28 Adolescence
Adolescence
G N Swanson
Allegheny General Hospital, Pittsburgh, PA, USA
ã 2007 Elsevier Inc. All rights reserved.
This article is a revision of the previous edition article by
G N Swanson, volume 1, pp 32–41, ã 2000, Elsevier Inc.
Introduction
Normal Adolescence
Common Stressors
Unusual Stressors
Glossary
Adolescence A stage of life from puberty to adulthood
usually thought of as occurring between
the ages of 12 and 19 years. It is character-
ized by marked physical, psychological,
and social change. The developmental
task of adolescence is the change from
dependence to independence.
Identity A central aspect of the healthy personal-
ity, consisting of an inner awareness of
continuity of self and an ability to iden-
tify with others, share in their goals, and
participate in society.
Puberty A normal growth process that begins in
early adolescence, lasts 2–4 years, and
leads to sexual and physical maturity.
Resiliency The ability to overcome or adapt to
stress by maintaining developmental
progress and adequate social and aca-
demic functioning.
Introduction
Adolescence has been characterized as a challenging
stage of life, defined by the psychological task of
identity formation. Adolescents develop better coping
skills as they mature both as a consequence of their
cognitive and emotional development and because
of the changes they experience. Teenagers generally
respond successfully to many common stressors,
such as puberty, school demands, family changes,
and peer relations. Unusual stressors may lead to
some difficulties, especially in those who are more
vulnerable.
Traumatic stressors, although not universally
harmful, often impinge on the emotional wellbeing
of teenagers and may leave lasting scars. An adoles-
cent’s ability to cope with stressors depends on a
number of factors, including family support, cogni-
tive development, previous experiences, and their
own unique temperament.
Normal Adolescence
The discrete stage of adolescence has been recognized
for only a short period of time. It seems to have come
about in Western society as a consequence of the
Industrial Revolution, when social changes necessi-
tated the prolongation of childhood. Children, who
had previously been able to enter the adult world at
an early age, did not have the skills or abilities to
perform adult work. Child labor laws were passed,
and public schools were established. Families were
also better able to financially provide for children
for a longer period of time. The transition from child-
hood to adulthood lengthened, encompassing most of
the second decade of life. Indeed, many teenagers
nowadays maintain their dependency on their parents
during college, thereby extending this transition even
further. Puberty is often identified as the starting
point of adolescence, although this can normally
start as early as 9 or 10 years of age. The endpoint
has been less well defined, as there are differences in
the legal age of adulthood (18–21 years), and the
criteria of independence, the completion of school,
starting a new family, and getting a job are even
more variable.
Adolescence is often thought of as a period of
rebellion, marked by conflicts with parents as a
child grows to be an adult. Anna Freud, G. Stanley
Hall, and others characterized this stage of life as a
time of storm and stress. Psychoanalysts believed that
it was an indication of pathology if these stormy
relations did not occur. Erik Erikson believed that
the psychological task of this stage of life is the devel-
opment of identity. Specifically, he thought that the
adolescent would commit to a core set of values and
assume a sex role and career plan. Failure to complete
this task would result in identity diffusion, leading to
further difficulties in adulthood. Adolescence was the
period of an identity crisis, which led to considerable
emotional turmoil.
However, Offer and associates have shown that
the vast majority (80%) of adolescents do not
experience significant emotional distress. Instead, these
teenagers manage the transition to adulthood smoothly,
without experiencing a severe identity crisis. They
have a positive self-image and are not afraid of the
physical changes associated with puberty. They do not

report significant conflicts with their parents and have
positive feelings toward their families. They are confi-
dent, optimistic about the future, and are willing to
work hard in order to reach a goal.
However, a significant minority (20%) of teen-
agers reports difficulties in these areas. They report
that they feel emotionally empty and overwhelmed by
life’s problems. They feel much less able to control the
world around them. These adolescents also report
that they are much less able to talk with their parents
about their problems. They appear to be more vul-
nerable to stressors and may exhibit more behavioral
and emotional problems as a result. It seems that
the stereotype of the moody, confused, and rebellious
teenager is more applicable to this smaller group than
to most adolescents.
Considerable cognitive development occurs during
adolescence. Early adolescents become very self-
conscious, which leads to a tendency to be more
egocentric. They tend to believe that the thoughts and
feelings that they have are unique. Furthermore, they
do not seem to recognize that their peers are going
through the same situation. In time, older teenagers
become better able to empathize, to think abstractly,
and to be introspective. They are able to consider pos-
sibilities and to imagine other realities. This leads them
to become more philosophical, and to question the
rules and realities of their lives in an attempt to gain a
clearer understanding of the world. These cognitive
abilities lead them to question their identity and to
see themselves as individuals with some control over
who and what they will be.
These changes become manifest in the adolescents’
social environment. In particular, the family becomes
less influential, while peer groups become more so.
Adolescents begin to establish and exercise indepen-
dence from parental controls. They learn to negotiate,
although some conflicts arise. They spend more time
with their friends than they did in childhood. They
often imitate influential peers and adults. They try on
different hats to see what they might look like, in
order to establish an identity of their own. However,
although they may dress like their friends or listen
to music that their parents abhor, they often retain
similar values and beliefs as their parents.
Adolescents tend to get better at coping with stress
as they get older. They learn skills over time, utilizing
their individual temperament and modeling parental
coping strategies. Early in adolescence, teenagers tend
to reactive defensively, denying problems, and think-
ing wishfully. They misinterpret situations, making
mis-attributions to others, and overlooking informa-
tion that would help them to see things more clearly.
They also tend to either under- or overestimate both
potential risks and their ability to handle them.
Adolescence 29
They may vent their frustration or anxiety in open
emotional outbursts or they may withdraw and try to
keep their feelings hidden. They seek solace and sup-
port from others, but do not readily ask for or listen
to advice. As they develop, they become better able to
appraise problems themselves. They try to change the
stressful situation and to negotiate solutions. They
learn that communication skills, the art of compro-
mise, and assertiveness are more effective responses
than are emotional outbursts or withdrawal. They
learn how much of their feelings they need to reveal
and become more adept at managing their emotions.
They also become better at reading social cues and
reacting appropriately. They think about ways to deal
with problems and discuss potential solutions with
others. Successful responses to stress lead to more
success, although at times they may revert to previ-
ous, less effective strategies, usually in an impulsive
fashion. Over time, most adolescents develop the
skills necessary to cope with stress effectively, although
some do not.
Common Stressors
Adolescents face a variety of challenges as a normal
part of their lives. These include the physical and
sexual changes associated with puberty; the demands
of school; the desire to initiate and maintain friend-
ships, both platonic and romantic; the need to start
working and to make a career choice; and the gradual
development of independence from the family. All of
these changes can be stressful, but most teenagers re-
port that they do not feel overwhelmed or unable to
deal with them. Regardless of gender, socioeconomic
status, or race, teenagers identify their most important
concerns as career, school performance, and college
plans. Many worry about violence, theft, and work.
Some report concerns about peer conflicts and paren-
tal expectations. Teens are least worried about drugs
and alcohol. Boys are more concerned about sexuality
and extracurricular activities, while girls are more
concerned about their appearance.
Puberty
Puberty, as the starting point for adolescence, is often
thought of as very stressful. The physical changes are
obvious, as is an increased sexual interest. Parents
and teachers often attribute all behavioral changes
to raging hormones, but the fact is that there are
other social, and psychological factors that must be
considered as well. Nevertheless, there is a biological
effect of puberty on cognitive, social, and emotional
development as well. In particular, the timing of
puberty can be stressful and does seem to have an
impact on academic and psychosocial functioning.
30 Adolescence
Boys appear to benefit academically and socially if
they reach puberty early, although they often end up
having a shorter stature than their later-developing
peers. Early in adolescence, girls seem to have a better
body image and are more popular if they develop
early. However, as a group, they do not seem to
do as well academically. Furthermore, by the time
adolescence ends, later developing girls have a better
body image than girls who reached puberty earlier do.
This may be related to the fact that girls with a later
onset of puberty are more slender, which more closely
fits with current cultural standards of attractiveness.
More importantly, girls who reach puberty later have
had a longer time to anticipate and adapt to these
changes and as a result seem better able to cognitively
process and cope with pubertal changes when they do
occur. Finally, puberty may be most stressful when it
is very early or very late, as this leads the adolescent
to be markedly different from other peers. This infor-
mation coincides with Offer’s reports that most ado-
lescents are comfortable with, and not distressed
by, the changes of puberty, as most adolescents will
enter puberty at about the same time as their peers
and experience it as a normative process.
Peer Relationships
Peer relationships take on much more importance
during adolescence. Teenagers expand their social
relationships, looking to increase their connections
with others. Girls in general seem to develop a capac-
ity for intimacy sooner than boys do. Most teenagers
believe they can make friends easily and that they can
tell their friends intimate details about themselves.
Early adolescents are very interested in being popular
and want to fit in with a popular same-sex peer group.
There is a degree of stress associated with this, espe-
cially if a young teenager wants to belong to a group,
yet does not. Most are able to find a group, however,
and do not find establishing friendships difficult. These
peer groups are often very supportive and discourage
deviant behavior.
In middle adolescence, boys and girls begin to mix.
Romance and dating become extremely important.
Once again, teenagers report some stress during this
phase, as they grapple with the new social skills re-
quired to establish romantic relationships. However,
most report that they believe they are interesting to
members of the opposite sex and believe that they are
capable of finding a romantic partner.
Dating usually begins between the ages of 12 and
16 years. Adolescents may face some peer pressure to
date and may be dropped from a particular group if
they do not do so. Similarly, they may feel pressure to
engage in a similar level of sexual activity as their
peers. The pressure to conform to a perceived peer
norm, which is in conflict with cultural, religious,
family, or individual values, seems to be the most
stressful aspect of romantic relationships. There are
many similarities between adult and adolescent love
relationships.
However, adolescent relationships are notably more
transient, with strong feelings that do not usually
lead to enduring intimacy or self-disclosure. Cognitive
development as adolescence progresses helps teenagers
to better cope with relationship changes. Gay adoles-
cents are especially vulnerable to stress, due to feelings
of isolation from peers and family and to difficulty
integrating homosexuality into their identity.
Parents of teenagers frequently describe family life
as stressful, due to the ongoing development of ado-
lescent independence. This reflects a change in family
roles, which parents may perceive as more difficult
than adolescents do. Early adolescence is marked
by considerable variation in roles, as the adolescent
vacillates between asserting independence and main-
taining dependency. There is some anxiety associated
with becoming independent, felt by both parent and
child. As they become older, most teenagers are con-
fident about their ability to make decisions and try to
demonstrate this to their parents. However, although
they are in the process of individuating, they neither
sever their emotional attachments to their parents nor
become free of their parents’ influences. Adolescents
appear to be less distressed when parents utilize an
authoritative parenting style which encourages and
supports independence. Parents provide limits and
controls with explanations, while allowing the ado-
lescent to express their views. Nevertheless, tensions
are still present as negotiations proceed and opposing
needs are balanced.
Race and Culture
Racial and cultural issues pose interesting challenges,
particularly for the adolescent. A child forms both
gender and ethnic identities around the ages of
3–5 years. Children become familiar with cultural
differences and history long before puberty begins.
However, it is in adolescence that teenagers make
a conscious commitment to be a member of their
culture. They will generally embrace the values of
their culture, which may not be the same as the dom-
inant culture. This may lead to stress, especially if
they have frequent interactions with peers of other
cultures. They also can understand the abstract con-
cepts of racism and inequality. They may be more
likely to experience these as they leave their family
and have more contact with peers and adults from
other walks of life. Nonwhite adolescents are twice as

likely as their white peers to be funneled into the
juvenile justice system rather than the mental health
system when they have a problem with the law. They
are also more likely to identify their main stressors as
environmental ones (such as living in a dangerous
neighborhood) rather than more personal ones. Most
teenagers come to terms with their ethnic identity and
with negative stereotypes and prejudices. They are
able to accept themselves and their place within both
society and their own ethnic culture. Those that do not
do so have more difficulty with self-image and psycho-
logical adjustment. Adolescents who immigrate to a
new country face additional stress, as they become
more dependent on their families at a time when they
are trying to develop independence. If they do push to
be more independent, they may be more likely to join
an inappropriate peer group.
Academics and School
School situations and academic demands are yet
other common stressors that teenagers confront. The
transition to middle school and the transition to high
school are both major life events. Most teenagers
report a combination of eagerness and apprehension
as they move up to a bigger school with more chal-
lenging assignments, more complicated schedules,
and more competent upper classmen. Middle schools
represent a challenge as they are more impersonal and
may require independence than early adolescents are
capable of. Most middle-school students have not
mastered the social skills needed for this setting, al-
though they may learn them quickly if provided with
opportunities to succeed in small groups.
High schools offer more extracurricular activities,
which provide opportunities to join in new peer groups,
but the many choices may be overwhelming and
confusing, and some adolescents may end up feeling
excluded. Grades become more meaningful, especially
for those planning on college. Parental expectations,
Scholastic Amplitude Test (SAT) scores, and college
applications create tension, as does the search for a
job after graduation.
Work
Most teenagers express a desire to work and feel
satisfaction in a job well done. Earning money helps
older adolescents become more independent and
enables them to practice some of the skills they will
need as adults. However, trying to balance a part-time
job with school demands, sports, and social activities
is often difficult. Adolescents who work are less
invested in school, spending less time on homework
and missing classes more often than peers who do not
Adolescence 31
work. They usually work in low-paying jobs and have
little authority or opportunity to advance. Those who
work the most hours tend to have the lowest grades.
However, part-time work has also been associated
with better self-esteem and a sense of responsibility in
adolescents. Teenagers cope with the stress of work best
if they can balance the time they work with their other
priorities. Working raises other issues, as adolescents
may be overwhelmed with the choices they have.
Establishing a life goal is a daunting task for ado-
lescents. Many are reluctant to commit to a specific
career path, as this means eliminating other possibi-
lities. This lack of commitment may be interpreted as
a lack of motivation by parents, leading to conflicts.
Adolescents also have many misconceptions and
cognitive distortions about themselves and the careers
they are considering. Accurate information and a
frank discussion of their strengths and weaknesses
are important. The support of a mentoring adult is
often very helpful, as is providing the perspective that
any choice is not etched in stone. This issue is also one
that tends to extend adolescence most often, as it is
commonly the last one resolved.
Unusual Stressors
Some teenagers face more unusual challenges. These
can include family problems, such as mental or phys-
ical illness; drug or alcohol abuse; parental separation
or divorce; social problems, such as poverty and vio-
lence; and individual problems, such as pregnancy,
serious illness, and school failure. In some instances,
teens may experience traumas such as abuse or the
death of a loved one. Adolescents with adequate cog-
nitive abilities, emotional development, and support-
ive families seem better able to cope with these
problems successfully. Teenagers who have experi-
enced multiple stressors, have a previous history of
psychopathology, or have little parental support are
much more vulnerable.
Parent with Medical/Psychiatric Illness
Adolescents who are raised in homes where a parent
has a serious medical or psychiatric illness have the
ability to understand the illness better than younger
children and may have more questions as a result.
They are also more likely to exhibit anger and acting
out behaviors. This may occur because of the conflict
involved between the family’s needs for help from the
adolescent and the adolescent’s needs to become more
independent. Younger children may be more likely to
avoid discussion of the parent’s illness and to experi-
ence intrusive thoughts and feelings, while adoles-
cents are more likely to exhibit symptoms of anxiety
and depression. This is particularly true of teenage
32 Adolescence
girls whose mothers have cancer. Parental coping
skills play a part in how adolescents respond to
parental illness. Parents who are less anxious and
depressed have a positive effect on their children.
There are some important differences to be consid-
ered when a family member has a severe mental
illness as opposed to a physical illness. Parents with
mental illness are much less likely to be in treatment,
which means that professional education and advice
are much less forthcoming. There is considerable stig-
ma associated with mental illnesses (although some
physical illnesses carry a stigma, such as HIV infec-
tion). Adolescents may therefore be much less likely
to seek peer or adult support as a result. Teenagers are
at a higher risk for depression and other mood dis-
orders when their parents have a chronic mental ill-
ness, but studies have not been able to separate
genetic influences from psychosocial effects on chil-
dren and adolescents. Finally, parental conflicts, di-
vorce, and inconsistent parenting practices often are
present in families where a parent has a severe mental
illness. These multiple risk factors compound the
stress on an adolescent, more so than in families
where a parent has a severe physical illness. Adoles-
cents who cope best when parents have a serious
medical or psychiatric illness share several character-
istics. They tend to be actively involved in school,
church, work, and other outside activities. They
have a close relationship with a supportive adult.
They also understand that they are not responsible
for their parents’ illness. Their families are more
cohesive, flexible, and are able to maintain family
rituals. Finally, their families effectively communicate
information and feelings about the parental illness
and are able to make plans for the future.
Parental Alcohol Abuse
The effects of parental alcohol abuse have also been
studied, although more attention has been paid to
younger children in alcoholic families. Adolescents
raised in alcoholic families have been found to have
a higher risk of conduct disorder, substance abuse,
sexual acting-out, physical and sexual abuse, and
academic problems. They also have more difficulties
in their peer relationships and are more likely to have
romantic relationships with adolescents with sub-
stance abuse problems themselves. Some adolescents
may take on a more adult role within the family in
an attempt to maintain family functioning, while
others may disengage. Boys seem to have a higher
risk of problems than girls do. Teenagers who cope
effectively with parental alcoholism tend to have
healthy and supportive relationships with adults out-
side of the family. Families that are able to main-
tain family rituals (e.g., such as holiday celebrations,
family dinners, and church attendance) have teen-
agers that are more resilient in the face of parental
substance abuse.
Adolescents with an easy temperament, at least av-
erage intelligence, and an internal locus of control are
also more resilient. Not all teenagers from alcoholic
homes require treatment, although parents with alco-
holism should be referred for treatment. However,
it is not clear what effect, if any, parental recovery
has on adolescents who are already exhibiting pro-
blems. Alateen, a self-help program for adolescents
from alcoholic families in the USA and Canada, has
been effective in providing information and improving
mood and self-esteem for teenagers. Group, individu-
al, and family therapy have been helpful. All inter-
ventions should provide education regarding the
adolescent’s increased risk of substance abuse in an
attempt at prevention.
Parental Marital Conflict and Divorce
Parental conflict and divorce is a fairly common, but
nonetheless major, stressor in today’s culture. Most
research on separation and divorce has focused on
younger children. Studies with adolescents suggest
that they too may have difficulty adjusting to this
stressor. In addition, children who experience divorce
may not manifest problems until adolescence. It is
important to remember that most children and ado-
lescents do adapt to divorce and are able to function
effectively as adults. Younger adolescents whose par-
ents divorce are more likely to be noncompliant and
aggressive and to have problems with substance
abuse than are adolescents in nondivorced families.
Gender differences have been reported. Adolescent
girls from divorced families have had more problems
with self-esteem and promiscuity, while adolescent
boys have a higher incidence of substance abuse.
Both boys and girls have lower academic achieve-
ment, but teenage boys are also likely to drop out of
school if their parents have divorced and they are
living with their mother. Girls are at a greater risk of
dropping out if they live with their remarried mother
and stepfather. These findings appear to hold even
when factors such as race and socioeconomic status
are controlled for. Conflict between divorced mothers
and their adolescent daughters is common, possibly
connected to the teenage girls’ tendency to increased
sexual acting out. Adolescent boys have a higher risk
of disengaging from their family and to engage in
delinquent behavior with peers. This may be related
to the absence and lack of influence of the noncusto-
dial father, which is all too common in divorce. Many
factors mediate adolescents’ responses to divorce. An
authoritative custodial parent seems to be the most
important factor, as the parent is able to provide
 Adolescence 33

the understanding and support needed while main- These teenagers already tend to be at a higher risk
taining an authority position in the family. Generally, for other stressors, as outlined above. However,
teenagers are better able to cognitively process and considerable study has been given to these issues.
understand the reasons for parental divorce than Teenage girls who get pregnant are less prepared
younger children are. However, those who have lim- than their adult counterparts to raise children. They
ited insight, poor problem solving skills, and a history know less about infants and are more distressed by
of temperamental difficulty are more vulnerable the pregnancy. Around 40% choose abortion, while
to experiencing problems with the divorce. The de- 45% choose to keep their child. The other 15% either
gree of conflict between parents and the amount of miscarry or choose adoption. Teenage mothers are
contact with each parent are also important. Depres- less responsive to the needs of their babies than are
sion and delinquency have been connected to pro- adults. However, longitudinal studies have shown
longed parental conflict. that a majority of teenage mothers complete high
school and hold regular employment thereafter.
Poverty and Violence Most support themselves and their children, although
they are on welfare at times. They do not end up
Sociocultural stressors such as poverty and violence
having more children than peers who have children
have long been recognized as stressful for children
later. Most importantly, the majority seems to cope
and adolescents. However, it is very difficult to disen-
effectively over the long run.
tangle the specific effects these stressors have from
In contrast, teenage girls who ultimately choose
each other as well as from other associated risk
abortion report considerable psychological distress
factors, such as parenting styles and other environ-
during the time of pregnancy. This seems to fade
mental stressors. Approximately 20% of American
somewhat after the abortion. However, studies of
children live in poverty – the highest rate for any
women who have undergone abortion indicate that
Western industrialized country. Black children are
most negative reactions and distress occur in those
twice as likely to experience poverty as white children
who are young, unmarried, previously nulliparous,
are. Length of time spent in poverty varies, although
and who delay the procedure until the second trimes-
around 90% of poor children spend less than 5 years
ter. Adolescents are much more likely to fit into this
in poverty. Contrary to popular belief, poverty is
profile and so appear to be at a higher risk for psycho-
more common in rural rather than urban areas.
logical sequelas as a result of the abortion. The debate
Adolescents who experience poverty have a higher
about the psychological effects of abortion is unre-
rate of delinquency, depression, and poor self-image.
solved, as this particular group remains difficult to
They may also incorporate the idea of poverty into
study due to the many other stressors that they face.
their identity rather than to see it as a temporary exter-
nal condition. Again, parental responses and styles
have a marked effect on adolescent coping strategies. Serious Illness
Families living in poverty are more likely to utilize
It is estimated that 5–10% of teenagers face a serious
inconsistent, punitive, and authoritarian parenting
illness during adolescence. Adolescents who suffer
styles, which leads to increased stress and conflict.
from serious illnesses struggle with a variety of issues.
In contrast, poor but supportive parents, who have a
Early adolescents tend to try to deny the existence of
positive outlook on the future, have less distressed teen-
their illness, using avoidant coping strategies. These
agers. Teenagers are also able to recognize when they
problems are more likely to occur in families where
live in less desirable neighborhoods and are well aware
there is little cohesiveness. This often leads to treat-
of the risks of violence. Living with this chronic stress
ment noncompliance and more problems with the
is difficult and can have a marked effect on their out-
illness itself. Conversely, chronic or serious illnesses
look on the future. They may be more fatalistic and
may impair normal adolescent development.
experience more posttraumatic stress disorder (PTSD)
This seems to be due to the fact that the illness and
symptoms as a result of their exposure to violence.
treatment requirements make the adolescent more
Anecdotes abound, both describing those who have
dependent on his parents. They in turn may be more
problems and those who have been resilient. However,
unwilling to let the teenager be more independent.
at this time there are no systematic studies that have
Adolescents may also incorporate their illness into
assessed these issues.
their identity. In some situations, such as diabetes,
these may be unavoidable due to the nature of the
Pregnancy
illness. For those who have cancer, however, this may
Some teenagers face significant individual stressors, be more problematic. Adolescents with a history of
such as pregnancy, serious illness, or school failure. cancer are not more likely to be depressed, but they
34 Adolescence
are more likely to have somatic complaints and
preoccupations and to be distrusting of their bodies.
They also tend to have greater difficulties in romantic
relationships. Misattributions and misunderstand-
ings about their illness and its prognosis should be
addressed when present. Parents and adolescents
often need much more education and support than
they receive. Efforts should be made to help adoles-
cents understand both their illness and treatment, and
information should be made readily available to
them. This should occur in a stepwise fashion, allow-
ing teenagers some time to adjust to changes and react
to them emotionally and intellectually.
Dropping Out of School
Approximately 10–15% of adolescents drop out of
school. Often, they have parents or siblings who have
done the same. Parental attitudes about education
have a great impact on academic performance, even
in adolescence. Adolescents whose home lives are al-
ready distressed or whose fathers are absent are much
more likely to drop out. Those who have already failed
a class or who have been held back a grade are at
greater risk as well. Many are working, and many
have children. Teenagers find dropping out is very
stressful and would recommend against it. Job oppor-
tunities are limited and they are often unable to func-
tion independently. Successful prevention requires
strong cooperation between parents and schools,
providing the support and guidance necessary to
vulnerable teenagers.
Peer Victimization
Several forms of adolescent victimization have been
recognized, including bullying, sexual harassment,
and interpersonal violence and emotional abuse in
dating relationships. Research is limited, but most
adolescents have had some limited experiences of
victimization. There may be significant differences
based on gender, socioeconomic status, and racial
and ethnic groups. Those teenagers who complain
of significant levels of psychological distress tend to
have been targeted on multiple occasions, and in
several forms of victimization. They also feel less of
a sense of school belonging. In addition, adolescents
who have experienced bullying are more likely to
have self blaming attributions than those who have
not been clinicians and school personnel should be
carefully assessing for the occurrence of victimization
in multiple areas if a teenager reports experiencing
any one form of victimization.
Trauma Trauma often leads to emotional and
behavioral changes. Most studies on trauma have
looked at younger children, children and adolescents
together, or at adolescents who were traumatized as
children. However, adolescents can be abused physi-
cally, sexually, emotionally, or in combination. Due in
part to their increasing independence and to their
cognitive and emotional development, adolescents
are less likely than are children to be abused by family
members. However, they are more likely to be the
victims of rape, assault, or robbery than younger
children or adults. There are some gender differences
in adolescents, as girls are more likely to experience
sexual trauma, while boys are more likely to witness
the injury or death of another. Catastrophic life events
also may occur, including the death of a parent,
sibling, or peer due to illness, accident, violence, dis-
aster, or terrorism. Although age-based differences in
stress reaction have received research attention, find-
ings have been inconsistent, due in large part to
the lack of normative and pretrauma psychological
functioning data.
Teenagers who have been abused may come to
attention for incidents that have just recently
occurred and been disclosed or may have occurred
many years earlier. The length of time since the occur-
rence of abuse or trauma does not mitigate the severi-
ty of symptoms or the need for treatment. It is also
not clear if abuse or trauma at an earlier or later age
leads to more problems. Adolescents are less likely to
be abused than are young children. However, many
adolescent victims of abuse have been abused as chil-
dren. Therefore, teenagers who present with physical
or sexual abuse may have a lengthy history of abuse
and may have more difficulty as a result.
Multiple neurotransmitter systems are involved in
the response to traumatic stress, and chronic stress
has been associated with long-term changes in neuro-
nal function in structure. A comprehensive study by
De Bellis et al. demonstrated alterations in biological
stress systems and adverse influences on brain devel-
opment in maltreated children and adolescents with
PTSD. Increased levels of catecholaminergic neuro-
transmitters and steroid hormones during traumatic
experiences could negatively affect brain development.
Causal relationships have not yet been established,
however, and it is unclear how traumatic stress
specifically affects the still developing adolescent brain.
Abuse Teenagers who have been sexually abused
are less likely to show unusual sexual behaviors or
preoccupations than are young children. Abused
teens also are more likely than children to disclose
purposefully, usually out of anger toward the perpe-
trator. Adolescents are also more likely to have their
reports substantiated. However, because they are
older, victimized adolescents may be blamed, just as

women who are victims of domestic violence are
often blamed for not seeking help or leaving an
abusive situation. In addition, adolescents who are
physically abused may be seen as provoking a parent,
thereby earning physical discipline. This is particular-
ly true in teenagers who have a history of physical
aggression, threats, delinquent behavior, noncompli-
ance, and/or defiance. The juvenile justice system is
more likely to be involved in these situations and may
be less cognizant of the possibility of abuse than
either mental health or child protective services.
When evaluating adolescents who have been
abused, it is important to be sensitive and to allow
them some control over what, when, and how much
they disclose. Teenagers will often want to avoid
talking about the issue and to minimize the effects it
has had on them. Recognition and support for their
attempts to cope with the abuse should be provided,
in keeping with their psychological development,
especially their need to be independent and success-
ful. In addition, it may be helpful to separate the
problem from their identity as a person. Hecht et al.
suggest a statement such as, ‘‘I’ve talked with a lot of
people your age who have been through sexual abuse.
We talk about the effects it has had on them. Every-
one’s different, but I want to find out if some of the
things that have bothered other young people have
bothered you. I’d also like to find out what sorts of
things you have done that seem to help the most.’’ It is
also important to understand the adolescent’s attribu-
tions about the abuse. As adolescents are more in-
dependent and society holds them more responsible
for their actions, they may be more likely to blame
themselves.
Furthermore, teens may want to maintain the idea
that they have control over what happens to them, in
keeping with their developmental stage. At the same
time, adolescents will often fear disclosure to their
peers, perhaps believing that they will be stigmatized
or that their peers will hold them responsible.
Nevertheless, having the support and understanding
of a peer is often very helpful. In assessing an adoles-
cent who has been abused, it is important to obtain a
complete history as well as to address possible PTSD
symptoms. In addition, any problems with aggression,
impulsivity, social skills, attention span, academic per-
formance, depression, anxiety, substance abuse, and
delinquency should be explored. Abused adolescents
are also at a higher risk for eating disorders, sleep
problems, and self-injurious behavior.
Treatment interventions should be individualized,
but may include sexual education, information about
PTSD symptoms and abuse, and, perhaps most im-
portantly, an attempt to work out with the adolescent
an explanation as to why the abuse happened. Group
Adolescence 35
and individual therapies have both been utilized with
success. Treatment interventions should address both
the needs of parents and the adolescent. Social skills,
problem-solving, and cognitive treatments have been
effective with adolescents, but family interventions in
particular seem to help maintain progress over the
long term. Court-mandated treatment helps to keep
abusive parents in treatment.
Death Adolescents rarely experience the death of a
parent, sibling, or of a close friend. Furthermore,
studies of children who have lost a parent usually
group younger children with adolescents. As a result,
unique characteristics of adolescent bereavement are
difficult to identify. Adolescents are able to conceptu-
alize death abstractly. This allows them to consider
religious and philosophical issues and may lead to
more uncertainty than in younger children. Adoles-
cents who have never experienced a death have a
difficult time adjusting to this change. Adolescents
who have experienced the death of a parent are at a
higher risk for delinquency, anxiety and depressive
symptoms, somatic complaints, and PTSD symp-
toms. Adolescents who have experienced a disaster
are more likely to experience PTSD symptoms if they
lost a loved one (parent, friend, or classmate) in the
event. However, displacement from home, community,
and school also contributes to these problems.
Teenage boys who lose a father are at a higher risk
for behavioral and emotional problems as are early
adolescents. Sudden deaths are clearly more difficult
to cope with than deaths that occur after a protracted
illness, as adolescents have a chance to prepare emo-
tionally and intellectually for the event. However, a
strong and supportive surviving parent can offer some
protection. Once again, teens that can confide in an
another adult (such as a relative, teacher, or neighbor)
seem to cope better, as they are able to talk about
their dead parent openly. It is important to remember
that subsequent events, such as graduation, making
a sports team, dating, or getting a job, may reopen
grief feelings and should be considered as additional
stressors. Nevertheless, the majority of adolescents
appear to cope effectively with the death of a parent.
The death of a peer is also a rare event. Studies in this
area have been limited and have primarily focused
on peers who commit suicide. In these instances, ado-
lescents have exhibited depressive symptoms, but have
not had an increase in suicide attempts.
See Also the Following Articles
Adolescent suicide; Alcohol and Stress: Social and
Psychological Aspects; Childhood Stress; Divorce,
36 Adolescent Suicide
Children of; Economic Factors and Stress; Familial Patterns
of Stress; School Stress and School Refusal Behavior.
Further Reading
Cobb, N. (1995). Adolescence – Continuity, Conformity
and Change (2nd edn.). Mountain View, CA: Mayfield.
Cohen, J., Mannarino, A. and Deblinger, E. (2006). Treat-
ing traumatic stress and grief in children: a clinician’s
guide. New York: Guilford Press.
De Bellis, M., Baum, A. S., Birmaher, B., et al. (1999).
Developmental traumatology. Part I Biological stress
systems and Part II brain development. Biological
Psychiatry 45, 1259–1284.
Eth, S. and Pvnoos, R. (1985). Developmental perspectives
on psychic trauma in childhood. In: Figley, C. (ed.) Trau-
ma and its wake. New York: Brunner/Mazel.
Haggerty, R., Sherrod, L. R., Garmezy, N., et al. (eds.)
(1996). Stress, risk and resilience in children and adoles-
cents. Cambridge: Cambridge University Press.
Hecht, D., Chaffin, M., Bonner, B. L., et al. (2002). Treating
sexually abused adolescents. In: Myers, J., Berliner, L.,
Adolescent Suicide
M Berk, R Suddath and M Devich-Navarro
University of California, Los Angeles, CA, USA
ã 2007 Elsevier Inc. All rights reserved.
Risk Factors for Suicide in Adolescents
Neuroscientific Findings in Adolescent Suicide
Treatments and Possible Effects of Antidepressants
Glossary
Serotonin (or An indole amine that is a key chemical
5-hydroxytryp- neurotransmitter in the nervous sys-
tamine; 5-HT) tem. Disordered serotonin transmission
is implicated in depression, suicide,
schizophrenia, anxiety and other mental
disorders.
Serotonin Receptors are docking sites for bioactive
receptors molecules such as serotonin. There are
more than 15 serotonin receptor sub-
types all located in the cell membrane.
With the exception of the 5-HT3 recep-
tor, a ligand gated ion channel, all other
5-HT receptors are G protein coupled
seven transmembrane (or heptahelical)
receptors that activate an intracellular
second messenger cascade. The different
Briere, J., et al. (eds.) The APSAC handbook on child
maltreatment. Thousand Oaks, CA: Sage.
Hersen, M., Thomas, J. and Ammerman, R. (2006). Com-
prehensive handbook of personality and psychopathology –
child psychopathology (Vol. 3). New York: Wiley.
Kendall-Tackett, K. and Giacomoni, S. (2005). Child vic-
timization. Kingston, NJ: Civic Research Institute.
LaGreca, A., Silverman, W. K., Venberg, E. M., et al.
(2002). Helping children cope with disasters and terrorism.
Washington DC: American Psychological Association.
Lewis, M. (2002). Child and adolescent psychiatry – a
comprehensive textbook. Baltimore, MD: Williams &
Wilkins.
Offer, D., Ostrov, E., Howard, K. and Atkinson, R. (1990).
Normality and adolescence. Psychiatric Clinics of North
America 13, 377–388.
Saigh, P. and Bremner, J. D. (1999). Posttraumatic stress
disorder: a comprehensive textbook. Boston, MA: Allyn
and Bacon.
Youngblade, L. and Belsky, J. (1990). Social and emotional
consequences of child maltreatment. In: Ammerman, R.
& Hersen, M. (eds.) Children at risk. New York: Plenum.
subtypes subserve different functions and
are targets for different drugs. Thus, for
example, the 5-HT2A receptor is the
docking target for the hallucinogen,
Lysergic acid diethylamide (LSD).
Serotonin The serotonin transporter (SERT) is a 12-
transporter transmembrane protein that mediates
serotonin uptake (back into the neuron)
and thus reduces extracellular serotonin
levels in the brain and especially at
synapses. SERT is a major target for ther-
apeutic intervention, and the selective
serotonin reuptake inhibitors (SSRIs) are
the most frequently prescribed antide-
pressants worldwide. Increased synaptic
serotonin concentrations generated by
SSRIs are thought to alleviate depression.
Adolescent suicide is a serious public health problem.
According to the most recent statistics, suicide is the
third leading cause of death among 10- to 24-year-
olds in the United States, accounting for 11.7% of all
deaths in this age group. Nonfatal suicide attempts are
also a significant concern in their own right. In
2002, approximately 124 409 visits to U.S. emergency
departments were made after attempted suicide or