**3.1 Cognitive development**

Adolescence is a sensitive and critical period for both normal and maladaptive patterns of development. This period was formerly described as the time of transition from concrete operational thinking to formal logical (abstract) thinking, including development in reasoning and judgment.

New perspectives emphasize that adolescent thinking is a function of social, emotional, and cognitive processes (Steinberg, 2005). There is growing evidence that the brain continues to mature throughout adolescence and into early adulthood (Gogtay et al., 2004). During this period, brain, behavioral, and cognitive development systems mature at different rates, causing adolescence to be a period of increased vulnerability and adjustment.

Two issues are especially relevant to understanding adolescent psychological development. First, brain development in this period is mostly in regions that have an important role in regulation of behavior and emotion and to the perception and evaluation of risk and reward. Significant changes include myelination and synaptic pruning, which increase the efficiency of information processing and enhance transmission of brain messages (Paus, 2005). Areas associated with more basic functions, including the motor and sensory areas,

Reproductive health also varies across regions. Adolescent females are less likely to use contraceptives than adult women, and adolescent mothers are more at risk of developing complications related to pregnancy than adult mothers (Nugent, 2005). An adolescent mother is also more likely to drop out of school and be less educated than an adolescent female who has not become pregnant. Marital age has increased in many parts of the world, yet in some regions, child marriage (marriage by 18 years) continues to occur and is largely driven by 'poverty, parental concerns about premarital sex and pregnancy, and other

Because of these differences, a pediatrician's approach to the psychosocial history of an adolescent needs to be tailored to meet the needs of different regions/countries. Although we recognize each country, and sometimes different parts within the same country, may have their own unique issues, it is impossible to address matters of every single country. For this reason, in this chapter, we have decided to focus on some regions of the world and give an example of one country per region, though keeping in mind that this may not apply to

Many changes occur during adolescence, the most obvious being the physical ones. Pediatric and other medical references tend to focus on these physical changes, and this information is readily available. For this reason, the physical changes that occur during puberty and adolescence will not be discussed here. Rather, the focus will be on the other developmental changes that occur: the cognitive and emotional changes. These develop more insidiously and health care providers may be less familiar with them. In addition, healthcare providers may be deceived by the physical appearances of adolescents which are

Adolescence is a sensitive and critical period for both normal and maladaptive patterns of development. This period was formerly described as the time of transition from concrete operational thinking to formal logical (abstract) thinking, including development in

New perspectives emphasize that adolescent thinking is a function of social, emotional, and cognitive processes (Steinberg, 2005). There is growing evidence that the brain continues to mature throughout adolescence and into early adulthood (Gogtay et al., 2004). During this period, brain, behavioral, and cognitive development systems mature at different rates,

Two issues are especially relevant to understanding adolescent psychological development. First, brain development in this period is mostly in regions that have an important role in regulation of behavior and emotion and to the perception and evaluation of risk and reward. Significant changes include myelination and synaptic pruning, which increase the efficiency of information processing and enhance transmission of brain messages (Paus, 2005). Areas associated with more basic functions, including the motor and sensory areas,

economic and cultural reasons' (Nugent, 2005).

every single country within the same region.

**3.1 Cognitive development** 

reasoning and judgment.

**3. Developmental changes that occur during adolescence** 

not necessarily proportionate to their cognitive and/or emotional development.

causing adolescence to be a period of increased vulnerability and adjustment.

mature in the early teen years, while the prefrontal cortex, the reasoning area of the brain and an important area for controlling impulses, emotions and executive functioning, appears to reach adult dimension in the early 20s, with girls developing earlier than boys (Geidd et al., 1999; Gogtay et al., 2004; Luna et al., 2010). Executive functions include the ability to inhibit impulses, weigh consequences of decisions, prioritize, strategize, long-term planning, decision-making, self-evaluation, self-regulation, and the coordination of affect and cognition. Second, changes in arousal and motivation brought on by pubertal maturation precede the development of regulatory competence (Blakemore et al., 2010). The brain's reward center, the ventral striatum, also is more active during adolescence than in adulthood.

This creates a gap between the adolescent's affective experience and the ability to regulate arousal and motivation. While the adolescent brain continues to strengthen its connections between reasoning and emotion related regions, each adolescent progresses at varying rates in developing their ability to think and their own view of the world.

Adolescent thinking becomes more multidimensional and they are better to contemplate hypothetical situations and the relationship between varied actions or decisions and outcomes, but decision-making remains susceptible to emotions.

Adolescent cognitive development can be characterized into 3 stages: early, middle, and late (Cromer, 2011; Radzik et al., 2007).

In early adolescence, the use of formal logical operations is mainly focused on schoolwork and in home environments. This includes questioning authority and societal standards. There is development of enhanced ability to verbalize thoughts and views, starting with those related to their life. These include choices regarding engaging in sports, peer groups, dress, and parental rules that adolescents think should be changed. At this stage, they may be unable to perceive long-term outcomes of current decision-making.

In middle adolescence, more complex thinking processes are used. The focus expands to include more philosophical and futuristic concerns. Middle adolescents tend to question and analyze more extensively in order to form their own code of ethics, identity, and possible future goals, which may begin to influence relationships with others. They may perceive future implications, but may not apply it in decision-making.

In late adolescence, complex thinking processes are used to focus on less self-centered concepts as well as personal decision-making. Adolescents may think about more global concepts such as justice, history, politics, and patriotism. They develop idealistic views on specific topics or concerns and may debate and develop intolerance of opposing views. They tend to focus on making career decisions and think about their emerging role in society. At this stage, they are able to think things through independently and weigh consequences before making decisions. Table 1 summarizes the cognitive changes that occur during adolescence.

Understanding cognitive development during this period is helpful in understanding age differences in judgment and decision-making, risk-taking, sensation-seeking, and also why adolescence can be a time of increased risk for the onset of a wide range of emotional and behavioral problems, including depression, violent delinquency, and substance abuse.

Adolescent Psychosocial Developmentand Evaluation: Global Perspectives 185

Adolescence has been quaintly described as "that awkward period between sexual maturation and the attainment of adult roles and responsibilities"(Dahl, 2004). It is a time of great change with concurrent but asynchronous physical, cognitive, and emotional development. Although most adolescents progress through this phase unscathed with gradual, appropriate changes, some may experience significant challenges. Adolescents experience many changes in how they interact with their family, peers, society, and themselves (Choudhoury et al., 2006). They move from an idealistic opinion of parents during childhood, into increased conformity to peer group expectations and values, to the development of their own personal values and principles as they progress through early, middle, and late adolescence (B. Newman & P. Newman, 1999). This movement mirrors a shift in emotional support from family to peers and then to self and intimate partners. This is not to say there is or should be separation from the family, as healthy emotional development is highly dependent on continued positive interaction with parents throughout (Larson & Brown, 2007). However, there is gradual change until parents and the adolescent or young adult accept their individual roles and are able to share and challenge each others'

As previously mentioned, emotional and cognitive development are inextricably linked as brain development progresses throughout adolescence into early adulthood. Cognition has a significant impact on expression of emotions, and conversely emotion and situational contexts have a significant impact on adolescents' behavioral choices (Steinberg, 2005). Emotional development during adolescence involves learning to recognize and master the control of emotions experienced so as to facilitate functioning within expected societal norms. Emotions serve many important functions including motivating positive behavior, achieving goals, providing information about self, and facilitating relationships, including intimacy (Larson & Brown, 2007). It involves self-discovery and self-characterization to acquire a specific role in society which is facilitated by the enhanced abstract thought acquired during adolescence. There is evidence to support an association between cognitive maturation and increased regulation of emotional behavior; however it has been proposed that these changes are non-linear unlike development during childhood and adulthood (Casey et al., 2010). The subcortical limbic system -including the amygdala is important in the processing of emotions and emotional responses to social stimuli, whereas the prefrontal cortex is responsible for the cognitive control or regulation of emotional behavior. An "Imbalance Model" has been put forward that proposes that an imbalance between the development of these two systems may be related to the development of psychopathology (Casey et al., 2010). Sensitivity to rewards seems to peak in adolescence and may have a positive impact, such as academic or athletic achievements or negative influence with thrill seeking through use of substances or other high-risk behaviors. This incentive response suggests behaviors may be defined from a motivational perspective, and the dorsal and ventral striata which receive input from the cerebral cortex have been found to be involved in these responses (Somerville & Casey, 2010). There is also a significant association between the pubertal stage of maturation and affective measures including sensation-seeking, sex and sexual arousal, emotional sensitivity, and sleep, with sensation-seeking peaking in

**3.2 Emotional development** 

personal views and beliefs in a healthy way.

middle adolescence (Steinberg, 2005).


Table 1. Cognitive and emotional developmental changes that occur during adolescence

#### **3.2 Emotional development**

184 Complementary Pediatrics

used

Emergence of formal logical operations

Focus on personal

decisions, demonstrated in schoolwork and

environments

May be unable to perceive long-term outcomes of current decision-

home

making

support

of same sex interaction

Increasing awareness of a wider range of emotions begins

Peers are an increasingly important source of

Increased closeness

Increased need for privacy with increased interest in personal physical appearance and body image

**Cognitive development** 

**Emotional development** **Early adolescence Middle adolescence Late adolescence** 

Complex thinking processes used

Focus on less selfcentered concepts as well as personal decision-making

Able to think things

independently and weigh consequences before making decisions

Adolescent – parent communication improves

Increased autonomy from parents

Improved cognitive

emotional responses

control over

Increased confidence in personal beliefs and ability to express

them

through

Focus expands to include more philosophical and futuristic concerns

May perceive future implications of actions, but may not apply it in decision-

Increased conflict with parents as peer group interest peaks

Increased experience of a wide range of

Cognitive control over emotional responses limited

Sensation seeking at its peak with

increased risk taking

Increased sexual arousal with increased sexual activity and experimentation

behavior

Table 1. Cognitive and emotional developmental changes that occur during adolescence

making

emotions

More complex thinking processes

Adolescence has been quaintly described as "that awkward period between sexual maturation and the attainment of adult roles and responsibilities"(Dahl, 2004). It is a time of great change with concurrent but asynchronous physical, cognitive, and emotional development. Although most adolescents progress through this phase unscathed with gradual, appropriate changes, some may experience significant challenges. Adolescents experience many changes in how they interact with their family, peers, society, and themselves (Choudhoury et al., 2006). They move from an idealistic opinion of parents during childhood, into increased conformity to peer group expectations and values, to the development of their own personal values and principles as they progress through early, middle, and late adolescence (B. Newman & P. Newman, 1999). This movement mirrors a shift in emotional support from family to peers and then to self and intimate partners. This is not to say there is or should be separation from the family, as healthy emotional development is highly dependent on continued positive interaction with parents throughout (Larson & Brown, 2007). However, there is gradual change until parents and the adolescent or young adult accept their individual roles and are able to share and challenge each others' personal views and beliefs in a healthy way.

As previously mentioned, emotional and cognitive development are inextricably linked as brain development progresses throughout adolescence into early adulthood. Cognition has a significant impact on expression of emotions, and conversely emotion and situational contexts have a significant impact on adolescents' behavioral choices (Steinberg, 2005). Emotional development during adolescence involves learning to recognize and master the control of emotions experienced so as to facilitate functioning within expected societal norms. Emotions serve many important functions including motivating positive behavior, achieving goals, providing information about self, and facilitating relationships, including intimacy (Larson & Brown, 2007). It involves self-discovery and self-characterization to acquire a specific role in society which is facilitated by the enhanced abstract thought acquired during adolescence. There is evidence to support an association between cognitive maturation and increased regulation of emotional behavior; however it has been proposed that these changes are non-linear unlike development during childhood and adulthood (Casey et al., 2010). The subcortical limbic system -including the amygdala is important in the processing of emotions and emotional responses to social stimuli, whereas the prefrontal cortex is responsible for the cognitive control or regulation of emotional behavior. An "Imbalance Model" has been put forward that proposes that an imbalance between the development of these two systems may be related to the development of psychopathology (Casey et al., 2010). Sensitivity to rewards seems to peak in adolescence and may have a positive impact, such as academic or athletic achievements or negative influence with thrill seeking through use of substances or other high-risk behaviors. This incentive response suggests behaviors may be defined from a motivational perspective, and the dorsal and ventral striata which receive input from the cerebral cortex have been found to be involved in these responses (Somerville & Casey, 2010). There is also a significant association between the pubertal stage of maturation and affective measures including sensation-seeking, sex and sexual arousal, emotional sensitivity, and sleep, with sensation-seeking peaking in middle adolescence (Steinberg, 2005).

Adolescent Psychosocial Developmentand Evaluation: Global Perspectives 187

Within all this diversity is a need to discuss basic psychosocial issues with children,

• *Home*: The vast majority of North American adolescents live with at least one parent. Careful questioning will elicit the family constellation, which may include grandparents, step-parents, siblings and step-siblings, and unrelated friends. Some young people may see a pet as being a member of the family. Questions must be asked in a way that allows for the teen to disclose that they are homeless, have difficult relationships, or have a non-traditional family, such as one with two fathers or two

• *Education*: Throughout North America, there is mandatory schooling, usually until age 16. Most young people continue through secondary education, which is usually grade 12 or age 18. Urban areas, particularly in the United States, have high rates of students who do not complete high school. If one asks a young person what their school performance is like, they all know that the correct answer is "fine" or "OK". Specific questions about marks, the level of the courses they are taking (with much variation in terms of level of

schooling offered), how much school they miss, and career goals are all important. • *Eating*: Eating disorders are prevalent in North America, resulting in young people being both underweight and overweight. The current focus in schools and health systems on obesity focuses on the importance of being thin, which may be a trigger for anorexia nervosa or bulimia. More and more, eating disorders are being diagnosed in pre-adolescents, often associated with significant anxiety or anxiety disorders. Poverty is strongly associated with childhood obesity, with less nutritious foods being available

and limited opportunities for safe exercise for those living in inner cities.

for boys and girls within a family.

• *Activities*: Some North American adolescents are extremely active as athletes, volunteers, or workers. Working more than 16 hours a week often interferes with scholastic achievement. Some places require volunteer work for students to graduate from high school. Direct questions about screen time are essential, with many young people spending 5 or more hours a day in front of a computer or TV screen. Many are unaware of the dangers of revealing personal information on the internet to a legion of "friends" they have never met. Peer relationships should also be addressed, including questions about how the young person spends their lunchtime, if they see their friends outside of school, whether their parents allow them to have friends outside their religious or cultural group, and if there are discrepancies in the rules about friendship

• *Adherence*: Chronic health conditions are not uncommon in North America, with adolescents surviving with conditions that were previously fatal. Adolescents have many reasons for not taking medications—their family might not be able to afford them, they may see them as a sign that they are different from their friends, a chaotic household does not lend itself to the organization needed to be adherent, and mental health issues can interfere with the ability to regularly take medication. Medications that affect physical appearance, such as steroids, can be quite problematic for young people. Questions need to be asked in a sensitive manner without making assumptions

about adherence and the importance placed on medications within a family. • *Drugs*: Most drugs are readily available to North American youth. Alcohol is the most common substance used by youth, followed by marijuana and tobacco. Young people may respond well to being asked about drugs in their environment first, such as asking, "At your school, do students tend to drink more or take drugs?" You can then go on to

adolescents, and youth. The original HEADS acronym now has many variations.

mothers.

High intensity emotions may also have a significant impact on adolescents' thought processes and by extension to their behavioral choices – these have been referred to as 'hot' and 'cold' cognitions (Dahl, 2004; Somerville & Casey, 2010). 'Hot cognitions' refer to thinking amidst high intensity emotions and often result in poor decision-making. 'Cold cognitions' refer to thoughts in a state of calm, more commonly resulting in appropriate decision-making. This may explain why the adolescent who is usually even-keeled may, under certain 'hot' circumstances, make an otherwise unexpected poor decision.

Healthy emotional development is a key developmental task for adolescents who are learning to negotiate increasingly complex and ambiguous social interactions and utilize lessons learned from previous experiences to assist in determining future choices. Discordance during this time of development may serve as the root of psychopathology. Adolescents who fail to learn how to modify their own emotions may become impulsive with progression to delinquent behavior or may become alienated both from peers and family, leading to parental conflict, relationship challenges, and an increased risk of depression, substance abuse, and suicide risk.
