Approach to adolescent turmoil

APPROACH
TO
ADOLESCENT TURMOIL
Total slides –65
6/7/2021 1
Presenter
Dr Rachit Sharma
Junior Resident (Psychiatry)
Armed Forces Medical College,
Pune
Moderator
Dr Kalpana Srivastava,
Clinical Psychologist & Scientist ‘G’
Dept of Psychiatry
Armed Forces Medical College,
Pune

Contents
1. Introduction
2. Adolescent development and Challenges
– Physical
– Cognitive
– Emotional
– Social
– Behavioural
3. Risk factors and Protective factors
4. Take Home Points
6/7/2021 2

Age cycle
Age (in years) Stage
0-1 Infant
1-2 Toddler
3-5 Early childhood
6-12 Late childhood
12-19 Adolescent
20-40 Early adulthood
40-65 Middle adulthood
65+ Late adulthood
Phases of Adolescence (WHO)
Early 12-14 Yrs
Middle 15 -16 Yrs
Late 17- 19 Yrs
http://www.who.int/pub/guidelines/2013/intro/keyterms/en/
Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of Psychiatry.LW&W. 10th edi. 2018
6/7/2021 4

Definition
• Adolescence: Latin word adolescere – “to grow”
• Definition:
– Period of time from puberty to the completion of
physical growth (Morgan & King 7th edi.)
– Adolescence is a critical period characterized by
neurobiological and physical maturation leading to
enhanced psychological awareness and
higher-level social, cognitive, and emotional
interactions with peers and adults (CTP 10th edi.)
6/7/2021 5

Adolescent Turmoil
1. Adolescence - A time of hypersensitivity to
both appetitive and aversive emotional
experiences
2. Adolescents - most susceptible to mortality
and morbidity due to behaviours directly
related to emotional experiences
3. Period of both vulnerability and opportunity
hinged on the power of affective systems to
influence behaviour
Dahl RE. Adolescent brain development: a period of vulnerabilities and opportunities. Keynote address.
Annals of the New York Academy of Sciences. 2004 Jun 1;1021(1):1-22.
6/7/2021 6

Adolescence:
Historical background
1. Manusmriti
– Keshant: Haircut at the beginning of puberty or
adolescence.
– Samavartan: Completion of education and the
young person leaves Gurukul for his home. It
marks the end of adolescence and beginning of
young adulthood
2. Vedic ashram system
– Brahmacharya (student), Grihastha
(householder), Vanaprastha (retired) and
Sannyasa (renunciate)
Sitholey P, Agarwal V, Vrat S. Indian mental concepts on children and adolescents. Indian journal of
psychiatry. 2013 Jan;55(Suppl 2):S277.
6/7/2021 7

Adolescence:
3. G. Stanlay Hall (1844-1924) –
– Expansion of Darwin's concept of biological
"evolution" into a psychological theory of
recapitulation
– Book -"Feelings and Psychic Evolution“
– A period of “Sturm und Drang" -Storm and Stress
– “Never again does the peer group have such a
strong influence over the person”
– A new birth, "for the higher and more completely
human traits are now born"
Muuss RE. Theories of adolescence. Crown Publishing Group/Random House; 1988.
6/7/2021 8

Adolescence:
3. Sigmund Freud
– Psychoanalytical theory of adolescent development
– Individual passes through the earlier experiences of
mankind in his psychosexual development
– Adolescence was a universal phenomenon and
includes behavioural, social and emotional changes
– Physiological changes are related to emotional
changes - Increase in negative emotions
6/7/2021 9

Adolescence:
4. Anna Freud –
– Critical influence of Sexual maturation (sexual
glands) on psychological sphere
– Interaction results in the instinctual reawakening
of the libidinal forces bring about
psychological disequilibrium (between Ego&Id)
– Conflict of Puberty endeavour to regain
equilibrium
6/7/2021 10

Adolescent turmoil:
Neurobiology
1. Surge in gonadal hormones during
adolescence
– Male- Increased testosterone levels –
• Deviant peer group - Deviant behaviours and social
dominance
• Non-deviant peer group - Increased leadership and
social status
– Female - Increased estradiol levels –
• Heightened emotionality and increased risk-taking
and substance use behaviours
Guyer AE, Silk JS, Nelson EE. The neurobiology of the emotional adolescent: From the inside out.
Neuroscience & Biobehavioral Reviews. 2016 Nov 1;70:74-85.
6/7/2021 11

Adolescent turmoil:
Neurobiology
Casey BJ, Jones RM. Neurobiology of the adolescent brain and behavior: implications for substance use disorders.
Journal of the American Academy of Child & Adolescent Psychiatry. 2010 Dec 1;49(12):1189-201.
6/7/2021 12

ADOLESCENT
DEVELOPMENT
6/7/2021 13

Adolescent development
• It encompasses:
1. Physical development
2. Cognitive development
3. Emotional development
4. Social development
5. Behavioural development
• Changes in one area of development typically
leads to, or occurs in conjunction with,
changes in other areas
6/7/2021 14

PHYSICAL DEVELOPMENT
6/7/2021 15

Physical development:
Body changes
External changes
1. Height
2. Weight
3. Body proportions
4. Sex organs
5. Secondary sex
characteristics
Internal changes
1. Digestive system
2. Circulatory system
3. Respiratory system
4. Endocrine system
5. Body tissues
6/7/2021 16

Physical development
1. Growth spurt
– Rapid skeletal growth
• Girls – 10-12 yrs
• Boys – 12-14 yrs
2. Sexual maturation
– Achieving fertility and physical changes that
support fertility
• Girls – 10-12 yrs Development of breast, Menstruation
• Boys – 12-14 yrs Enlargement of testis
6/7/2021 17

2. Variations in Physical changes-
– Early maturing girls
• Higher risk for substance use
• Disruptive behaviours
• Eating disorders
• Depression
• STDs and Unwanted pregnancies
– Early Maturing boys
• High risk behaviours- Sexual activity, Substance
abuse, Delinquency
6/7/2021 18

– Late Maturing boys
• High risk – Depression, Conflict with parents and
School problems
• High risk for being bullied
• Adolescent’s autonomy should be linked with
their chronological age and social &
emotional development rather than physical
development
American Psychological Association. Developing adolescents: A reference for professionals. Washington, DC: American
Psychological Association. 2002 May.
6/7/2021 19

3. Concerns about physical appearance
– Paramount importance in adolescence
– Comments by peers - More worrying
4. Physical activity and weight
– Overweight adolescents
– High risk for social discrimination, bullying, low
self esteem, medical co-morbidities and
depression
– Multiple factors associated with increased weight
6/7/2021 20

Approach to turmoil
Strategies during puberty
– Educating children about puberty, depending on the
curiosity and the maturity level of the child
– Take comments about appearance seriously and
spend time actively listening to such concerns
– Make them talk about their feelings, fears, and
stressors about the physical changes
– Provide emotional support, knowledge and
assurance about changes in the body
6/7/2021 21

Approach to turmoil
Disordered eating
– Preoccupied with their physical appearance 
begin to diet obsessively to achieve/maintain a
thin body
– Female> Male
– Anorexia nervosa, Bullimia nervosa
– Risk factors - Low self esteem, poor coping skills,
childhood physical / sexual abuse, family history
6/7/2021 22

Approach to handle turmoil
7. Strategies to protect against developing
eating disorder
– Promoting the acceptance of a broad range
of appearances
– Promoting positive self-image and body image
– Educating about the detrimental consequences
of a negative focus on weight
– Promoting a positive focus on sources of self-
esteem
6/7/2021 23

COGNITIVE
DEVELOPMENT
6/7/2021 24

Cognitive development
Jean Piaget (1970)
Age Stage Characteristics
First 2 Years Sensorimotor stage 1. Incorporation of reflex pattern into
intentional movements
2. Object Permanence
2 – 7 years Preoperational stage 1. Language development
2. Symbolic play
3. Egocentrism
4. Animism
5. Representational thought
6. Transductive reasoning
7-12 years Concrete operational 1. Reversibility
2. Conservation
3. Hierarchical thinking
12 years
onwards
Formal Operational Abstract thinking and other capacities
Morgan CT, Richard A. King, John R. Weis and John Schopler. Introduction to Psychology. 7th edi. Tata McGraw-Hill
Education; 1993
6/7/2021 25

1. Formal Operations: Thinking Abstractly
– To assume a mental set voluntarily
– To shift voluntarily from one aspect of a
situation to another
– To keep in mind simultaneously various aspects
of a situation
– To grasp the essentials of a whole and to break
a whole into its part
– To discern common properties
– To plan, to assume make-believe attitudes
– To think or act symbolically
6/7/2021 26

2. Hypothetical thinking
– How thing are to How things can be? If certain
changes took place
– It allows to judge the reasonableness of a
reasoning
3. Inductive thinking
– Logical process by which general principles are
inferred from particular instances
Morgan CT, Richard A. King, John R. Weis and John Schopler. Introduction to Psychology. 7th edi. Tata McGraw-Hill
Education; 1993
6/7/2021 27

4. Deductive thinking
– Reasoning from abstract, general principles to
specific hypothesis that follow from these
principles
5. Interpropositional Logic
– The capacity to judge whether or not statements
are logically connected (Formal relationship) to
one another (regardless of whether they are true
or not)
Morgan CT. Richard A. King, John R. Weis and John Schopler. Introduction to Psychology. 7th edi. Tata McGraw-Hill Education;
1993
6/7/2021 28

5. Reflective Thinking
– The process of evaluating and testing one’s own
reasoning
• To be one’s own critic – to find errors or weak point
• To evaluate a process, idea or solution from the
perspective of outsider
– Makes one a experimenter, strategist, a problem
solver
Morgan C T, Richard A. King, John R. Weis and John Schopler. Introduction to Psychology. 7th edi. Tata McGraw-Hill
Education; 1993
6/7/2021 29

Moral development: Theory
• Lawrence Kohlberg (1976) – Studied the
development of moral reasoning by asking
people of various ages to resolve moral
dilemmas
• He focussed was not on what people said
about the dilemma; instead, how they arrived
at their decision!
• Indl passes through stages of egocentric moral
judgements to abstract moral principles
6/7/2021 30

Stages of Moral development
Age Level Stage and Characteristics
3 -7 Years
Level 1
(Preconventional)
(Moral reasoning is
controlled by
external rewards and
punishments)
Stage 1
Obedience and Punishment driven
Stage 2
Self interest driven
7- 11 Years
Level 2
(Conventional)
(Internal standards
are imposed by
others)
Stage 3
Good boy attitude
Stage 4
Law and order morality
11 Years onwards
Level 3
(Postconventional)
(Morality is internal
not based on
external standards)
Stage 5
See Laws as Social contract
Stage 6
Develops universal ethics and focus on
fairness and justice
6/7/2021 31

Moral development
To replace the moral concept of childhood with
general moral principles
To formulate their own concepts into a moral code
To use these moral codes as a guide to their
behaviour
To exercise inner control of behaviour (morally
mature)
Hurlock EB. Developmental Psychology. 5th edi. Tata McGraw-Hill Education; 1978
6/7/2021 32

Cognitive development:
Approach to handle turmoil
1. Are Moral thought and moral actions linked?
2. It’s normal for Adolescent to-
– Argue for the sake of arguing
– Jump to conclusions
– Be self-centered
– Constantly find fault in the
adult’s position
– Be overly dramatic
6/7/2021 33

EMOTIONAL
DEVELOPMENT
6/7/2021 34

Emotional development
1. Emotionality during adolescence
– As a result of physical and glandular changes
– Adjustment of new pattern of behaviour and new
social expectations
– Worries about the future
2. Emotional patterns in Adolescence
– Differs in stimuli that gives rise to emotions
– Differs in expression of their anger by sulking, refusal
to eat, loudly criticizing those who annoyed them
– Envious of those with more materialistic possessions
6/7/2021 35

Emotional development:
Identity
1. Achieving identity: Who am I?
– Key developmental task of adolescence
– Developing a realistic and coherent sense of
identity in context of
• Relating to others
• Learning to cope with stress and manage emotions
2. Gains of Achieving identity-
– A feeling of being at home in one’s body
– A sense of psychological well being
By experimenting with their
Appearance, Behaviour and
Thinking
6/7/2021 36

Erickson’s Psychosocial stages
6/7/2021 37

Emotional development:
Identity
3. Identity includes
Self-Concept (Set of belief
one has about oneself)
One’s attributes
Goals
Interests, Values
and Beliefs
Self- esteem ( How one
feels about one’s self concept)
Specific
Global
6/7/2021 38

4. Conditions influencing self concept
Self-
Concept
Age of
maturing
Appearance
Sex-
appropriateness
Names and
nicknames
Family
relation
ships
Peers
Creativity
Level of
aspiration
6/7/2021 39

5. Low self esteem – Depression, Eating
disorders, Delinquency and Adjustment
problems
6. Characteristics identified with low self
esteem
1. Feeling low
2. Lacking energy
3. Disliking ones appearance and rejecting
compliments
4. Feeling insecure or inadequate most of the time
5. Having unrealistic expectations of oneself
6. Having serious doubts about future
7. Being excessively shy and rarely expressing one’s
point of view
8. Conforming to what others want and assuming a
submissive stance in most situations
6/7/2021 40

Approach to Emotional turmoil
1. How to help adolescent raise his self-esteem?
– Identify and improve their self concepts in specific
valued areas
– Helping them to face a problem instead of avoiding it
2. Education about emotional maturity
– To assess a situation critically before reacting
– To wait for a convenient time and place and to react
in a socially acceptable manner
– Understanding others perspective
– To make them learn to use emotional catharsis
6/7/2021 41

Group differences in emotional development
– Gender differences
– Ethnic diversity
• Ethnic minority
– Lesbian, Gay, Bisexual, Transgender youth
• Development of homosexual identity
• Exploring their identity? Questioning or experimenting
• Denial  Stigma
• Higher risk – Substance use, verbal and physical violence,
stress
6/7/2021 42

SOCIAL DEVELOPMENT
6/7/2021 43

Social development:
Peer relationship
1. Important functions sub served by peer
groups-
– Provides a reference point for a developing sense
of identity
– Contributes in development of moral judgement
and values
– Source of information about the world and about
themselves
– Source of popularity, status, prestige and
acceptance
6/7/2021 44

Social development:
Peer relationship
2. Positive peer relationships – Positive
psychosocial adjustment
3. Peer rejected teens – Negative behaviours
4. Structure of peer groups-
– Younger adolescents – Primary peer group
– Middle adolescents - Mixed gender groups
– Late adolescents – One-on-One relationships and
romantic relationship
6/7/2021 45

Social development:
Peer relationship
– Ethnic minority – Higher emphasis on peer
groups throughout adolescence
5. Dating and sexual behaviours
– Change in preference - From primary peer group
to members of opposite sex
– Most pronounced change in social attitude
– Cyberdating, Romantic relationships, Earlier
sexual involvement, unnatural sexual practices
6/7/2021 46

Social development:
Peer relationship
– Grief and sense of loss associated with the
ending of romantic relationship
6. Adolescents in a relationship with signs of
physical or emotional abuse
– Uncontrolled anger, Jealousy or Possessiveness
– Shoving, Slapping or Forced sex
– Help adolescent understand abuse and need for
action
6/7/2021 47

Social development:
Family relationship
6/7/2021 48

Social development:
Family relationship
• Parent –teen conflict
– To gain independence from parents while learning
new ways of staying connected to them
– Spontaneous conflicts over day to day matters
– Conflict over important issues
– Tend to peak with younger adolescents
– More distressing to parents than to adolescent
6/7/2021 49

Social development:
Family relationship
Common causes of family friction during
adolescence-
1. Parent’s standard of behaviour – Cultural gap
2. Methods of discipline
3. Relationship with siblings
4. Feeling victimized
5. Hypercritical and punitive attitude of parents
6. “Latchkey” problems
6/7/2021 50

Approach to
Family relationship turmoil
1. Encourage parents to modify parenting
practices
– Warm and involved
– Provide firm guidelines and limits
– Have appropriate expectations
2. Level of parental supervision and monitoring
differs depending on the peer and
neighbourhood environments
Schmied V, Tully L. Effective strategies and interventions for adolescents in a child protection context: Literature review.
2009
6/7/2021 51

Approach to
Family relationship turmoil
3. New type of relating- Encourage the parents
to stay involved
4. To educate parents not to take conflicts as
rejection of their values or their parenting as
failure
2009
6/7/2021 52

BEHAVIOURAL
DEVELOPMENT
6/7/2021 53

Behavioural development
1. Risk taking behaviours
– Cigarette smoking
– Alcohol use
– Other substance use
– Weapon carrying, fighting
– Sexual acts
6/7/2021 54

2. Reasons for Adolescent risk taking:
– More amount of free unsupervised time
– Need for excitement, fun and novel intense
sensations  Override the potential dangers of
particular activity
– To win the approval of peers or to avoid peer
rejection
– Modelling of adult behaviour
6/7/2021 55

– Develop realistic assessments of themselves,
other people and the world
– Experimentation to shape their Identities
– Try out new decision making skills
6/7/2021 56

Neurobiology:
Risk taking behaviour
Casey BJ, Jones RM. Neurobiology of the adolescent brain and behavior: implications for substance use disorders.
Journal of the American Academy of Child & Adolescent Psychiatry. 2010 Dec 1;49(12):1189-201.
6/7/2021 57

3. When does a risk taking behaviour becomes
a problem behaviour?
– Alcohol and drug abuse
– Pregnancy and STDs
– School failure and dropping
out
– Delinquency, Crime and
violence
– Accidents
6/7/2021 58

RISK FACTORS &
PROTECTIVE FACTORS
6/7/2021 59

Risk factors
1. Individual
– Personality variables
– Developmental delay
2. Family
– Low Socioeconomic
status
– Mental illness
– Family conflict
– Coercive parenting
3. Peer
– Peer rejection
– Deviant peer group
4. School
– Academic failure
– Low committment to
school
5. Community
– Neighbourhood
6/7/2021 60
2009

Protective factors
1. A strong sense of connectedness to parents,
family, school, community institutions, adults
outside the family
2. Development and enhancement of academic
and social competence
3. Involvement in extracurricular activities that
create multiple friendship networks
4. Religious and spiritual anchors
6/7/2021 61

Take home points
1. Adolescence is a transitional period
2. It is a period of change
– Increased affiliation with peer group
– Striving for more autonomy from parents
– Increased ability to mentalize
– Increase in risk taking behaviours
3. It is a time for search for identity
4. Adults can nurture, teach, guide and protect
them on their journey to adulthood
6/7/2021 62

References
1. Hurlock EB. Developmental Psychology. Tata McGraw-Hill Education;
1978.
2. Sadock BJ, Sadock VA, Pedro Ruiz. Comprehensive Textbook of
Psychiatry.LW&W. 10th edi. 2018.
3. American Psychological Association. Developing adolescents: A reference
for professionals. Washington, DC: American Psychological Association.
2002 May.
4. Morgan CT. Richard a. King, John R. Weis and John Schopler,“Introduction
to Psychology” Tata McGraw-Hill Education; 1993.
5. Schmied V, Tully L. Effective strategies and interventions for adolescents
in a child protection context: Literature review. 2009.
6. Muuss RE. Theories of adolescence. Crown Publishing Group/Random
House; 1988.
6/7/2021 63

References
8. Hjelle LA, Ziegler DJ. Personality theories: Basic assumptions, research,
and applications. McGraw-Hill Book Company; 1992.
9. Dahl RE. Adolescent brain development: a period of vulnerabilities and
opportunities. Keynote address. Annals of the New York Academy of
Sciences. 2004 Jun 1;1021(1):1-22.
10. http://www.who.int/pub/guidelines/2013/intro/keyterms/en
11. Guyer AE, Silk JS, Nelson EE. The neurobiology of the emotional
adolescent: From the inside out. Neuroscience & Biobehavioral Reviews.
2016 Nov 1;70:74-85.
12. Sitholey P, Agarwal V, Vrat S. Indian mental concepts on children and
adolescents. Indian journal of psychiatry. 2013 Jan;55(Suppl 2):S277.
13. Casey BJ, Jones RM. Neurobiology of the adolescent brain and behavior:
implications for substance use disorders. Journal of the American
Academy of Child & Adolescent Psychiatry. 2010 Dec 1;49(12):1189-201.
6/7/2021 64

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