This document introduces two special issues of the Journal of Pediatric Psychology focused on adolescent health and illness. It provides an overview of a developmental framework for understanding adolescent development and adjustment. The framework emphasizes how biological, psychological, and social changes during adolescence impact developmental outcomes through interpersonal contexts. It discusses how this developmental perspective can strengthen research on adolescent health behaviors and chronic illnesses. The issues include studies examining family and peer factors that are developmentally relevant to adolescent health and adjustment. Longitudinal research designs that track outcomes as adolescents change are advocated for as the best approach.

1. Journal of Pediatric Psychology, Vol. 27, No. 5, 2002, pp. 409–415
A Developmental Perspective on Adolescent
Health and Illness: An Introduction to the
Special Issues
Grayson N. Holmbeck, PhD
Special Issue Editor
Loyola University of Chicago
This and the next issue of the Journal of Pediatric Psy- In the “Call for Papers” for these issues, I sought
chology (JPP) will include articles submitted for a manuscripts that focused on adolescents with
special issue on “Adolescent Health and Illness,” the chronic physical conditions as well as those that fo-
first issues of JPP devoted exclusively to research on cused on adolescent health-related behaviors (e.g.,
adolescents. A review of recent issues of JPP as well smoking, substance use, sexual risk-taking). In re-
as journals from the fields of clinical psychology sponse to the call, 27 papers were submitted across
and psychiatry reveals that adolescent health has both of these areas. This issue of the journal in-
been the focus of considerable scientific attention cludes six articles focusing on adolescents with
over the past several years. For example, the Journal chronic illnesses and physical conditions and the
of Consulting and Clinical Psychology publishes a spe- next issue includes six articles that focus on adoles-
cial issue on health psychology every 10 years; for cent health behaviors. This is an introduction to
the first time, an article on “adolescent health psy- both issues.
chology” will appear in the 2002 installment of this
series (Williams, Holmbeck, & Neff, in press). Also,
a former Section of Division 12 (the Section on The Utility of a Developmental
Clinical Child Psychology) of the American Psycho- Perspective
logical Association (APA) is now Division 53 of APA
and has been renamed the Society for Clinical Child Adolescence is a transitional developmental period
and Adolescent Psychology. Related to this, the between childhood and adulthood characterized by
journal of this division has been renamed the Jour- more biological, psychological, and social role
nal of Clinical Child and Adolescent Psychology. The changes than any other stage of life except infancy
Society for Research on Adolescence had its first (Feldman & Elliott, 1990). Moreover, this stage of
conference in 1986 and published the first issue of development is a critical period for the establish-
its journal, the Journal of Research on Adolescence, in ment of lifelong positive and risky health-related
1991. Given the intense focus on the second decade behaviors in both typically developing adolescents
of life both in the media and in the scientific jour- and in those with chronic conditions. It is also a
nals and academic societies, it seemed an opportune time when one’s developmental and health trajec-
time to highlight recent empirical work on adoles- tories can be altered dramatically in positive or neg-
cents in pediatric psychology. ative directions. Given the changes that charac-
terize adolescent development, it is not surprising
All correspondence should be sent to Grayson N. Holmbeck, Loyola Uni-
versity of Chicago, Department of Psychology, 6525 N. Sheridan Road,
that there are also significant changes in the types
Chicago, Illinois 60626. E-mail: gholmbe@luc.edu. and frequency of health problems and psychologi-
᭧ 2002 Society of Pediatric Psychology

2. 410 Holmbeck
cal disorders during this developmental period, as aptation and adjustment (Figure 1; see Holmbeck et
compared to childhood. Moreover, distinctions be- al., 2000, and Holmbeck & Shapera, 1999, for a
tween normal and abnormal are sometimes less more complete overview of the model). The model
clear during this developmental period than they presented here is biopsychosocial, insofar as it em-
are in earlier developmental periods (e.g., the dis- phasizes the biological, psychological, and social
tinction between substance use experimentation vs. changes of the adolescent developmental period
problem use; Cicchetti & Rogosch, 2002). Given (see Figure 1). In addition to this focus on intra-
that “change” is the defining feature of adolescence individual development, I have also attempted to
and given the opportunities for having a positive incorporate more recent discoveries from studies of
impact on a “system” already in a state of flux (Cic- contextual effects during adolescence (Steinberg,
chetti & Toth, 1996), many pediatric and health 1995).
psychologists have focused their sights on this criti- At the most general level, the framework pre-
cal period of development. sented in Figure 1 illustrates how the primary devel-
Because adolescent health and illness occur opmental changes of adolescence have an impact
within a changing developmental context, the on the developmental outcomes of adolescence via
quality of research on adolescents likely will be ad- the interpersonal contexts in which adolescents de-
vanced if a developmental perspective is adopted by velop. In other words, the developmental changes
investigators who study the second decade of life of adolescence have an impact on the behaviors of
(Holmbeck et al., 2000; Seiffge-Krenke, 1998; Wal- significant others, which, in turn, influence ways
lander & Siegel, 1995). I often like to use the follow- in which adolescents resolve the major issues of
ing litmus test to determine whether a particular adolescence, namely, autonomy, sexuality, identity,
piece of research involving adolescent participants and so on. For example, suppose that a preadoles-
has been conducted from a developmental perspec- cent girl begins to physically mature much earlier
tive. Specifically, I pose the following question: than her agemates. Such early maturity will likely
Could the same study have been conducted on chil- affect her peer relationships, because early maturing
dren or adults with the same hypotheses and mea- girls are more likely to date and spend time with
sures? In other words, I examine whether the in- older males than are girls who mature on time
vestigator has focused on constructs, variables, and (Magnusson, Stattin, & Allen, 1985). Such changes
measures uniquely relevant to adolescents, thus in peer relations are, in turn, likely to influence an
making the study developmentally oriented. early maturing girl’s level of sexual activity and her
What variables are uniquely relevant to adoles- sexual identity. In this way, the behaviors of peers
cent participants and what is to be gained by in- in response to the girl’s early maturity could be said
cluding measures of such variables in one’s research to mediate associations between pubertal timing and
protocol? To answer this question, I first provide a sexual outcomes (Baron & Kenny, 1986; Holmbeck,
brief overview of a developmental-contextual 1997, 2002). Such mediational influences may also
framework for the study of adolescent adaptation be moderated by demographic, intrapersonal, and in-
and adjustment, and I provide examples of how terpersonal variables (Figure 1; e.g., ethnicity, gen-
variables highlighted in the framework are relevant der, socioeconomic status [SES], family relations).
to the study of adolescent health and illness. Next, I For example, early pubertal maturity may lead to
discuss implications of the framework for designing early sexual debut only when family members react
research studies where adolescent participants are to early pubertal development in certain ways (e.g.,
the focus. Finally, I review the 12 studies included with increased restrictiveness and supervision).
in these two special issues of JPP and discuss their With respect to chronic illness, management of
strengths and contributions as well as the degree to the disease is often at odds with normal adolescent
which these studies adopt a developmental perspec- strivings. For example, considerable evidence sug-
tive to the study of adolescents. gests that adherence to medical regimens decreases
from childhood to adolescence (e.g., Anderson, Ho,
Brackett, Finkelstein, & Laffel, 1997). With respect
A Developmental-Contextual Framework to the developmental framework, the cognitive
for the Study of Adolescents changes of adolescence make it more likely that ad-
olescents will think differently about adherence be-
In this section, I provide an overview of a develop- haviors than they did during childhood. On the
mental framework for understanding adolescent ad- positive side, they are more able to solve problems

3. Special Issue: Adolescent Health and Illness 411
Figure 1. A framework for understanding adolescent development and adjustment (source: Holmbeck, G. N., & Shapera, W. [1999]. Research
methods with adolescents. In P. C. Kendall, J. N. Butcher, & G. N. Holmbeck [Eds.]. Handbook of research methods in clinical psychology [2nd
ed., pp. 634–661]. New York: Wiley; reprinted with permission).
and consider the future consequences and risks of increases in a child’s management of his or her own
their health behaviors (Thomas, Peterson, & Gold- illness if parental involvement in illness manage-
stein, 1997). On the negative side, they are more ment evolves in tandem with the child’s increasing
able to consider costs and benefits of their adher- cognitive sophistication (including increases in
ence behaviors. For example, an adolescent with needs for privacy, control, and peer acceptance; An-
type 1 diabetes may choose to be nonadherent to derson & Coyne, 1993). Although speculative, it
gain the full benefit of participation with his or her appears that a maladaptive “miscarried helping”
peer group (Brooks-Gunn, 1993). Of course, the im- process can ensue when such parental adaptations
pact of peers need not be negative. The degree to are not made (Anderson & Coyne, 1993). Recent
which an adolescent’s peers are supportive of the findings suggest that excessive parental control dur-
child’s attempts to be adherent may buffer (i.e., ing this period of development is linked with lower
moderate) the impact of cognitive development on levels of autonomy, which are, in turn, associated
health behaviors. However, little research has been with higher levels of problem behaviors (Holmbeck
conducted that examines links between develop- et al., 2002).
mental change and health behaviors or factors that Chronic illness may also have an impact on the
moderate such links. timing of puberty. In children with spina bifida, for
Similarly, with respect to parent-child relations, example, the incidence of precocious puberty is
increases in cognitive development during adoles- higher in this population owing to premature acti-
cence are likely to be associated with appropriate vation of the hypothalamo-pituitary-gonadal axis

4. 412 Holmbeck
in some children with hydrocephalus (Greene, may end up with very different outcomes later in
Frank, Zachmann, & Prader, 1985). Because chil- life. Studies from a multifinality perspective could
dren with spina bifida are also more likely to be also explain why some adolescents with substance-
socially isolated (Blum, Resnick, Nelson, & St. abusing parents end up abusing substances them-
Germaine, 1991), such early puberty may produce selves and why others do not. The task for the re-
developmental asynchronies with respect to physi- searcher is to isolate factors that account for such
cal and social development, which may, in turn, af- differential outcomes. Also from a developmental
fect the developmental outcomes noted in Figure 1. psychopathology perspective, studies of atypical
The physical changes of puberty may be late in chil- populations can provide information about con-
dren with other conditions (e.g., cystic fibrosis; Saw- structs of interest to those who study typical devel-
yer, Rosier, Phelan, & Bowes, 1995) or may have a opment, particularly when the phenomena of in-
direct impact on the illness itself and affect illness terest occur with greater frequency in these atypical
management (e.g., diabetes). populations. For example, Quittner and Opipari
(1994) examined parental differential attention to
siblings in families where one child had cystic fi-
Developmentally Oriented Research brosis. Given the potentially extreme levels of dif-
Strategies in Studying Adolescent Health ferential attention to siblings in such families (and
and Illness the potential absence of differential attention in
families of typically developing children), such a
Research in the area of developmental psychology sampling strategy allowed the investigators to con-
alerts us to the importance of considering the fol- tribute knowledge about the “differential atten-
lowing (Graber & Brooks-Gunn, 1996): the timing tion” construct.
(early vs. late) of developmental events, the cumu- What types of research designs permit examina-
lative impact of multiple events that occur simulta- tion of developmentally oriented research ques-
neously, and the fit between the developmental tions? In the “future directions” section of most
needs of an adolescent and the adolescent’s envi- articles in the Journal of Pediatric Psychology, scholars
ronmental context. The field of developmental psy- often suggest that future studies be longitudinal
chopathology has provided us with a vocabulary with rather than cross-sectional, arguing that this strat-
which to explain phenomena that we have ob- egy would allow one to track an outcome over time
served clinically and seek to examine empirically or to determine the causal ordering of the variables
(e.g., developmental trajectories, resilience, risk and studied. The benefits of longitudinal studies go be-
protective processes, continuity/discontinuity of yond these advantages, however. In a recent review
adaptive and maladaptive processes, multifinality, of the literature on effects of illness on child and
equifinality; Cicchetti & Rogosch, 2002). family adjustment, Wallander and Varni (1998) per-
Despite the importance of contributions from haps said it best: “General developmental processes
the fields of developmental psychology and develop- should become more salient features of the concep-
mental psychopathology, pediatric health psycholo- tualizations of adjustment in this special group.
gists have been slow to incorporate developmental Longitudinal designs need to become the norm”
principles into their research and intervention work (p. 42).
(Drotar, 1997; Wallander & Varni, 1998). For ex- In other words, the quality of research studies in
ample, the timing of developmental events (e.g., the area of adolescent health and illness will im-
puberty) may have added importance for the child prove if they are longitudinal and if indices of de-
with a chronic condition, but this has received little velopmental level and variables developmentally-
attention in the literature. Autonomy development relevant to adolescents are included (e.g., pubertal
is a highly salient issue for many adolescents with a status, changes in cognitive developmental level,
chronic condition, but scant research has examined changes in level of peer intimacy, autonomy devel-
trajectories of autonomy development during the opment, changes in parenting behaviors; see Figure
adolescent developmental period. 1). It is not enough to simply document whether
The concept of multifinality from the field of a certain outcome increases or decreases over time
developmental psychopathology could be applied (Steinberg, 2002). Instead, it is of interest to track
in studies of pediatric populations. This concept in- important outcomes over time (e.g., adherence and
volves the notion that children born with the same quality of life in studies of pediatric populations or
chronic condition (at the same level of severity) substance use, sexual activity, and positive health

5. Special Issue: Adolescent Health and Illness 413
behaviors in studies of adolescent health) as a func- The studies included in these issues have several
tion of changes in important developmental pro- notable strengths. First, many of the studies focused
cesses (Drotar, 1997; Wallander & Varni, 1998). For on the interpersonal contexts of adolescence, as
example, it may be of interest to isolate different noted in Figure 1. Specifically, several studies exam-
adherence trajectory groups, such that some adoles- ined parent or family factors as predictors (Chassin
cents remain adherent, some exhibit decreases in et al., in press; Logan et al., 2002) or outcomes
adherence, while others exhibit increases. It may (Coakley et al., 2002; Seiffge-Krenke, 2002). In sev-
then be of interest to examine how such trajectory eral cases, fathers were also included in the studies
groups differ developmentally or as a function of (Chassin et al., in press; Coakley et al., 2002; Seiffge-
concurrent changes in developmentally relevant in- Krenke, 2002). Other articles focused on the peer
dividual, family, or peer variables. Simply put, a (Bachanas et al., in press; Bearman & La Greca,
study of adolescents becomes developmentally ori- 2002; Pendley et al., 2002) or school context
ented when the researcher includes measures that (Aloise-Young et al., in press). Second, differences
tap constructs such as those noted in Figure 1 and in findings as a function of gender (Bearman & La
when development and outcome are both tracked Greca, 2002; Boutelle et al., in press; Coakley et al.,
longitudinally. 2002; Rae et al., in press; Seiffge-Krenke, 2002; Wil-
By examining development and outcome over liams et al., in press) and ethnicity (Aloise-Young et
time, one acknowledges that both are processes al., in press; Bachanas et al., in press; Boutelle et al.,
than evolve. From a developmental perspective, in press) were highlighted in several articles.
one could make the case that many problems re- Third, relevant developmental factors are con-
lated to adolescent health behaviors and the man- sidered in several studies (see Figure 1). Age is a pri-
agement of illness during adolescence occur, at least mary variable in some of the articles (Bearman & La
in part, because of difficulties in managing the Greca et al., 2002; Madsen et al., 2002; Pendley et
normative developmental events and milestones of al., 2002). Moreover, pubertal change was the focus
the adolescent period. If this is true, it further em- of one article (Coakley et al., 2002). Relatedly, sev-
phasizes the utility of a developmental perspective. eral of the articles were longitudinal (Chassin et al.,
in press; Coakley et al., 2002; Seiffge-Krenke, 2002;
Williams et al., in press).
The Studies in these Special Issues of JPP Finally, although self-report data collection strat-
egies were the norm, other methods were also used:
As noted earlier, half of the papers accepted for coding of observed family interaction data (Coakley
these two issues are studies of adolescents with a et al., 2002; Seiffge-Krenke, 2002) and a laboratory
chronic condition (Bearman & La Greca, 2002; attitudes task (Chassin et al., in press). Moreover,
Coakley, Holmbeck, Friedman, Greenley, & Thill, multiple informants were used in several studies
2002; Logan, Radcliffe, & Smith-Whitley, 2002; Mad- (Chassin et al., in press; Coakley et al., 2002; Logan
sen, Roisman, & Collins, 2002; Pendley et al., 2002; et al., 2002; Pendley et al., 2002; Seiffge-Krenke,
Seiffge-Krenke, 2002). The other half are studies of 2002). Some of those that did not include multiple
adolescent health behaviors (Aloise-Young, Cruick- informants had very large sample sizes (Aloise-
shank, & Chavez, in press; Bachanas et al., in press; Young et al., in press; Boutelle et al., in press). One
Boutelle, Neumark-Sztainer, Story, & Resnick, in study examined reports of pediatric psychologists
press; Chassin, Presson, Rose, Sherman, & Prost, (Rae et al., in press). Another study was a measure
in press; Rae, Sullivan, Razo, George, & Ramirez, in development investigation (Bearman & La Greca,
press; Williams, Colder, Richards, & Scalzo, in 2002).
press). The latter articles will appear in the next is-
sue of JPP. Of the studies on chronic physical con-
ditions, four examined adolescents with type 1 dia- A Look to the Future
betes, and there was one each on adolescents with
sickle cell disease and spina bifida. Of the six ado- Given the diversity of topics of interest to the read-
lescent health studies, two focused on adolescent ers of JPP, I was not able to include papers on all
smoking, one focused on self-assessed health, one topics relevant to the study of adolescent health
focused on obesity, one focused on risky sexual be- and illness. For example, only one intervention or
haviors, and one focused on adolescent health risk prevention study was submitted for the special is-
behaviors more generally. sues (Madsen et al., 2002), although there was also

6. 414 Holmbeck
a paper on help-seeking behaviors (Logan et al., the blurring of boundaries between typical and
2002). Such a lack of submissions on interventions atypical complicates the assessment of clinically sig-
is consistent with the lack of treatment studies on nificant change in treatment studies and the deter-
adolescents in the child-clinical and pediatric liter- mination of whether treated individuals differ
atures. Also, no studies of medical adherence were significantly from normative samples (Kendall,
accepted for the special issues. Very few studies ex- Marrs-Garcia, Nath, & Sheldrick, 1999). Knowledge
amined process-oriented mediational or modera- of normative development (and developmental
tional models and few included measures of devel- changes) informs not only the accurate identifica-
opmental level. A resiliency perspective was also tion of those in need of services but also the proper
not represented in the studies published here; why range for determinations of the quality of treatment
is it that some adolescents remain psychologically outcomes (Kendall & Sheldrick, 2000).
and physically healthy even when major risk factors In closing, I hope that this collection of articles
are present (Williams et al., in press)? Although will stimulate more research on adolescent health
studies focusing on the transition to early adoles- and illness, particularly in areas not covered by the
cence were represented, no papers focused specifi- 12 papers accepted for these special issues. Adoles-
cally on the period of emerging adulthood (Arnett, cence is a “critical period,” when lifelong health be-
2000). Particularly for adolescents with chronic con- haviors are consolidated. Because “change” is the
ditions, this late adolescent developmental period defining feature of the adolescent developmental
is critical for the development of self-reliance skills. period, this is also a period of development when
It will also be of interest to integrate across the ado- we can expect to have a significant impact with ef-
lescent illness and adolescent health research strate- fective interventions. But I believe that advances in
gies. For example, increases in substance use during our knowledge of the second decade of life will be
adolescence likely complicate the medical treat- possible only if developmentally oriented variables
ments of adolescents with chronic illnesses. are included in research conducted longitudinally.
In reviewing the developmentally relevant con- In this way, we will come to better understand the
structs in Figure 1, one soon realizes that measures unfolding of health and risk behaviors over time
are not available for many of these variables. Per- and be in a better position to design empirically
haps most important, we know very little about the supported prevention and intervention strategies to
cognitive developmental correlates of adolescent benefit both typically developing adolescents and
risky behaviors; more work on measure develop- those with chronic physical conditions.
ment in the areas of adolescent cognitive develop-
ment and decision making is needed (Williams et Received November 28, 2001; accepted December 1,
al., in press). 2001
With respect to adolescent health psychology,
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