Parents can be very confused and worried about the behavior of their adolescent children. The worries are exacerbated by real risks as adolescents venture into real world demands and exposure to substance use.
Teenagers can be much less predictable than grade school-aged children. They can be very dependent, like younger children, and then fiercely independent. They can be friends with a peer group parents consider appropriate and, weeks later, befriend a clique that is disreputable or delinquent. A teenager can cry on a parent’s shoulder one night and be distant, even rejecting, the next morning. They can talk about going to graduate school and then, without appreciating the discontinuity, discuss dropping out or casually considering far-fetched careers such as being a rock star, with little understanding of the demands or odds against success those choices carry.
Parents will ask pediatricians to make sense of their teenagers’ behavior and seek advice. They describe these behavioral changes and wonder which path their teenager will follow. Is today’s behavior transient or permanent? Should a parent be supportive, unconditionally accepting, demanding, critical, or impose tough love? Can the pediatrician predict future behavior or provide any reassurance that teenagers will straighten out?
This article aims to provide the pediatrician with a framework for understanding adolescent behavior. Psychology is but one lens through which to view adolescent development, but before highlighting this perspective it is important to note some other lenses that have major impact:
Puberty: All the physical, sexual, and hormonal changes, plus the secondary psychological effects of the rate of change, variations in growth compared to peers, etc. Puberty includes mental development with variability in brain regions that affect judgment, impulsivity, and emotional vulnerability.1,2
Cognition: Intellectual ability and movement from concrete to abstract reasoning, appreciation of nuance, and a restless readiness to invest emotionally and intellectually in philosophy, religion, politics, etc.
Culture: Family history and myths embedded in cultural/religious traditions and expectations.
Social class: The impact of privilege, poverty, schooling, and neighborhood (eg, gangs).
Psychological steps
Young people do not move in a linear fashion from childhood to adolescence. Typical adolescent development is characterized by moving forward toward adulthood and moving back toward childhood in cycles or a pendulum motion.3 However, the back-and-forth movement from more childish to more adult functioning is governed by emotions, which results in an even-uneven momentum. Sometimes the pendulum swings quite far back to a toddler-like tantrum, and can also move toward adult behavior demonstrating a work ethic in dealing with a complex interpersonal situation in a very mature manner, or even being parental in soothing a stressed father, mother, or sibling. All these movements are typical and to be expected.
This momentum is governed by puberty, expectations, relationships, culture, and cognitive and emotional development. The short-term retreats into childish behavior allow for a respite, an easing of stress, and some new energy generated by an argument (clean up your room) or nurturance (I made your favorite dinner). After some time in childhood, the teenager is ready to meet the next challenge; for example, recovering from a rejection (by a friend) or defeat (not getting the desired role in a school play) to try again going forth more autonomously.
Two underlying factors add to the intensity of feelings for all concerned: loss and self-image. Of course, adolescence brings wonderful opportunities, excitement, and is eagerly anticipated by late childhood. There will be much to accomplish; however, feelings of loss play a powerful role for parents and teenagers. For parents, time with a school-aged child seems endless, comfortable, not as complex. At 13 or 14 years, academic work gets more serious, independent, and relevant to college hopes. Time becomes finite and imaginable—4 or fewer years until they leave for college. Adolescents take risks autonomously, can keep secrets, choose and discard friends on their own, and can give up previously valued pursuits such as a sport or musical instrument.
After 10 years of childhood intimacy, something is lost with the onset of puberty that can never be recovered. Arguments about bedtime or curfew, when to do homework, use of cell phones, and what to wear often reflect parental attempts to maintain control, to limit a sense of loss and the teenager’s swing toward autonomy.
There is a similar underlying sense of loss for the teenager. Although explicitly desperate to be more independent, the teenager also knows that except for short periods it is impossible to reverse development, to fully go home. There is a longing at times for the more dependent days but spending any length of time back in childhood is uncomfortable, a sense of disease often remedied by a rapid pendulum swing toward adulthood sometimes facilitated by an irritable outburst.
To leave home (metaphorically) with a sense of certainty requires an enormous boost of self-confidence on the part of the teenager, a certainty that the adolescent can handle any situation, become a doctor, a lawyer, or both, or can make the varsity team or senior orchestra. Parental attempts to provide a realistic framework to deflate (and protect) the teenager’s unreasonable expectations are seen as insulting and even ignorant. Like an explorer boasting of leaving home base for uncharted territory, this burst of confidence is normal and necessary rocket fuel to energize a journey to adolescent lands never experienced before puberty. This fuel also provides a false sense of safety or even infallibility, which adds to the lure and danger of risk-taking behavior. All these dynamics are expected and essential.
Steps toward adult relationships
Younger teenagers will begin to form a more intense relationship with some adult outside the home. It may be a relative or neighbor, the parent of a friend, a teacher in an area of strength (piano, math), or a coach of a sport. At this age the teenager may spend more or as much time as possible at the neighbor’s house or go to school early to be with the teacher. The nature of this attachment will be deeper than to anyone other than parents. Some parents will wonder why their 12- or 13-year-old is so devoted to someone who has not raised them and is not that different in parental/adult approach or values. This is a safe first step away from the parents while still holding on quite intensely to another adult prior to the next step which is a major commitment to peer relationships. This movement is often more of a sign of a close parental relationship and evolving an identity than rejecting the parents.
Usually after this investment in a nonparent adult relationship, a young teenager’s peers become increasingly meaningful.4 The peers’ opinions about clothing, style, and relationships gain importance. It is normal for the peer group to change, sometimes quite suddenly and radically, from an academic group to a sports group to, alarmingly, a more alienated group with use of substances or disdain for school. These shifts in group allegiances are part of trying on temporary identities to see which aspects may fit and which swing toward or away from parental acceptance and traditions.
Early in the shift to nonparental adults and peer groups, many teenagers experience a crush—a moment when their sexual and personal attraction to another teen is so strong that the opportunity to catch sight of this new, critically meaningful peer is enough to sidestep a parent’s rule. Although this crush may not last long and may be one-sided, it is a moment that some believe signals the true psychological beginning of adolescence.
By mid-adolescence there are key adults including a coach, teacher, or adviser, as well as several peer groups that have been explored and tested as aspects of an emerging identity. These relationships have been augmented by videos, chats, social media, and thousands of text and image communications between an inner circle of peers and a huge number of others influencing the teenager.
By later adolescence, identity begins to solidify, though still plastic, and choices are about college and tentative career aspirations. More intimate interpersonal relationships supplement or at times supplant peer groups. Toward the end of adolescence, development evolves into a firmer concept of “what my 20s will be like.”
As the teenager experiences puberty, family expectations, school demands, and peer acceptance and rejection, the stress can be overwhelming. The only solution is to retreat, grieve, deflect, and reframe. The pendulum that has been in the zone of facing all these demands swings back and the adolescent may find solace with an intense investment in 1 peer group or activity to the exclusion of all else, a desperate leaving of the circumstances by running away or turning to drug use, or retreating by picking fights or seeking parental comfort.
Time spent being childish is moving against the tide of puberty, mastery, and development. The temporary comfort for normal adolescents will become increasing uncomfortable and they will begin to swing back—sometimes with irritability, sometimes with maturity. These swings are often microscopic, such as not caring about a difficult exam and afterward being able to move on with care (preparing better after a poor grade).
Retreating for too long can signal a more serious pathological break in development, the pendulum being stuck in behaviors that block progression and are self-perpetuating, such as addiction, premature or promiscuous sexuality, or serious violation of parental rules. These situations can make the teenager feel they have no way home. For one of every few thousand teenagers in high school, the effort to reach adulthood feels hopeless, substance use and/or impulsivity impair judgment, and/or there is a biologic vulnerability to depression, all of which may tragically result in suicide. Further, under these stressors, some teenagers will have suicidal ideation and a smaller subset attempt suicide.
The parental worries about adolescents vividly stick in our minds compared to the good outcomes that are much more common. For the vast majority of teenagers, the pendulum swings are not as severe. Support systems at home and school, or the collective wisdom/judgment of peers are all adequate to the task, and movement to adulthood is mostly successful.
The pediatrician’s role
The adolescent patient eliciting parental concern is an individual with a temperament, personality, level of self-esteem, and strengths and weaknesses. When asked to evaluate the mental health of your patient, you are being given a parentally edited snapshot. The snapshot that brings the teenage patient to your attention is often an argument or a high-risk behavior that is an accurate reflection of that moment but is only 1 frame of a 10-year-long movie that starts from finding a school locker or having a crush and ends with graduating college.
Almost nothing is harder than seeing an upset, difficult, or depressed adolescent and fully understanding their personal struggles, helping parents reflect on their own behavior, advising how to help their teenager, and predicting the future trajectory. Putting the snapshot into perspective means asking about preadolescent development and seeing whether any patterns or trauma are continuing to affect the pendulum movements.
Threads of current loss, failed hopes, and peer and parental relationships can be followed from the current crisis back to earlier times to assess whether development proceeded as expected. Is the behavior designed to distant the parents? How is the adolescent functioning in school, at home, in activities? Do they have hope? Are they connected to friends, religion, school, or activities? Are they depressed or addicted to a substance?
The pediatrician can take all this into account and humbly recommend some steps to meet the adolescent where they are and provide suggestions to move the pendulum toward a developmental trajectory. These suggestions could include parental advice on providing more support/structure or allowing more autonomy, reframing a situation to recommend options (talking to a teacher or guidance counselor to deal with an academic problem), reframing the adolescent’s perspective, offering a follow-up appointment sooner to continue the discussion, or, if needed, a mental health referral. Sometimes sharing a similar situation from a previous patient or from one’s own experience can provide an option or hope.
Much of the pediatrician’s insight will be based on the quality of the relationship between the teenager and this known, respected, nonparental adult. Building the relationship at ages 10, 11, and 12 years is helpful. Creating a safe, kind, respectful setting is a major step and listening with empathy and tolerance will often lead to a readiness by the adolescent to listen.
References
1. Diekema DS. Adolescent brain development and medical decision-making. Pediatrics. 2020;146(suppl 1):S18-S24. doi:10.1542/peds.2020-0818F
2. Blakemore SJ. Inventing Ourselves: The Secret Life of the Teenage Brain. Doubleday UK; 2018
3. Rageliene T. Links of adolescents identity development and relationship with peers: a systematic literature review. J Can Acad Child Adolesc Psychiatry. 2016;25(2):97-105.
4. Blos P. The second individuation process of adolescence. Psychoanal Study Child. 1967;22:162-186. doi:10.1080/00797308.1967.11822595
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