletal growth is not consistent; head, hands, and feet reach their adult size earliest. Bones calcify, replacing the cartilaginous composition of bones making them denser and stronger.

During this period of bone growth, muscles also increase in size and strength. Strength is greatest around 12 months after an adolescent’s height and weight have reached his or her peak. The related development in coordination and endurance results in an overall improvement in skilled motor performance.¹¹ These gains in muscle mass and increased capacity in heart and lung functions are greatest in males, and their performance peaks around 17 to 18 years of age.⁹ The difference between the sexes in strength and gross motor performance continues throughout adulthood.

Girls show an increase in motor performance earlier, around the age of 14 years. It also includes enhanced speed, accuracy, and endurance. However, motor performance changes in girls’ are highly variable. A complex interaction of physical and social factors such as their musculoskeletal development and menses as well as their interest, motivation, participation, and attitude toward physical activities influence their motor performance and response to their physical abilities.⁹

Many adolescents find social confidence in fitting within the “typical” pattern of physical development. They derive comfort in being similar to their peers, but there are also advantages in physical competence in sport activities that build self-esteem and enhance social status. In particular, early-maturing boys are more likely to be described as being popular, well adjusted, and leaders at school and in social groups. These adolescents are often more concerned about being liked and adhering to rules and routines than later-developing males. However, there is a downside to early physical development; it brings about the expectations of coaches, parents, and peers to excel in physical activities. This unwelcome pressure can lead to anxiety. In contrast, late-maturing boys are reported to feel self-conscious about their lack of physical development.⁵⁰ A comparable pattern of early physical competence and increased social status is not observed in girls.

Case study

Alisha is an attractive 14-year-old girl, 5 ft 3 in tall. Her outward appearance to her friends, family, and teachers is that of a successful adolescent. She achieves good grades, plays in the high school band, and is a member of the dance team. However, in the past 6 months she has become increasingly self-conscious, especially about her developing body and about the fact that she does not have a boyfriend like her friends do. To her delight, Alisha quickly loses weight on a diet program. However, her dramatic weight loss does not change Alisha’s belief that she is overweight and unattractive. She withdraws from her friends and increases her exercise routine. When her mother finds Alisha purging after eating, she becomes concerned and takes her to a psychiatrist. The psychiatrist diagnoses Alisha’s condition as anorexia nervosa, a disorder characterized by a distorted self-image and a dysfunctional pattern of restricting food intake, purging, or both.

Negative body image, such as Alisha’s view of herself, reflects low self-esteem. Both are often associated with mental health problems. Depression, anxiety, and body image disorders (e.g., dysphoria and anorexia nervosa) are common among adolescents. It is estimated that between 40% and 70% of girls, especially in early adolescence, are dissatisfied with two or more aspects of their physical appearance.²² When listening to conversations among teenage girls, one is likely to hear comments such as “Do you think my backside is too big in these jeans?” or “I’m too fat, I need to lose weight.” Studies of body image report that body dissatisfaction is universal and that most girls, regardless of ethnicity, express a desire to be thin.³⁹ Boys also experience dissatisfaction with their bodies. Their internalized perception of how they “should” be in relation to the images of masculinity involves greater muscle definition and muscle mass, typically in the upper body (i.e., shoulders, arms, and chest).⁶⁵

Adjusting to these physical changes and developing a healthy body image contribute to a positive self-concept. This is a process of self-evaluation related to other abilities and competencies in physical activities (e.g., competitive sports). It also involves experimenting with changing one’s physical appearance to express individuality. This can be simple and temporary, such as dying or cutting one’s hair, or a more permanent statement such as body piercing and tattoos.

Adolescents with disabilities do not always have opportunities to make choices about their appearance and to experiment with change as part of their adolescence experience. Exploring self and body image is more difficult for them, since these adolescents may depend on others for their self-care, may not have their own money, and often lack independence in community mobility. Maintaining their child-like status, rather than adjusting to the emotional and psychological changes and demands of adolescence, may be more comfortable for their parents. Within the framework of therapy, OT practitioners can facilitate experimentation and also support parents in their attempts to encourage typical adolescent activities.

Another dimension of physical maturation is sexual identity. Adolescents explore their sexuality and learn to form intimate relationships. Similar to physical development in strength and motor performance, early sexual maturity has social consequences. An outward appearance of sexual maturity can make adolescents seem older than their actual age, resulting in demands and expectations from peers and adults that they are not psychologically prepared to handle. As mentioned earlier, physically mature adolescents are more likely to have concerns about being liked than later-maturing peers. Despite these concerns, they are often popular and are successful in heterosexual relationships, whereas late-maturing boys are more likely to develop inappropriate dependence, feel insecure, exhibit disruptive behaviors, and abuse substances.^21,65 Some late-maturing boys find validation in academic pursuits and nonphysical competitive activities, especially those from middle and upper socioeconomic families that value such achievement.²⁴ However, studies report that early-maturing girls do not fare as well as do their male counterparts. They have lower self-esteem, have poorer body image, and are more likely to experience psychological difficulties such as eating disorders and depression than do their average maturing peers.⁶⁶ Like late-maturing boys, they are also are more likely to have lower grades, engage in substance abuse (alcohol, drugs), and exhibit behavioral problems.

With sexual maturation of the body, adolescents also develop further awareness of their gender and sexual orientation. Gender identity refers to a person’s perception of and identification with being either masculine or feminine, which is not the same as being biologically female or male. Gender identity is subjective and internal to the individual; it is expressed through personality and how a person presents himself or herself to others.

Sexual orientation refers to a person’s preference pattern of physical and emotional arousal, and sexual attraction toward others of either the opposite sex or the same sex/gender.¹⁹ Adolescence is a time of sexual exploration, dating, and romance, and this period heightens awareness of one’s sexual orientation.

Most adolescents identify their sexual orientation as heterosexual, whereas about 15% of teens in mid-adolescence experience an emotional and/or sexual attraction to their same sex. Approximately 5 percent of teens will identify themselves as gay or lesbian, but they often delay openly identifying their sexual orientation until late adolescence or early adulthood.⁵¹ This postponement of identification as gay or lesbian is attributed to lack of support and acceptance among peers, prejudicial attitudes, and experiences of verbal and physical harassment in high school.¹⁹

Openness as well as willingness to discuss emerging sexuality and sexual and gender orientation is important in all OT practitioners. This openness includes using gender-neutral language (e.g., partner rather than boyfriend or girlfriend; protection rather than birth control), inquiring if they suspect violence in intimate relations, and providing nonjudgmental support.

Cognitive development

The quality of thinking evolves in adolescence. Cognitive development is the evolution of mental processes: higher-level thinking, construction, the acquisition and use of knowledge, as well as perception, memory, and the use of symbolism and language.⁴⁸ Piaget, the most notable theorist of cognitive development, referred to this phase as formal operations, the development of logical thinking.

The development of formal operation varies among adolescents. Their ability to think becomes more creative, complex, and efficient (speed and adeptness). It is more thorough, organized, and systematic than it was in late childhood.¹¹ Adolescents’ ability to problem-solve and reason becomes increasingly sophisticated, and they develop the capacity to think abstractly (i.e., they do not require concrete examples). Initially, they are less likely to apply this more sophisticated thinking to new situations.^31,65

The distinction between preadolescent thinking, which is characterized by consideration of possibilities as generalizations of real events, and logical thinking is the realization that the world is one of possibilities, imagined as well as real.⁴⁸ This process of thinking about possibilities without the use of concrete examples is referred to as hypothetical–deductive reasoning and is essential for problem-solving and arguing. This type of reasoning makes it possible for a person to identify, imagine, and theoretically explore potential outcomes to determine the most likely or best one. With this newly acquired abstract thinking, adolescents develop the ability to make decisions about their behaviors that integrates values and weighs options. For the first time in their lives, adolescents begin to develop a perspective of time that is future oriented. They see the relationship between their present actions and the future consequences of these actions.

Some gender differences are present in cognitive development. On average, girls exceed boys in verbal abilities, possibly because they acquire language skills earlier. In contrast, boys tend to outperform girls in tasks that use visual–spatial skills, especially manipulating images (e.g., mental rotation). In the area of math performance, boys demonstrate skills in geometry and word problems, whereas girls excel in computational tasks.⁵⁰

As advanced cognitive abilities become established, adolescents achieve independence in thought and action.¹⁰ The quality of performance in academic learning activities (i.e., educational achievement) improves, and adolescents begin to consider and develop occupational skills that will translate into career and work. Personal, social, moral, and political values that denote membership in adult society also evolve. Kohlberg, an important moral development theorist, describes this level of thinking as postconventional.²⁶ It refers to the ability to base one’s moral judgment on one’s own values and moral standards. Adolescents comprehend the bases of laws, the principles that underpin right and wrong, and the implications of violating these principles. This development of moral and social reasoning enables them to deal with concepts such as integrity, justice, truth, reciprocity, and ambiguity.²⁶

Cognition informs occupational performance. One dimension of cognition in the American Occupational Therapy Association (AOTA’s) Practice Framework is self-regulation, the ability to control and monitor one’s behavior and emotions relative to the situation and social cues.¹ Impulsive ill-conceived behaviors with little or no consideration of the consequences are more characteristic of junior high school or early high school students.³⁰ Adolescents with mild-to-moderate cognitive impairments associated with head injuries, severe mental health disorders, and mild intellectual disabilities also exhibit impulsive and poor self-monitoring of their behaviors. They sometimes fail to comprehend the consequences of their actions or to recognize the subtle social cues used as feedback to modify our responses. Difficulty in processing social cues (nonverbal body language and facial expressions) adversely influences the quality of their social interactions and ability to maintain relationships.⁵⁵ Their cognitive impairment may also result in limited problem-solving skills and poor insight as to the implications of behaviors and decisions. Box 9-3 lists some strategies for working with adolescents with cognitive impairments.

Psychosocial development

Psychosocial development is the essence of adolescence. There are three characteristic phases of psychosocial development. Phase 1 is early adolescence during the middle school years between the ages of 10 and 13; phase 2 is middle adolescence during the high school years between the ages of 14 and 17; and phase 3 is late adolescence between the ages of 17 and 21 in the first years of work or college.^2,50 Table 9-2 outlines common behaviors seen in each of these phases.