ADOLESCENCE
Psychologic Aspects
of Adolescent Patient Health Care
Alice James Kimball, Ph.D.,
THE
the adolescent
advice
meeting.
PHYSICIAN is often a resource for anxious parents and their sons and daughters on health, school, behavior and other problems. The adolescent often finds it easier to talk to a physician than to the parents about the bodily changes of physical and sexual maturity and other health-related problems as they occur. The physician who is receptive and comfortable working with teenagers, and can develop an accepting supportive relationship with them, will often find a wide range of concerns being brought up for discussion. to
Communicating with the Adolescent This calls for very different approaches from those which are useful with younger children. The adolescent has a strong need for identity and autonomy, and must be considered as an individual distinct from the rest of the family. Hence, for the initial appointment, it is always preferable to meet with him or her alone before interviewing the parents, unless From the Adolescent
Clinic, Child Development and
Mental Retardation Center,
WJ-10, University of Wash-
98195. Clinical Assistant Professor, Department of Pediatrics, University of Washington; Staff Psychologist, Adolescent Clinic. &dag er; Lecturer, Departments of Pediatrics, and Psychiatry and Behavioral Sciences, University of Washington; Staff Psychologist, Adolescent Clinic.
Seattle, Washington, ington, *
Mary
M.
Campbell, Ph.D.†
specifically requests
a
joint
,
A useful technique for obtaining basic information about a new adolescent patient is the Rotter Incomplete Sentences Blank14 (see Appendix). If the adolescent can read and write at a literate level and the task is not or threatening, he can fill out the blank while waiting for the appointment, or later while the parents are being interviewed. He or she should fill out this form without parental assistance, in a private room if possible. Assurance should be given that responses will be kept confidential and not shared with parents or teachers. Unlike most adults, many teenagers are willing to write revealing material, and they may find this task less stressful than a face-to-face interview where they are required to give verbal replies. Written responses often include concerns otherwise difficult to obtain during a first visit. Areas of conflict with parents, peers, and teachers, as well as the degree of anger and depression of the teenager, may be uncovered with this test, the information for later discussion of sensitive areas. (This test is described in the Appendix, with directions for administration and interpretation of results.) During the interviews, it is informative to ask the parents and the teenager separately to give their most important reasons for making this appointment. Initially the adoles-
embarrassing
15 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
may emphasize health and academic reasons, and only later bring up family and personal problems. In contrast, parents often describe family conflicts, school difficulties, running away, or family differences in friends or values as being behind the referral. When working with this age group, the physician must be constantly on the alert neither to over-identify with the adolescent nor to be critical of the parents. Attitudes of adults in our society are so often negative toward adolescents in general that there is a temptation to try to establish immediate rapport with the teenager by becoming his aggressive advocate. Unfortunately, this tends to undermine the physician’s effectiveness in dealing objectively with the teenager, parents, and school personnel. It is equally important to avoid giving the impression of being another authority figure who assumes a parental role. Particularly in the many cases where the reason for referral is conflict between adolescent and family or school, it is important not to escalate anger or intensify the crisis situation by making early, biased judgments which may impede later negotiations. The interviewer’s role should clearly be that of mediator. cent
Communicating
with School Personnel
These often make or suggest the adolescent’s referral. When this occurs, the school can be a most useful source of information concerning academic performance, attendance, classroom behavior, social interactions, and self-attitudes. Speaking directly by telephone to the principal, vice-principal, coun-
selor, nurse, school psychologist or home-room teacher is a very effective means for obtaining information and understanding. A prepared list of questions is useful. Some physicians follow the telephone call with a brief form
requesting specific information, including of psychologic and teacher assessments. Written information, while useful, can not take the place of personal contacts with school personnel who have worked directly with the adolescent. When requesting information, it is helpful to ask about the procedures used in trying to alleviate the school difficulties. School records usually contain scores on group achievement
intelligence tests. If the student has no reading problem, achievement tests may give a fairly reliable estimate of school achievement and changes in performance over the years. It is important to remember, however, that when taking any group test the student is not individually supervised, and his effort and and
motivation
cannot
be assured. If there has
The adolescent has a strong need for identity and autonomy, and must be
considered as an individual distinct from the rest of the family. Hence, for the initial appointment, it is always preferable to meet with him or her alone before
interviewing the parents, unless specifically requests meeting.
adolescent
been
the a
joint
individual psychologic evaluation, the Wechsler Intelligence Scale for Children’8 or the Wechsler Adult Intelligence Scale’9 may be available, and these may point out strengths and weaknesses in specific areas. One must keep in mind that a student can be passed along and attain junior high school or even high school standing without acquiring the basic skills needed to succeed at this level. Because academic demands increase abruptly after elementary school, many adolescents experience a distinct drop in school performance at the junior high level,&dquo; and are unable to improve their grades in high school after this drop. Both academic and behavior problems may result. When there is a reading delay of two or more grades, a student is described as having a &dquo;learning disability.&dquo; If intelligence is at least average and there are no significant contributan
scores on
ing emotional or social factors, the learning disability is often referred to as &dquo;dyslexia.&dquo; This widely misused and vague term irequently mislabels a child at a young age, perpetuating the disability by limiting teachers’ expectations. Although the standard level for literacy and everyday reading is sixth grade, this level may be a severe handicap in doing high school work. The teenager with a marked
16 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued
on
page 19)
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued from page 16) reading delay often has great difficulty with spelling as well. This may make it impossible to demonstrate his capabilities on written examinations or assignments. Reports on reading ability may include grades for word recognition, vocabulary, comprehension and rate of reading paragraphs. When there is no report of basic school skills (reading, arithmetic and spelling), the physician may have an assistant in the office give screening tests. The Wide Range Achievement Test9 and the Peabody Picture Vocabulary Test, described more fully in the Appendix, can be given reliably after practice. Referral for further analysis and remediation of a reading disability should be discussed with school personnel. Whatever the nature, it is imperative to help the adolescent recognize that this is a special learning problem and that he or she is not generally &dquo;slow.&dquo; Other reasons for school referrals may be underachievement in spite of adequate ability and good basic skills (often described as &dquo;lack of motivation&dquo;), or truancy, or school refusal, or disruption of classroom behavior. When studying these problems, it is necessary to assess how realistic and often stressful the family’s expectations are for their teenager. Are their expectations so high that the teenager is afraid of failure? Is underachieving a passive-aggressive expression of rebellion? It is important for the physician to be familiar with the &dquo;junior high school scene&dquo; and the new stresses and fears of failure that accom8 pany the transition from elementary school. The stage of physical and psychologic development at which each adolescent enters junior high school bears directly on how stressful the new school environment will be. Adolescent Responses to
Development
With the exception of the period of rapid growth in infancy, changes in the areas of physical and sexual development, cognitive abilities,5 and social relationships are more radical thy teen years than at any other formative period? In early adolescence,
adjustments
to the outward differences and in changes appearance and to inner hormonal changes result in heightened awareness of a
body image, and inevitably to &dquo;vulnerability to real or imagined assaults on bodily new
integrity. 118 Accompanying the dramatic physical and psychologic changes are enhanced needs to become a separate person in one’s own right and to be accepted by peers of the same and of the opposite sex. At the time, nevertheless, the teenager is also fearful of relinquishing the security
of childhood. Stierlin15 describes
The interviewer’s role should be that of mediator.
some
clearly
of the serious difficulties parents have in
separating from their children-often expecting them to compensate for achievements they attained in their own lives. It is essensearch for the family tension and tial to distress that may occur .during this parental of period emancipation.~~ Sometimes professional help may be indicated for the parents. Even parents who are sincerely trying to foster independence often need assurance in accepting their adolescent’s changes in life style in his endeavors to become independent. Sometimes parents obstruct forward changes in development because their own expectations are not realistic, or they have not kept up with the changes of the adolescents’ role in have
not
1
society Questioning and rebelling against accepted rules may be the most important mode of beginning emancipation. This should, if feasible, be interpreted to both the adolescent and parents as a constructive phenomenon. Adolescents must be expected to question the cultural values learned in earlier childhood, and to a varying degree they will accept or reject the roles expected by their parents. The outcome of ongoing process is strongly influenced by the to be accepted by the peer group. AM professionals who are working with adolescents must keep familiar with the current standards for fashion, recreation, and dating practices if they are to mediate family conflicts where these values are to be arbitrated. Actingout behavior must be evaluated in the context of the adolescent norms set up by the family,
19 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
as a whole-all of which in the past few have shifted radically may decades. In other words, the professionals working with teenagers must try to disassociate themselves from their own values and standards for behavior. There have been important changes such as earlier dating, greater sexual freedom, undefined sex roles, and greater mobility. At the same time, as long as the teenager is living at home, the family’s rights and expectations must be respected by the adoles-
school, and society
cent
and the
professional.
Phenomena c~f Late Adolescence
phase of development, the search for self-identity and independence broadens to include more intense relationships with the opposite sex, vocational planning, a growing In this
desire to be a useful member of the community, and finding and maintaining a job. A sign of the successful completion of adolescence is the achievement of satisfying separation from the family and the ability to live independently on
one’s own. Such an older adolescent should
develop the ability to relate to the family in a mature, friendly manner. As the adolescent works
to
achieve these
goals, his or her behavior and dramatic mood swings are influenced both by cultural expectations and by the new coping mechanisms or defenses which now appear, with capacity for logical thinking and greater social awareness. Ambivalence and indecisiveness increase with the ability to see alternatives. Introspection and defensiveness, or the covering up of real
Written information, white useful, cannot take the place of personal contacts with school personnel who have worked directly with the adolescent.
feelings, are characteristic of this stage in development. Any difference from other teenagers, particularly in body image, caused by illness or a physical handicap may be particularly threatening. Common defenses are passive aggressiveness, denial, and acting-out, with occasionally
more severe
withdrawal and
projection.
Ado-
lescents, like adults, may express depression through withdrawal, boredom, underachieveand somatic complaints, or even suicidal or reckless behavior. The actual statistics for adolescent suicide may be underreported because some &dquo;accidents&dquo; should be included in this category. Depressed actingout adolescents may be reflecting their apprehension and anxiety related to separation from parents. Many need to learn new ways of behaving and talking out feelings rather than expressing them through delinquent behavior. ment
gestures
General Principles of
Management
The defense mechanisms described above have important implications for treatment. An adolescent may be irregular in attending individual or group sessions because of reluc-
divulge feelings. The physician should blame himself or herself for these fluctuations and should recognize them as a natural course of events which may require more reaching out and direct involvement than is expected with adult patients and with younger children. Although many adolescents are emotionally labile, the physician must be alert for signs of incipient psychosis, such as extreme anxiety, tance to
not
confused thinking,
or
significant depression.
There are some psychologic screening tests which may assist in the recognition of these serious emotional problems. Two of these, the Psychological Screening ~nventory~° and the Wahler Self-Description Inventory, 17 are described in the Appendix. When suicidal thoughts or suicide attempts are suggested by responses in screening tests or interviews, it is crucial to evaluate them carefully and to obtain a detailed family history to find out whether the mother, for example, is depressed or ill, or whether some member of family has committed suicide. The depressed teenager should always know how to get help at night and over weekends, and should be encouraged to call the physician during times of crisis. Temporary removal from the family or hospitalization may be the treatment of choice for seriously depressed teenagers. For further psychologic or psychiatric
20 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
evaluation, the physician may arrange for this local clinic or through a psychologist or psychiatrist in private practice. When making a referral to a psychologist, it is preferable to ask specific questions such as &dquo;What is your estimate of the adolescent’s ability, and what would be his most helpful school placement?&dquo; rather than asking for an I.Q. score or specifyat a
ing particular
tests.
Suggestions for Management Specific Problems
of
Behavior problems which primarily involve family conflicts over responsibilities and privileges can sometimes be resolved through a few sessions with all the family meeting together and drawing up a written or verbal agreement. It is important that the adolescent participate in offering suggestions in planning the contract and rewards, both for himself and for the parents.2.a,6,12 Should serious problems in the family require long-term intensive counseling, referral to a local community mental health clinic or to a private counselor is recommended. More critical behavior problems which involve the school or community, such as longterm school refusal or serious delinquent acts, require conferences with school personnel, other community agencies, or the court, in order to coordinate plans for helping the adolescent. The physician should have a list. oaf agencies which offer long-term counseling and group living for adolescents. The list should also identify private professionals, psychiatrists, social workers, and psychologists who specialize in working with this age group. Some of the specific problems of teenagers are often better dealt with in group settings. The goals of such a group, like those of individual counseling, bye planned jointly by the teenagers and an experienced therapist. Building self-esteem, developing alternative ways of communicating with adults and peers, learning to use self-assertion as opposed to aggression and passivity are topics to be considered by adolescents working in a group. A few suggestions on particular behavior problems which may accompany physical problems should be mentioned. Growth differences, especially excessive weight gain in
or girls, and small stature in boys often evoke behavior or emotional problems. The assistance of a nutritionist and a local metabolic clinic or consultant are resources which may be helpful after the initial diagnostic workup. As mentioned, any variation from &dquo;normal&dquo; in ability or physical capacity is particularly difficult to cope with in adolescence. One result may be that the chronically ill teenager will ignore taking care of himself. As examples, a diabetic may refuse to take insulin at regular times, or an adolescent physically disabled may attempt inappropriate physical activities. In such situations, it becomes extremely important to treat the person rather than the specific disease and try to understand his behavior in the context of his adolescent
boys
development. Physically handicapped teenagers need help in accepting their differences in body images and in recognizing their capacity for sexuality. A recent publication by Snohomish Planned Parenthood’4 covers this topic well for women, and includes a particu-
larly comprehensive chapter on family planning for the physically handicapped. The retarded adolescent and family present another challenging area for counseling.&dquo; Special adolescent concerns about sexual behavior, vocational training, future marriage, and parenthood are often brought to the physician. Behavioral management techniques may be needed for particular problems such Because academic demands increase abruptly after elementary school, many adolescents experience a distinct drop in school performance at the junior high level, and are unable to improve their grades in
high school
as
drop. Both academic problems may result.
after this
and behavior
seif-aggressive or nervous habits. Adolesbrings a host of new problems to the
cence
retarded teenager who may have been appropriately overly dependent as a. young child, but who needs more experiences outside of his home just as all adolescents do. Parents may need encouragement and special instruction (Continued on page 24)
21 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued from page 21} in order to teach self-help skills such as riding the bus and going to the store alone. The Division of Vocational Rehabilitation, with local offices in each state, is a resource for job training and evaluation for the developmentally disabled and the physically handicapped.
Recapitulation In summary, the major developmental changes occurring in adolescence are: 1. Dramatic physical and psychologic changes, with puberty resulting in a new body image and vulnerable self-esteem. 2. Rebellion and withdrawal from parents and other adults in an effort to become
independent. 3. Greater attachment to peer group and excessive sensitivity to other teenagers’ ap-
proval or disapproval. 4. Development of new coping mechanisms with new capacity for logical thinking and social awareness. 5. Emancipation and successful separation from family, vocational and economic independence, and acceptance of adult responsibilities in the community. Although these developmental changes are complex, and communication with the adolescent and family requires considerable experience and finesse, there are a number of positive aspects to working with patients this age. Many teenagers are enthusiastic and responsive when they are provided with an objective, sympathetic listener. They will relate quickly and warmly if they are convinced the physician is really interested in them. Most important is their remarkable potential for change-sometimes in a relatively brief period of time. Counseling teenagers can be extremely rewarding and well worth the time
energy required.
References 1.
M. M., and Cooper, K.: Parents’ perception of adolescent behavior problems. J. Youth Adol. 4: 309, 1975. 2. Deibert, A. M.: New Tools for Changing Behavior. Champaign, Illinois, Research Press, 1970.
Campbell,
3. Dreikurs, R., Gould, S., and Corsini, R.
Council.
J.: Family Chicago, Henry Regnery, 1974. M.: Peabody Picture Vocabulary Test
4. Dunn, L. Manual. Circle Pines, Minnesota, American Guidance Service, 1959. 5. Elkind, D.: Children and Adolescents. New York, 6.
Oxford University Press, 1970. Gordon, R.: Parent Effectiveness Training. New York, Wyden, 1970.
7.
Group on
for Advancement of Psychiatry (Committee Adolescence): Normal Adolescence. New York,
Scribners, 1968. B. A.: Coping in early adolescence. In: American Handbook of Psychiatry, Caplan, G., Ed. New York, Basic Books, 1974.
8.
Hamburg,
9.
Jastak, J., Bijou, S.,
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
and Jastak, S.: Wide Range Achievement Test Manual. New York, Guidance Associates, 1965. Lanyon, R. I.: Psychological Screening Inventory Manual. Goshen, New York, Research Psychologists Press, 1968. Offer, D., and Offer, J.: Developmental psychology of youth. In: Youth: Problems and Approaches, S. J. Shamsie, Ed. Philadelphia, Lea and Febiger, 1972, pp. 43-69. Patterson, G. R.: Families— Applications of Social Learning to Family Life. Champaign, Illinois, Research Press, 1971. Robinson, N. M., and Robinson, H. B.: The Mentally Retarded Child, 2nd ed. New York, McGraw-Hill, 1976. Rotter, J. B.: Incomplete Sentences Blank—High School Form. New York, Psychological Corporation, 1950. Stierlin, H.: Separating Parents and Adolescents. New York, Quadrangle Books, 1972. Task Force on Concerns of Physically Disabled Women: Toward Intimacy: Family Planning and Sexuality Concerns of Physically Disabled Women. Planned Parenthood of Snohomish County, 1977. Wahler, H. J.: Wahler Self-Description Inventory Manual. Los Angeles, Western Psychological Services, 1971. Wechsler, D.: Wechsler Intelligence Scale for Children (Revised) Manual. New York, Psychological Corporation, 1974. Wechsler, D.: Wechster Intelligence Scale for Adults Manual. New York, Psychological Corporation, 1955.
24 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Appendix
Incomplete Sentences Blank (Rotte~~’~ The sentence completion method is a semistructured questionnaire in which the subject is asked to finish a sentence where the first word or words are supplied. The subject should be urged to write a complete sentence if possible. Responses suggest areas of conflict and assist in assessing the degree of depression of the adolescent. Feelings of sadness, alienation, eating and sleeping disturbances and thoughts of harming oneself are often included and should be followed up with indepth interviewing. The examiner must be alert to overly defensive responses; he should not always accept replies at face value when a teenager insists he has no problems whatever.
Psychological Screening ln~enta~r°y° A brief &dquo;mental health screening device&dquo; which compares the scores of the client to those of hospitalized psychiatric patients, incarcerated prisoners, and teenagers without serious problems. Scores on this test are helpful in deciding how disturbed a teenager may be, and whether psychiatric, psychologic, or social work consults would be useful.
Wahler
Self- Description In~rentct~y~’
The subject rates himself on favorable and unfavorable attributes on a nine point scale. This test yields a score which indicates the subject’s perception of his own competence and shortcomings, or level of self-confidence. Inspection of critical items will also indicate
the degree of depression and suggest areas for further interviewing.
Peabody Picture Vocabulary Test (PPVT)4
easily administered test can be given quickly by teachers, physicians, nurses, and counselors. Required are familiarity with the test materials and some practice in giving the This
The age range is from 3 to 17 years, and the test is particularly useful for a shy or nonverbal child. Interpretation of the Mental Age, Percentile Scores, and I.Q. obtained with this test must be limited to the measurement of language development-the child’s &dquo;hearing vocabulary&dquo;-vahieh is related to, but not the same as, his general intellectual development. There may be serious deficits in other areas which are not measured by this test, which may make school achievement difficult or impossible. test.
Wide
Range Achievement Test9
A teacher or nurse can quickly learn to administer this easily given screening test to determine approximate grade level for Reading (word recognition only), Spelling, and Arithmetic. Word recognition at approximately grade 6 is taken as the &dquo;literacy level&dquo; which enables the subject to read a newspaper or popular magazine. If the test is to be used for prediction of success in school, reading speed and comprehension should be evaluated also by a psychologist or educational consultant.
25 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Psychologic Aspects
of Adolescent Patient Health Care
Alice James Kimball, Ph.D.,
THE
the adolescent
advice
meeting.
PHYSICIAN is often a resource for anxious parents and their sons and daughters on health, school, behavior and other problems. The adolescent often finds it easier to talk to a physician than to the parents about the bodily changes of physical and sexual maturity and other health-related problems as they occur. The physician who is receptive and comfortable working with teenagers, and can develop an accepting supportive relationship with them, will often find a wide range of concerns being brought up for discussion. to
Communicating with the Adolescent This calls for very different approaches from those which are useful with younger children. The adolescent has a strong need for identity and autonomy, and must be considered as an individual distinct from the rest of the family. Hence, for the initial appointment, it is always preferable to meet with him or her alone before interviewing the parents, unless From the Adolescent
Clinic, Child Development and
Mental Retardation Center,
WJ-10, University of Wash-
98195. Clinical Assistant Professor, Department of Pediatrics, University of Washington; Staff Psychologist, Adolescent Clinic. &dag er; Lecturer, Departments of Pediatrics, and Psychiatry and Behavioral Sciences, University of Washington; Staff Psychologist, Adolescent Clinic.
Seattle, Washington, ington, *
Mary
M.
Campbell, Ph.D.†
specifically requests
a
joint
,
A useful technique for obtaining basic information about a new adolescent patient is the Rotter Incomplete Sentences Blank14 (see Appendix). If the adolescent can read and write at a literate level and the task is not or threatening, he can fill out the blank while waiting for the appointment, or later while the parents are being interviewed. He or she should fill out this form without parental assistance, in a private room if possible. Assurance should be given that responses will be kept confidential and not shared with parents or teachers. Unlike most adults, many teenagers are willing to write revealing material, and they may find this task less stressful than a face-to-face interview where they are required to give verbal replies. Written responses often include concerns otherwise difficult to obtain during a first visit. Areas of conflict with parents, peers, and teachers, as well as the degree of anger and depression of the teenager, may be uncovered with this test, the information for later discussion of sensitive areas. (This test is described in the Appendix, with directions for administration and interpretation of results.) During the interviews, it is informative to ask the parents and the teenager separately to give their most important reasons for making this appointment. Initially the adoles-
embarrassing
15 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
may emphasize health and academic reasons, and only later bring up family and personal problems. In contrast, parents often describe family conflicts, school difficulties, running away, or family differences in friends or values as being behind the referral. When working with this age group, the physician must be constantly on the alert neither to over-identify with the adolescent nor to be critical of the parents. Attitudes of adults in our society are so often negative toward adolescents in general that there is a temptation to try to establish immediate rapport with the teenager by becoming his aggressive advocate. Unfortunately, this tends to undermine the physician’s effectiveness in dealing objectively with the teenager, parents, and school personnel. It is equally important to avoid giving the impression of being another authority figure who assumes a parental role. Particularly in the many cases where the reason for referral is conflict between adolescent and family or school, it is important not to escalate anger or intensify the crisis situation by making early, biased judgments which may impede later negotiations. The interviewer’s role should clearly be that of mediator. cent
Communicating
with School Personnel
These often make or suggest the adolescent’s referral. When this occurs, the school can be a most useful source of information concerning academic performance, attendance, classroom behavior, social interactions, and self-attitudes. Speaking directly by telephone to the principal, vice-principal, coun-
selor, nurse, school psychologist or home-room teacher is a very effective means for obtaining information and understanding. A prepared list of questions is useful. Some physicians follow the telephone call with a brief form
requesting specific information, including of psychologic and teacher assessments. Written information, while useful, can not take the place of personal contacts with school personnel who have worked directly with the adolescent. When requesting information, it is helpful to ask about the procedures used in trying to alleviate the school difficulties. School records usually contain scores on group achievement
intelligence tests. If the student has no reading problem, achievement tests may give a fairly reliable estimate of school achievement and changes in performance over the years. It is important to remember, however, that when taking any group test the student is not individually supervised, and his effort and and
motivation
cannot
be assured. If there has
The adolescent has a strong need for identity and autonomy, and must be
considered as an individual distinct from the rest of the family. Hence, for the initial appointment, it is always preferable to meet with him or her alone before
interviewing the parents, unless specifically requests meeting.
adolescent
been
the a
joint
individual psychologic evaluation, the Wechsler Intelligence Scale for Children’8 or the Wechsler Adult Intelligence Scale’9 may be available, and these may point out strengths and weaknesses in specific areas. One must keep in mind that a student can be passed along and attain junior high school or even high school standing without acquiring the basic skills needed to succeed at this level. Because academic demands increase abruptly after elementary school, many adolescents experience a distinct drop in school performance at the junior high level,&dquo; and are unable to improve their grades in high school after this drop. Both academic and behavior problems may result. When there is a reading delay of two or more grades, a student is described as having a &dquo;learning disability.&dquo; If intelligence is at least average and there are no significant contributan
scores on
ing emotional or social factors, the learning disability is often referred to as &dquo;dyslexia.&dquo; This widely misused and vague term irequently mislabels a child at a young age, perpetuating the disability by limiting teachers’ expectations. Although the standard level for literacy and everyday reading is sixth grade, this level may be a severe handicap in doing high school work. The teenager with a marked
16 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued
on
page 19)
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued from page 16) reading delay often has great difficulty with spelling as well. This may make it impossible to demonstrate his capabilities on written examinations or assignments. Reports on reading ability may include grades for word recognition, vocabulary, comprehension and rate of reading paragraphs. When there is no report of basic school skills (reading, arithmetic and spelling), the physician may have an assistant in the office give screening tests. The Wide Range Achievement Test9 and the Peabody Picture Vocabulary Test, described more fully in the Appendix, can be given reliably after practice. Referral for further analysis and remediation of a reading disability should be discussed with school personnel. Whatever the nature, it is imperative to help the adolescent recognize that this is a special learning problem and that he or she is not generally &dquo;slow.&dquo; Other reasons for school referrals may be underachievement in spite of adequate ability and good basic skills (often described as &dquo;lack of motivation&dquo;), or truancy, or school refusal, or disruption of classroom behavior. When studying these problems, it is necessary to assess how realistic and often stressful the family’s expectations are for their teenager. Are their expectations so high that the teenager is afraid of failure? Is underachieving a passive-aggressive expression of rebellion? It is important for the physician to be familiar with the &dquo;junior high school scene&dquo; and the new stresses and fears of failure that accom8 pany the transition from elementary school. The stage of physical and psychologic development at which each adolescent enters junior high school bears directly on how stressful the new school environment will be. Adolescent Responses to
Development
With the exception of the period of rapid growth in infancy, changes in the areas of physical and sexual development, cognitive abilities,5 and social relationships are more radical thy teen years than at any other formative period? In early adolescence,
adjustments
to the outward differences and in changes appearance and to inner hormonal changes result in heightened awareness of a
body image, and inevitably to &dquo;vulnerability to real or imagined assaults on bodily new
integrity. 118 Accompanying the dramatic physical and psychologic changes are enhanced needs to become a separate person in one’s own right and to be accepted by peers of the same and of the opposite sex. At the time, nevertheless, the teenager is also fearful of relinquishing the security
of childhood. Stierlin15 describes
The interviewer’s role should be that of mediator.
some
clearly
of the serious difficulties parents have in
separating from their children-often expecting them to compensate for achievements they attained in their own lives. It is essensearch for the family tension and tial to distress that may occur .during this parental of period emancipation.~~ Sometimes professional help may be indicated for the parents. Even parents who are sincerely trying to foster independence often need assurance in accepting their adolescent’s changes in life style in his endeavors to become independent. Sometimes parents obstruct forward changes in development because their own expectations are not realistic, or they have not kept up with the changes of the adolescents’ role in have
not
1
society Questioning and rebelling against accepted rules may be the most important mode of beginning emancipation. This should, if feasible, be interpreted to both the adolescent and parents as a constructive phenomenon. Adolescents must be expected to question the cultural values learned in earlier childhood, and to a varying degree they will accept or reject the roles expected by their parents. The outcome of ongoing process is strongly influenced by the to be accepted by the peer group. AM professionals who are working with adolescents must keep familiar with the current standards for fashion, recreation, and dating practices if they are to mediate family conflicts where these values are to be arbitrated. Actingout behavior must be evaluated in the context of the adolescent norms set up by the family,
19 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
as a whole-all of which in the past few have shifted radically may decades. In other words, the professionals working with teenagers must try to disassociate themselves from their own values and standards for behavior. There have been important changes such as earlier dating, greater sexual freedom, undefined sex roles, and greater mobility. At the same time, as long as the teenager is living at home, the family’s rights and expectations must be respected by the adoles-
school, and society
cent
and the
professional.
Phenomena c~f Late Adolescence
phase of development, the search for self-identity and independence broadens to include more intense relationships with the opposite sex, vocational planning, a growing In this
desire to be a useful member of the community, and finding and maintaining a job. A sign of the successful completion of adolescence is the achievement of satisfying separation from the family and the ability to live independently on
one’s own. Such an older adolescent should
develop the ability to relate to the family in a mature, friendly manner. As the adolescent works
to
achieve these
goals, his or her behavior and dramatic mood swings are influenced both by cultural expectations and by the new coping mechanisms or defenses which now appear, with capacity for logical thinking and greater social awareness. Ambivalence and indecisiveness increase with the ability to see alternatives. Introspection and defensiveness, or the covering up of real
Written information, white useful, cannot take the place of personal contacts with school personnel who have worked directly with the adolescent.
feelings, are characteristic of this stage in development. Any difference from other teenagers, particularly in body image, caused by illness or a physical handicap may be particularly threatening. Common defenses are passive aggressiveness, denial, and acting-out, with occasionally
more severe
withdrawal and
projection.
Ado-
lescents, like adults, may express depression through withdrawal, boredom, underachieveand somatic complaints, or even suicidal or reckless behavior. The actual statistics for adolescent suicide may be underreported because some &dquo;accidents&dquo; should be included in this category. Depressed actingout adolescents may be reflecting their apprehension and anxiety related to separation from parents. Many need to learn new ways of behaving and talking out feelings rather than expressing them through delinquent behavior. ment
gestures
General Principles of
Management
The defense mechanisms described above have important implications for treatment. An adolescent may be irregular in attending individual or group sessions because of reluc-
divulge feelings. The physician should blame himself or herself for these fluctuations and should recognize them as a natural course of events which may require more reaching out and direct involvement than is expected with adult patients and with younger children. Although many adolescents are emotionally labile, the physician must be alert for signs of incipient psychosis, such as extreme anxiety, tance to
not
confused thinking,
or
significant depression.
There are some psychologic screening tests which may assist in the recognition of these serious emotional problems. Two of these, the Psychological Screening ~nventory~° and the Wahler Self-Description Inventory, 17 are described in the Appendix. When suicidal thoughts or suicide attempts are suggested by responses in screening tests or interviews, it is crucial to evaluate them carefully and to obtain a detailed family history to find out whether the mother, for example, is depressed or ill, or whether some member of family has committed suicide. The depressed teenager should always know how to get help at night and over weekends, and should be encouraged to call the physician during times of crisis. Temporary removal from the family or hospitalization may be the treatment of choice for seriously depressed teenagers. For further psychologic or psychiatric
20 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
evaluation, the physician may arrange for this local clinic or through a psychologist or psychiatrist in private practice. When making a referral to a psychologist, it is preferable to ask specific questions such as &dquo;What is your estimate of the adolescent’s ability, and what would be his most helpful school placement?&dquo; rather than asking for an I.Q. score or specifyat a
ing particular
tests.
Suggestions for Management Specific Problems
of
Behavior problems which primarily involve family conflicts over responsibilities and privileges can sometimes be resolved through a few sessions with all the family meeting together and drawing up a written or verbal agreement. It is important that the adolescent participate in offering suggestions in planning the contract and rewards, both for himself and for the parents.2.a,6,12 Should serious problems in the family require long-term intensive counseling, referral to a local community mental health clinic or to a private counselor is recommended. More critical behavior problems which involve the school or community, such as longterm school refusal or serious delinquent acts, require conferences with school personnel, other community agencies, or the court, in order to coordinate plans for helping the adolescent. The physician should have a list. oaf agencies which offer long-term counseling and group living for adolescents. The list should also identify private professionals, psychiatrists, social workers, and psychologists who specialize in working with this age group. Some of the specific problems of teenagers are often better dealt with in group settings. The goals of such a group, like those of individual counseling, bye planned jointly by the teenagers and an experienced therapist. Building self-esteem, developing alternative ways of communicating with adults and peers, learning to use self-assertion as opposed to aggression and passivity are topics to be considered by adolescents working in a group. A few suggestions on particular behavior problems which may accompany physical problems should be mentioned. Growth differences, especially excessive weight gain in
or girls, and small stature in boys often evoke behavior or emotional problems. The assistance of a nutritionist and a local metabolic clinic or consultant are resources which may be helpful after the initial diagnostic workup. As mentioned, any variation from &dquo;normal&dquo; in ability or physical capacity is particularly difficult to cope with in adolescence. One result may be that the chronically ill teenager will ignore taking care of himself. As examples, a diabetic may refuse to take insulin at regular times, or an adolescent physically disabled may attempt inappropriate physical activities. In such situations, it becomes extremely important to treat the person rather than the specific disease and try to understand his behavior in the context of his adolescent
boys
development. Physically handicapped teenagers need help in accepting their differences in body images and in recognizing their capacity for sexuality. A recent publication by Snohomish Planned Parenthood’4 covers this topic well for women, and includes a particu-
larly comprehensive chapter on family planning for the physically handicapped. The retarded adolescent and family present another challenging area for counseling.&dquo; Special adolescent concerns about sexual behavior, vocational training, future marriage, and parenthood are often brought to the physician. Behavioral management techniques may be needed for particular problems such Because academic demands increase abruptly after elementary school, many adolescents experience a distinct drop in school performance at the junior high level, and are unable to improve their grades in
high school
as
drop. Both academic problems may result.
after this
and behavior
seif-aggressive or nervous habits. Adolesbrings a host of new problems to the
cence
retarded teenager who may have been appropriately overly dependent as a. young child, but who needs more experiences outside of his home just as all adolescents do. Parents may need encouragement and special instruction (Continued on page 24)
21 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
(Continued from page 21} in order to teach self-help skills such as riding the bus and going to the store alone. The Division of Vocational Rehabilitation, with local offices in each state, is a resource for job training and evaluation for the developmentally disabled and the physically handicapped.
Recapitulation In summary, the major developmental changes occurring in adolescence are: 1. Dramatic physical and psychologic changes, with puberty resulting in a new body image and vulnerable self-esteem. 2. Rebellion and withdrawal from parents and other adults in an effort to become
independent. 3. Greater attachment to peer group and excessive sensitivity to other teenagers’ ap-
proval or disapproval. 4. Development of new coping mechanisms with new capacity for logical thinking and social awareness. 5. Emancipation and successful separation from family, vocational and economic independence, and acceptance of adult responsibilities in the community. Although these developmental changes are complex, and communication with the adolescent and family requires considerable experience and finesse, there are a number of positive aspects to working with patients this age. Many teenagers are enthusiastic and responsive when they are provided with an objective, sympathetic listener. They will relate quickly and warmly if they are convinced the physician is really interested in them. Most important is their remarkable potential for change-sometimes in a relatively brief period of time. Counseling teenagers can be extremely rewarding and well worth the time
energy required.
References 1.
M. M., and Cooper, K.: Parents’ perception of adolescent behavior problems. J. Youth Adol. 4: 309, 1975. 2. Deibert, A. M.: New Tools for Changing Behavior. Champaign, Illinois, Research Press, 1970.
Campbell,
3. Dreikurs, R., Gould, S., and Corsini, R.
Council.
J.: Family Chicago, Henry Regnery, 1974. M.: Peabody Picture Vocabulary Test
4. Dunn, L. Manual. Circle Pines, Minnesota, American Guidance Service, 1959. 5. Elkind, D.: Children and Adolescents. New York, 6.
Oxford University Press, 1970. Gordon, R.: Parent Effectiveness Training. New York, Wyden, 1970.
7.
Group on
for Advancement of Psychiatry (Committee Adolescence): Normal Adolescence. New York,
Scribners, 1968. B. A.: Coping in early adolescence. In: American Handbook of Psychiatry, Caplan, G., Ed. New York, Basic Books, 1974.
8.
Hamburg,
9.
Jastak, J., Bijou, S.,
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
and Jastak, S.: Wide Range Achievement Test Manual. New York, Guidance Associates, 1965. Lanyon, R. I.: Psychological Screening Inventory Manual. Goshen, New York, Research Psychologists Press, 1968. Offer, D., and Offer, J.: Developmental psychology of youth. In: Youth: Problems and Approaches, S. J. Shamsie, Ed. Philadelphia, Lea and Febiger, 1972, pp. 43-69. Patterson, G. R.: Families— Applications of Social Learning to Family Life. Champaign, Illinois, Research Press, 1971. Robinson, N. M., and Robinson, H. B.: The Mentally Retarded Child, 2nd ed. New York, McGraw-Hill, 1976. Rotter, J. B.: Incomplete Sentences Blank—High School Form. New York, Psychological Corporation, 1950. Stierlin, H.: Separating Parents and Adolescents. New York, Quadrangle Books, 1972. Task Force on Concerns of Physically Disabled Women: Toward Intimacy: Family Planning and Sexuality Concerns of Physically Disabled Women. Planned Parenthood of Snohomish County, 1977. Wahler, H. J.: Wahler Self-Description Inventory Manual. Los Angeles, Western Psychological Services, 1971. Wechsler, D.: Wechsler Intelligence Scale for Children (Revised) Manual. New York, Psychological Corporation, 1974. Wechsler, D.: Wechster Intelligence Scale for Adults Manual. New York, Psychological Corporation, 1955.
24 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
Appendix
Incomplete Sentences Blank (Rotte~~’~ The sentence completion method is a semistructured questionnaire in which the subject is asked to finish a sentence where the first word or words are supplied. The subject should be urged to write a complete sentence if possible. Responses suggest areas of conflict and assist in assessing the degree of depression of the adolescent. Feelings of sadness, alienation, eating and sleeping disturbances and thoughts of harming oneself are often included and should be followed up with indepth interviewing. The examiner must be alert to overly defensive responses; he should not always accept replies at face value when a teenager insists he has no problems whatever.
Psychological Screening ln~enta~r°y° A brief &dquo;mental health screening device&dquo; which compares the scores of the client to those of hospitalized psychiatric patients, incarcerated prisoners, and teenagers without serious problems. Scores on this test are helpful in deciding how disturbed a teenager may be, and whether psychiatric, psychologic, or social work consults would be useful.
Wahler
Self- Description In~rentct~y~’
The subject rates himself on favorable and unfavorable attributes on a nine point scale. This test yields a score which indicates the subject’s perception of his own competence and shortcomings, or level of self-confidence. Inspection of critical items will also indicate
the degree of depression and suggest areas for further interviewing.
Peabody Picture Vocabulary Test (PPVT)4
easily administered test can be given quickly by teachers, physicians, nurses, and counselors. Required are familiarity with the test materials and some practice in giving the This
The age range is from 3 to 17 years, and the test is particularly useful for a shy or nonverbal child. Interpretation of the Mental Age, Percentile Scores, and I.Q. obtained with this test must be limited to the measurement of language development-the child’s &dquo;hearing vocabulary&dquo;-vahieh is related to, but not the same as, his general intellectual development. There may be serious deficits in other areas which are not measured by this test, which may make school achievement difficult or impossible. test.
Wide
Range Achievement Test9
A teacher or nurse can quickly learn to administer this easily given screening test to determine approximate grade level for Reading (word recognition only), Spelling, and Arithmetic. Word recognition at approximately grade 6 is taken as the &dquo;literacy level&dquo; which enables the subject to read a newspaper or popular magazine. If the test is to be used for prediction of success in school, reading speed and comprehension should be evaluated also by a psychologist or educational consultant.
25 Downloaded from cpj.sagepub.com at University of Manitoba Libraries on June 12, 2015
