FAMILY WITH AN

ADOLESCENT

-JAYSON KING CRUZ

Period of Adolescence
Rapid growth
Interaction of physical, psychological, and environmental
factors
Off timing of systems (Dahl, 2004)
Puberty
Physical growth
Emotion and behavior regulation
Importance of understanding interaction of all the systems;
Transitions all occur sequentially but not necessarily at the
same time

Source:

Cooperative Extension System

Extension "CARES" for America's Children and Youth Initiative
March, 2001

Whats the Big Deal?

Adolescent morbidity
Health

Paradox (Dahl, 2004):

Developmental

period of strength and

resilience both physically and cognitively
Yet, morbidity & mortality rates increase 200%
DIFFICULTIES IN CONTROLLING BEHAVIOR
AND EMOTION

Overview
I.
II.
III.

Physical Development
Cognitive Development
Psycho-Social Development

I. Physical Development
Height & Weight Changes
Secondary Sex Characteristics
Continued Brain Development

Rapid Gains in Height & Weight

4.1 to 3.5 inches per year
Girls mature about 2 years earlier than boys
Weight gain = muscles for boys; fat for girls

Secondary Sex Characteristics:

Pubic hair
Menarche or penis growth
Voice changes for boys
Underarm hair
Facial hair growth for boys
Increased production of oil, sweat glands, acne

Continued Brain Development

Not completely developed until late
adolescence
Emotional, physical and mental abilities
incomplete
May explain why some seem inconsistent
in controlling emotions, impulses, and
judgements

Understanding the Adolescent Brain

Advances in brain imaging allow
for better understanding of what
occurs
Evidence for frontal lobe delays
Inability to delay gratification;
impulse control
Suggestion that puberty represents
a period of synaptic reorganization
and as a consequence the brain
might be more sensitive to
experiential input at this period of
time in the realm of executive
function and social cognition
Prefrontal cortex of interest
(Blakemore & Choudhury, 2006)

Brain: Developmental
Changes

Synaptogenesis: proliferation of synapses

Myelinazation: insulation around synapses
Synaptic pruning: frequently used connections are
strengthened, infrequently used connections are
eliminated

(Blakemore & Choudhury, 2006)

Bottom Line?

How do these change affect teens?

Usually studied as decision making (Steinberg,
2004)

In lab: similarities in adolescent & adult decision

making processes

Adolescents are uniquely vulnerable to risk taking

Novelty & sensation seeking increase dramatically at
puberty
Development of self-regulation lags behind

Risk taking as group behavior (Steinberg, 2004)

How Do These Changes

Affect Teens?
Frequently sleep longer - 9 1/2 hours
May be more clumsy because of growth
spurts-body parts grow at different rates
Girls may become sensitive about weight 60% trying to lose weight
1-3% have eating disorder

How Do These Changes

Affect Teens?
Concern if not physically developing at same
rate as peers - need to fit in (early vs. late
maturation)
Feel awkward about showing affection to
opposite sex parent
Ask more direct questions about sex - trying
to figure out values around sex

What Can Adults Do?

Expect inconsistency in responsibility
taking and in decision making
Provide opportunities for safe risk
taking
Avoid criticizing/comparing to others
Encourage enough sleep
Encourage/model healthy eating
Encourage/model activity
Provide honest answers about sex

II. Cognitive Development

Advanced Reasoning Skills
Abstract Thinking Skills
Meta-Cognition

Beginning to Gain Advanced

Reasoning Skills
Options
Possibilities
Logical
Hypothetically
What

if?

Think Abstractly
Can take others perspective
Can think about non-concrete things like
faith, trust, beliefs, and spirituality

Ability to Think About Thinking

Meta-cognition
Think about how they feel and what they are
thinking
Think about how they think they are perceived by
others
Can develop strategies for improving their
learning

How Do These Changes

Affect Teens?
Heightened self-consciousness
Believes no one else has experienced
feelings/emotions
Tend to become cause-oriented
Tend to exhibit a justice orientation
It cant happen to me syndrome

What Can Adults Do?

Dont take it personally when teens
discount experience
Discuss their behavior rules/consequences
Provide opportunities for community service
Ask teens their view and share own

III. Psycho-Social Development

Establishing identity
Establishing autonomy
Establishing intimacy
Become comfortable with ones sexuality
Achievement

Establishing Identity
Erikson (1959): identity vs. identity diffusion
Integrates opinions of other into own
likes/dislikesneeds interactions with diverse
others for this to occur
Outcome is clear sense of values, beliefs,
occupational goals, and relationship expectations
Secure identities-knows where they fit

Identity Exploration Process:

Commitment
present
present

Identity
Achievement

absent
Moratorium

Exploration
absent

Identity
Foreclosure

Identity
Diffusion

Marcia (1966)

Establishing Autonomy
Becoming independent and self-governing within
relationships
Make and follow through with decisions
Live with own set of principles of right/wrong
Less emotionally dependent on parents

Establishing Intimacy
Learns intimacy and sex not same thing
Learned within context of same-sex friendships;
then in romantic relationships
Develops close, open, honest, caring, and trusting
relationships
Learn to begin, maintain, and terminate
relationships; practice social skills, and become
intimate from friends

Becoming Comfortable
with Ones Sexuality
How educated/exposed to sexuality largely
determines if healthy sexual identity develops
More than half high school students are sexually
active
Mixed messages contribute to teen pregnancy
and sexually transmitted diseases

Predictors of Sexual Activity

Having a steady boy/girlfriend
Using alcohol regularly
Having parents with permissive values about
sex
Being worried about ones future occupational
success
Implication: focus on more than one risk factor

Achievement
Society fosters and values attitudes of
competition and success
Can see relationship between abilities, plans,
aspirations
Need to determine achievement preferences,
what good at, and areas willing to strive for
success

How Do These Changes

Affect Teens?
More time with friends
May keep a journal
More questions about sexuality
Begin to lock bedroom door
Involved in multiple hobbies/clubs
More argumentative
Interact with parents as people

What Can Adults Do?

Encourage involvement in groups
Praise for efforts and abilities
Help explore career goals and options
Help set guidelines/consequences
Establish rituals for significant passages
Know friends and what they are doing
Provide structured environment/clear expectations

Adolescent Psychosocial
Problems
Drug, tobacco, and alcohol use and
abuse
Eating disorders
Antisocial behavior and violence
Suicide
Runaways and homeless youth

Some principles...
Distinguish between occasional experimentation and
enduring patterns of dangerous behavior.
Distinguish between problems having origins and
onset during adolescence and those having roots in
earlier periods of development.
Many adolescent problems are brief and are resolved
by early adulthood.
Problem behavior during adolescence not a direct
consequence of the normative changes of
adolescence.

Adolescent drug use and

abuse
Risk factors
psychological
conflicted

family relationships

social
social

context

Protective factors include...

Positive mental health (e.g., high selfesteem)
High academic achievement
Close family relationships
Involvement in religious activities

Tobacco use
33% of 12-17 year olds have tried tobacco.
Most teens who smoke began before high
school years.
Antismoking education is critical in
elementary and middle school.
Contributing factors include advertising,
adult models, peer pressure, need for
status.

Alcohol use and abuse

Most adolescents have experimented
with alcohol.
80% of high school seniors have used
alcohol.
Most do not become problem drinkers.
Chronic drinking may be genetic or may
be modeled by parents who drink heavily.

Risk factors
Family history
Religiosity
SES
Place of residence
Social relationships
Peers uses

Juvenile
delinquency
Loneliness
TV viewing
Parental support
Deviant behavior
Other family-related
risk factors

Eating disorders
Dieting
Anorexia nervosa
Bulimia (binging and purging)
Obesity

Antisocial behavior and

violence
Exposure to violence in TV and video
games.
Adolescents two-and-a-half times more
likely to be victims of crime.
Homicide second leading cause of
death.

Suicide
warning signs:
Sudden, unexplained changes in behavior
Changes in sleeping or eating patterns
Loss of interest in usual activities
Social withdrawal
Experiencing a humiliating event
Feelings of guilt or hopelessness
Inability to concentrate
Talking about suicide
Giving away important possessions

Risk factors
Mental illness and/or biochemical
imbalances
Substance abuse
Stresses and chaotic family life
The availability of lethal means
(handgun in the home)
Prior suicide attempts

Runaways and homeless

youth
Provide care and support
Provide additional academic
assistance, as needed
Provide support for runaway youth
organizations and shelters
Work with social workers and family
services
Encourage peer acceptance

Disorders Usually First

Diagnosed in Infancy,
Childhood, or Adolescence

Mental Retardation
Mental retardation is defined as deficits in
general intellectual functioning and
adaptive functioning.

Mental Retardation (cont.)

Predisposing Factors
Five major predisposing factors
Hereditary factors
Early changes in embryonic development
Pregnancy and perinatal factors
General medical conditions acquired in infancy
or childhood
Environmental influences and other mental
disorders

Mental Retardation: Application of the Nursing

Process

Assessment
The extent of severity of mental retardation
is identified by the clients IQ level.
Four levels have been delineated:
* Mild (50 to 70)
* Moderate (
* Severe
* Profound (lower than 20)

Autistic Disorder
Autistic disorder is characterized by a
withdrawal of the child into the self and
into a fantasy world of his or her own
creation.

Autistic Disorder (cont.)

The affected child has markedly abnormal or
impaired development in social interaction
and communication and a markedly
restricted repertoire of activity and interests.

Autistic Disorder (cont.)

Predisposing Factors
Biological factors
Neurological

implications

Genetics
Perinatal

influences

Autistic Disorder: Application of the Nursing Process

(cont.)
Diagnosis/Outcome Identification
Risk for self-mutilation related to neurological
alterations
Impaired social interaction related to inability
to trust and neurological alterations

Autistic Disorder: Application of the Nursing Process

(cont.)

Diagnosis/Outcome Identification (cont.)

Impaired verbal communication related to withdrawal

into the self, inadequate sensory stimulation, and
neurological alterations
Disturbed personal identity related to inadequate
sensory stimulation; neurological alterations

Autistic Disorder: Application of the Nursing

Process (cont.)

Outcomes (cont.)
The client (cont.):
Is

able to communicate so that he or she can be

understood by at least one staff member
Demonstrates behaviors that indicate he or she
has begun the separation/individuation process

Attention Deficit/Hyperactivity Disorder (ADHD)

The essential feature of ADHD is a

persistent pattern of inattention and/or
hyperactivity-impulsivity
more frequent and
severe than typically
observed at a comparable
level of development.

ADHD (cont.)
Predisposing Factors
Biological influences

Genetics
Biochemical theory
Anatomical influences
Prenatal, perinatal, and
postnatal factors

ADHD (cont.)
Predisposing Factors (cont.)
Environmental Influences

Environmental presence of lead

Dietary factors
Psychosocial influences

ADHD: Application of the Nursing Process

Assessment
A major portion of the hyperactive childs
problems relate to difficulties in performing
age-appropriate tasks
Highly distractible
Extremely limited attention span
Impulsivity

ADHD: Application of the Nursing Process

(cont.)

Assessment
Difficulty forming satisfactory interpersonal relationships
Demonstrates behaviors that inhibit acceptable social
interaction
Disruptive and intrusive in group endeavors
Perpetual motion machines
Accident-prone

ADHD: Application of the Nursing Process (cont.)

Diagnosis/Outcome Identification
Risk for injury related to impulsive and
accident-prone behavior and the inability
to perceive self-harm
Impaired social interaction related to
intrusive and immature behavior

ADHD: Psychopharmacological Intervention

CNS stimulants
In

children with ADHD, the effects include

increased attention span, control of hyperactive
behavior, and improvement in learning ability.
Examples include Dexedrine, Ritalin, Cylert,
Adderall

ADHD: Psychopharmacological Intervention

(cont)
Selective norepinephrine reuptake inhibitor:
atomoxetine (Strattera)
Approved

by FDA in 2002 for treatment of ADHD

Mechanism of action in ADHD is
unknown

ADHD: Psychopharmacological Intervention

(cont.)

Antidepressants
Some

antidepressant drugs have been used

with some success in treatment of ADHD.
Examples include
Bupropion

(Wellbutrin)
Desipramine (Norpramin)
Nortriptyline (Pamelor)
Imipramine (Tofranil)

ADHD: Psychopharmacological
Intervention (cont.)
Nursing Implications (cont.)
To reduce adverse effect of anorexia,
medication may be administered
immediately after meals.
To prevent insomnia, administer last dose
at least 6 hours before bedtime.
Administer sustained-release forms in the
morning.

ADHD: Psychopharmacological
Intervention (cont.)
Nursing Implications (cont.)
The client should be weighed regularly (at least weekly)
during hospitalization and at home while on therapy with
CNS stimulants because of the potential for anorexia
and weight loss and for the temporary interruption of
growth and development.

ADHD: Psychopharmacological
Intervention (cont.)
Nursing Implications (cont.)

In children with behavior disorders, a drug holiday

should be attempted periodically under direction of the
physician to determine effectiveness of the medication
and need for continuation.

ADHD: Psychopharmacological
Intervention (cont.)
Nursing Implications (cont.)
Inform parents that over-the-counter (OTC)
medications should be avoided while the
child is receiving stimulant medication.

ADHD: Psychopharmacological
Intervention (cont.)
Nursing Implications (cont.)

Some OTC medications, particularly common cold and

hay fever preparations, contain sympathomimetic agents
that can compound the effects of the stimulant and
create a drug interaction that could be toxic to the child.

Conduct Disorders
With conduct disorder, there is a repetitive
and persistent pattern of behavior in
which the basic rights of others or
major age-appropriate
societal norms or rules
are violated.

Conduct Disorders (cont.)

Two subtypes

Childhood-onset type
Adolescent-onset type

Conduct Disorders (cont.)

Predisposing Factors
Biological influences

Genetics
Temperament
Biochemical factors

Conduct Disorders (cont.)

Predisposing Factors (cont.)

Psychosocial Influences
Peer

relationships

Conduct Disorders (cont.)

Predisposing Factors (cont.)
Family Influences
Parental rejection
Inconsistent
management with
harsh discipline
Early institutional
living
Frequent shifting
of parental figures

Conduct Disorders (cont.)

Predisposing Factors (cont.)
Large family size
Absent father
Parents with antisocial
personality disorder,
alcohol dependence, or both
Association with a delinquent subgroup

Conduct Disorders (cont.)

Predisposing Factors (cont.)
Marital conflict and divorce
Inadequate communication patterns
Parental permissiveness

Conduct Disorders: Application of the Nursing

Process

Assessment
Classic characteristic of conduct disorder is
the use of physical aggression in the
violation of the rights of others.
Stealing, lying, and truancy are common
problems.

Conduct Disorders: Application of the Nursing

Process (cont.)

Assessment (cont.)
The child lacks feelings of guilt or remorse.
Use of tobacco, alcohol, or nonprescription
drugs as well as participation in sexual
activities occurs earlier than the peer groups
expected age norm.

Oppositional Defiant Disorder

Oppositional defiant disorder is characterized by a
pattern of negativistic, defiant, disobedient, and hostile
behavior toward authority figures that occurs more
frequently than is typically observed in people of
comparable age and developmental level.

Oppositional Defiant Disorder (cont.)

Predisposing Factors
Biological influences
Family influences

Parental problems in disciplining, structuring, and limitsetting

Identification by the child with an impulse-disordered
parent who sets a role model for oppositional
and defiant interactions with
other people
Parental unavailability

Oppositional Defiant Disorder: Application of the

Nursing Process (cont.)

Assessment (cont.)

Usually these children do not see themselves as being

oppositional but view the problem as arising from other
people they believe are making unreasonable demands
on them.

Tourettes Disorder
The essential feature of Tourettes
disorder is the presence of multiple motor
tics and one or more vocal tics.
Tics may appear simultaneously or at
different periods during the illness.
Presence of tics causes
marked distress.

Tourettes Disorder (cont.)

Predisposing Factors
Biological factors

Genetics
Biochemical factors
Structural factors

Environmental factors

Tourettes Disorder: Application of the Nursing

Process

Assessment

Tics may involve the head, torso, and upper and lower
limbs.
Signs may begin with a single motor tic, most commonly
eye blinking, or with multiple symptoms
Palilalia-involuntary repetition of words or phrases
Echolalia-repetition of words spoken by others

Tourettes Disorder: Application of the Nursing

Process (cont.)

Diagnosis/Outcome Identification
Risk for self-directed or other-directed
violence related to low tolerance for
frustration
Impaired social interaction related
to impulsiveness and to oppositional and
aggressive behavior

Tourettes Disorder: Application of the Nursing

Process (cont.)

Diagnosis/Outcome Identification (cont.)

Low self-esteem related to shame
associated with tic behaviors

Tourettes Disorder: Psychopharmacological Intervention

(cont.)

Medications used to treat Tourettes

disorder include:
Haloperidol

(Haldol)
Pimozide (Orap) antipsychotic
Clonidine (Catapres)
Atypical antipsychotics

Separation Anxiety Disorder

The essential feature of separation anxiety
disorder is excessive anxiety concerning
separation from the home or from those to
whom the person is attached.

Separation Anxiety Disorder (cont.)

The anxiety exceeds that expected for
the persons developmental level and it
interferes with social, academic,
occupational, or other
areas of functioning.

Separation Anxiety Disorder (cont.)

Predisposing Factors
Biological Influences

Genetics
Temperament

Environmental Influences

Stressful life events

Family Influences

Separation Anxiety Disorder: Application of the

Nursing Process

Assessment
In most cases, the child has difficulty
separating from the mother.
Anticipation of separation
may result in tantrums, crying, screaming,
complaints of physical problems,
and clinging behaviors.

Separation Anxiety Disorder: Application of the

Nursing Process (cont.)

Assessment (cont.)
Reluctance or refusal to attend school is
especially common in adolescence.
Younger children may shadow.
Worrying is common.
Specific phobias are not uncommon.

Separation Anxiety Disorder: Application of the

Nursing Process (cont.)

Outcomes
The client:
Is

able to maintain anxiety at manageable level

Demonstrates adaptive coping strategies for
dealing with anxiety when separation from
attachment figure is anticipated

Separation Anxiety Disorder: Application of the

Nursing Process (cont.)

Outcomes (cont.)
The client (cont.):
Interacts

appropriately with others and

spends time away from attachment figure
to do so