Adolescent Development

Ovid: Kaplan & Sadock's Comprehensive Textbook of Psychiatry Page 1 of 21
Editors: Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro

Title: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition
Copyright 2009 Lippincott Williams & Wilkins
> Table of Contents > Volume II > 32 - Child Psychiatry > 32.3 - Adolescent Development
32.3
Adolescent Development
Caroly S. Pataki M.D.
Adolescence is a critical period characterized by neurobiological and physical maturation leading to

enhanced psychological awareness and higher-level social, cognitive, and emotional responses. During
adolescence dynamic interactions between the developing brain and experiences with social and
intellectual stimuli result in increasing self-reflection, affect regulation, abstract reasoning, and sensitivity
to social cues. Emerging evidence supports a correlation between the wave of additional frontal gray
matter in the brain observed to occur just before puberty, followed by its extensive pruning in the
prefrontal cortex during adolescence, with increasingly refined abilities to plan, reason, and problem solve
(executive functions). Cortical remodeling, especially in the prefrontal cortex, is believed to facilitate
cognitive capacities, including selective attention, working memory, and socially appropriate behavioral
inhibition. Although the overall volume of the brain remains stable, frontal lobe maturation during
adolescencethat is, thinning of cortical gray matterhas been shown to be associated with increased
performance on memory tests and tasks requiring the inhibition of behavioral responses. Adolescent
development depends on complicated transactions among maturational growth patterns in the brain, the
psyche, and the body mixed with intellectual, emotional, social, and relational experiences within the
surrounding cultural context.
Definition
Adolescence is the period of maturation between childhood and adulthood heralded by the physiological
signs and surging hormones of puberty. It is a time when peer relationships deepen, autonomy grows, and
intellectual pursuits intensify and a sense of social belonging is sought. Adolescence is a time of
accelerated social and psychosexual exploration, culminating in an integrated concept of self.
Adolescents can be viewed as neurobiological works in progress, often consumed by academic,
interpersonal, and emotional challenges and exploring new territories using their talents and experimenting
with social identities.
What is Normal Adolescence?

The concept of normality in adolescent development refers to the degree of psychological adaptation
achieved while navigating the developmental milestones characteristic of this period of development.
Historically, before the twentieth century, adolescence was portrayed as inherently stormy and
characterized by perpetual angst. In 1904, G. Stanley Hall promoted the notion that adolescent
development is comparable to a process of evolution from a state of primitive human
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life to civilized society. The conceptualization of adolescence as a continual struggle, with its defining
feature intense psychic pain and severe turmoil, lingered for many generations. The hypothesis that most
adolescents experience enduring severe psychological distress, intense depressive symptoms, severe mood
mk:@MSITStore:E:\Rafli\Perkuliahan\Ebook\Kaplan%20&%20Sadocks%20Comprehens... 7/20/2017
lability, and a disruption of their usual conduct was not borne out by epidemiological studies. Although
certain psychiatric disorders, such as major depression, schizophrenia, and bipolar disorders, emerge with
greater frequency in adolescents than in younger children, the majority of adolescents are free of
psychiatric disorders. For up to approximately 75 percent of youth, adolescence is a period of successful
adaptation to physical, cognitive, and emotional changes, largely continuous with their previous
functioning. Thus, the majority of adolescents display reasonable autonomy in decision making, increasing
independence in completing academic work, and successful peer relationships without significant
alienation from their families or the emergence of conduct-disordered behaviors. Psychological
maladjustment, self-loathing, disturbance of conduct, substance abuse, affective disorders, and other
impairing psychiatric disorders emerge in approximately 20 percent of the adolescent population.
Adolescent adjustment is, in general, continuous with previous psychological function; thus, psychologically
disturbed children are at greater risk for psychiatric disorders during adolescence. Adolescents with
psychiatric disorders are at increased risk for greater conflicts with families and for feeling alienated from
their families. Although up to 60 percent of adolescents endorse occasional distress or a psychiatric
symptom, this group of adolescents functions well academically and with peers and describes themselves as
generally satisfied with their lives. Studies conducted since the 1980s indicate that most adolescents
endorse more acceptance than rejection of their parents' values and lifestyles, and few report feelings of
isolation or alienation from their families.
The psychoanalytic developmentalist Erik Erikson characterized the normative task of adolescence as
identity versus role confusion. In other words, adolescents, faced with the task of applying childhood
talents, strengths, and experiences to their evolving physical and emotional selves, must be able
successfully to change who they are so as to build a more mature identity. The integration of past
experiences with current changes takes place in what Erikson termed ego identity. Adolescents express
various aspects of their psychological selves by becoming fans of heroes or other well-known musical or
political idols. Some adolescents appear consumed by their identification with a particular idol, whereas
others are more moderate in their expression. Adolescents who feel accepted by a peer group are less
likely to become consumed by adoration of an idol. Adolescents who are socially isolated, feel socially
rejected, and become overly identified with an idol to the exclusion of all other activities are at higher risk
for serious emotional problems and require psychiatric evaluation.
Adolescence is a time to search for ideals and social values that can be carried into adulthood. Erickson
used the term moratorium to describe that interim period between the concrete thinking of childhood and
a more evolved complex ethical development. He defined identity crisis as a normative task of adolescence
in which adolescents pursue alternative behaviors and styles and then successfully mold these different
experiences into a solid identity. A failure to do so results in identity diffusion, or role confusion, in which
there is a lack of cohesive or confident sense of identity. Adolescence is the time to bond with peers,
experiment with new beliefs and styles, fall in love for the first time, and explore creative ideas for future
endeavors.
The literature leads to the conclusion that the majority of adolescents go through this developmental
process with optimism and good self-esteem, maintain good peer relationships, and sustain basically
harmonious relationships with their families.
Stages of Adolescence
Early Adolescence
Early adolescence, from 12 to 14 years of age, is the period in which the most striking changes are
noticedphysically, attitudinally, and behaviorally. Growth spurts often begin in these years for boys,
whereas girls may have had rapid growth for 1 to 2 years already. At this stage, boys and girls begin to
define themselves as distinct members of their families, criticize usual family habits, insist on spending
time with peers with less supervision, and may question previously accepted family values.
In the early stage of adolescence, there is likely to be some withdrawal of emotional investment in family
outings, increased interest in spending time with peers, greater awareness of style and appearance, a
stated goal of becoming more independent, and claims of needing less parental involvement. A new
awareness of sexuality may be displayed by increased modesty and embarrassment with their physical
development or may exhibit itself in an increased interest in the opposite sex.
Early adolescents engage in subtle or overt displays of their growing desire for autonomy, sometimes with
challenging behaviors toward authority figures, including teachers and school administrators, and exhibit
disdain for rules. At this age, some adolescents begin to experiment with cigarettes, alcohol, and
marijuana. The Youth Risk Behavior Surveillance System (YRBSS) surveyed all public and private schools
from grades 9 to 12 throughout the United States (more information is available at
http://www.cdc.gov/yrbs). The 2005 report indicated that 48.7 percent of ninth-graders had tried smoking
cigarettes and 9.9 percent of male ninth-graders had smoked at least one cigarette every day consecutively
for 1 month. Cigarette smoking that included more than ten cigarettes per day was reported by 4.6 percent
of girls and 12.8 percent of boys in the ninth grade. The YRBSS reported that 36.2 percent of ninth-grade
girls and 36.3 percent of ninth-grade boys consumed at least one alcoholic drink in the month preceding
the survey. More serious drinking (more than five drinks of alcohol in a row within a few hours) was
reported by 19 percent of ninth-graders. In the year 2000, the reported rate of heavy drinking among
eighth-graders (consumption of at least five consecutive drinks one time in the last 2 weeks) was 14
percent for both boys and girls. Twelve percent of eighth-graders reported illicit drug use (including
marijuana, as well as cocaine, heroin, hallucinogens, and amphetamines) in the last 30 days from the
survey date. Over the last 5 years, lifetime alcohol, that is, at least trying alcohol at least once, was
almost 67 percent in both boys and girls in the ninth grade. Heavy drinking, defined as at least five drinks
of alcohol in a row, was present in 17.3 percent of ninth-grade girls and 20.7 percent of ninth-grade boys.
Marijuana was reported by 27.8 percent of ninth-grade girls and 30.9 percent of ninth-grade boys at least
once, and current use of marijuana was present among 17.4 percent of ninth-graders.
During early adolescence, there is normal variation in when new defining behaviors are acquired. For
example, some 12-year-olds are listening to popular music or wearing adolescent clothing, whereas other
adolescents are not as concerned with fitting in until age 13 or 14 years. Overall, whereas many early
adolescents make new friends and modify their public image, most maintain positive connections to family
members, old friends, and their family's values. Early adolescence has been viewed as a time of
overwhelming turmoil, during which there is a dramatic rejection of family, friends, and lifestyle,
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resulting in a powerful alienation of the adolescent. However, epidemiological surveys have not provided
evidence for this notion that adolescence is characterized by overwhelming alienation, profound angst, and
significant disruption of family relationships. On the contrary, for most adolescents, there is more
continuity with family values and lifestyle than disharmony and a more gentle metamorphosis toward
independence.
Laura, a 14-year-old adolescent who had just started high school as a ninth grader, was
apprehensive about starting a new, much larger school and was concerned about being
compared to her older sister, who was known as a troublemaker. Laura felt that her
teachers might not value her for being her own person and instead might
automatically assume that she was a marijuana user and always looking for a away to
avoid schoolwork. Laura did not smoke cigarettes, drink alcohol, or smoke marijuana,
and she found it extremely annoying that her parents were always checking up on her
just because her older sister had done those things in the ninth grade. Laura spent most
of her time out of school in her room with her door closed and was able to multitask,
doing homework while watching TV, instant messaging to her friends on her computer,
and text messaging her friends using her cell phone. Although Laura liked school, had
friends, and enjoyed playing violin in the orchestra, she found herself feeling tense much
of the time and fearing that she had forgotten to finish all of her homework or bring all
of the right books to school. She hesitated to think of what she might be missing and
walked slowly to classes. She found going to class more and more unpleasant. She also
experienced the school rules at her high school as increasingly irritating, especially being
locked out of the classroom if she got there after the bell rang. She felt that the
teachers were too strict, and never gave her the benefit of the doubt. To avoid getting
into trouble for being late, Laura began to cut classes whenever she thought she might
be late and then she began to cut the whole day of school if she thought she was late in
the morning. Before long, she had fallen behind in her work but was too embarrassed to
tell her parents. She told her friends, and they helped her get some of the schoolwork,
but she had missed so much work that it was difficult to catch up. Since it was getting
close to her first progress report and Laura knew that she could not talk to her parents,
she finally went to see her school counselor and told her that she was not going to many
classes because it was too stressful to get to them on time and that she was now in
danger of compromising her grades. The school counselor convinced Laura to tell her
parents about her problems, and even though she did not want to, she agreed to have a
meeting with the counselor and her parents. Laura's parents were shocked to find out
that she was as stressed as she was, since she had always told them that everything
was fine and that she was getting everything done in her room as long as everyone left
her alone. After the meeting with her parents and the school counselor, Laura realized
that instead of trying to be so independent and refusing the ride her parents had offered
her to school, she was actually making things more difficult for herself. Laura agreed to
accept her parents' help with a ride to school in the morning, and also agreed to have
several tutoring sessions to catch up on her work. Laura worked hard with her tutor and
began to leave her bedroom door open more often at home. She asked her parents and
sisters for help if she did not understand something and found that they were actually
helpful. Laura ended up with three A's and one B for the first grading period and she was
proud of herself. Laura felt less stressed after the first marking period and looked
forward to spending more time with friends and felt confident about continuing the ninth
grade.
Middle Adolescence
During the middle phase of adolescence (roughly between the ages of 14 and 16 years), adolescents'
lifestyles may reflect their efforts to pursue their stated goals of being independent. For example,
adolescents in this phase successfully learn to drive a car and, in some states, obtain a driver's license by
the age of 16 years, presenting them with the very real challenges of greater autonomy. Their abilities to
combine abstract reasoning with realistic decision making and the application of social judgment are put to
the test in this phase of development. Sexual behavior intensifies, making romantic relationships more
complicated, and self-esteem becomes a pivotal influence on positive and negative risk-taking behaviors.
The 2005 YRBSS reported more frequent cigarette use among white students (11.2 percent) and Hispanic
students (6.5 percent) than black students (3.7 percent). Use of alcohol, that is, report of at least one
alcoholic drink within 1 month of the survey time, was 42 percent for tenth-graders and 46 percent for
eleventh-graders. The prevalence of heavy drinkingfive drinks or more in a rowincreased slightly with
each increasing grade from ninth to twelfth grade. Tenth-graders reported rates of heavy drinking, 24.5
percent, which increased in eleventh-graders, 27.6 percent. Marijuana use was found to be somewhat
higher among boys than girls across all high school grades, and the overall prevalence of current marijuana
abuse was 21 percent among eleventh-graders. The prevalence of cocaine use was reported to be higher in
boys than girls, and lifetime cocaine use was 8.7 percent among eleventh-graders and 10.1 percent among
eleventh-grade boys.
In this phase of development, adolescents tend to identify with a group of peers who become highly
influential in their choices of activities, styles, music, idols, and role models. Adolescents' underestimation
of the risks associated with a variety of recreational behaviors and their sense of omnipotence, mixed
with their drive to be autonomous, frequently cause some conflict with parental requests and expectations.
These conflicts, however, for the most part, do not result in the destruction of meaningful relationships
with parents or siblings. For most teens, the process of defining themselves as unique and different from
their families can be achieved while they still maintain alliances with family members.
James, a 16-year-old junior in high school, had just gotten his driver's license. He
realized that he was lucky to have received his parent's old car as soon as he had turned
age 16 years, but he was constantly being called on to drive his friends around. James
drove his younger brother to school each morning, and this created tremendous friction
between them since James was always ready early and his brother, Tony, was always
late. James would threaten to leave without him in the morning, and on some days he
actually did. His parents would then become enraged with him for leaving his brother to
take the bus. James was a careful driver but felt pressured by his parents and by his
peers. When nobody hassled James, he would leave in time for school, find a parking
place at the crowded lot, and make it to class on time. He drove himself to his karate
class, where he functioned as an assistant teacher. James had difficulties, however,
saying no to his friends, who wanted to bring beer into his car and smoke marijuana on
the weekends when they were driving around. James would half-heartedly say no, but
felt that he would lose friends if he did not take risks. James continued to allow his
friends to bring beer into his car until he had a close call in which he felt that a police
car was tailing him. James began to experience panic but was able to continue driving
and reached his destination without being pulled over. After this, James decided that he
could no longer agree to drive friends around in his car who were going to bring beer or
marijuana. James told his friends that he would not give them rides any more, and
gradually he gravitated toward friends with other interests. Although James did lose
some of his old friends, he felt better and more in control of his life. James began to
spend more time playing his guitar and also began to play online interactive computer
games. He developed friendships with peers who also played the same game, but he
never felt that he was addicted to the game. James never allowed his game playing to
compromise the amount of time that he spent with friends. He looked forward to
applying to college and considered being more independent. James went on to take
difficult courses in high school, including multiple honors and advanced placement
courses, which were challenging and stimulating, and he felt that his decision to shun
drugs and alcohol, despite the loss of some peers, was the right decision for him.
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Late Adolescence
Late adolescence (between the ages of 17 and 19 years) is a time when exploration of academic pursuits,
musical and artistic tastes, athletic participation, and social bonds leads a teen toward greater definition
of self and a sense of belonging to certain groups or subcultures within mainstream society. As Erickson
aptly described, through this exploration, an adolescent gradually moves toward a solid identity
formation. Well-adjusted adolescents can be comfortable with current choices of activities, tastes,
hobbies, and friendships yet remain open to the idea that their identities will continue to be refined
during young adulthood. Peer interactions are primary, and some bridges may be formed with family
members to increase communication and social repartee. This transition spans the completion of high
school and at least the first year of college, where exploration of new relationships and interests, often in
a new setting away from home, is initiated. Prior to finishing high school, however, the use of cigarettes,
alcohol, and marijuana is higher than in the lower high school grades. The 2005 YRBSS reported that 17.1
percent of twelfth-graders had had the occasion to drive while they had been drinking alcohol, and 30
percent of twelfth-graders had been passengers with drivers who had been drinking alcohol. The
prevalence of current frequent cigarette use was reported to be 13.9 percent among twelfth-graders.
Alcohol use within 1 month of the survey was reported by 52 percent of twelfth-grade boys and 49.6
percent of twelfth-grade boys, with episodic heavy drinking of more than five consecutive drinks in a row
occurring in almost one third (32.8 percent) of twelfth-graders. Nationwide, current marijuana use was
reported by 26.1 percent of twelfth-grade boys and 19.5 percent of twelfth-grade girls. Cocaine was
reported to be used within 1 month of the survey in 10.4 percent of twelfth-grade boys and 7.4 percent of
twelfth-grade girls.
During this period of late adolescence, studies of brain function support hypotheses of the underlying basis
of observed increases in an adolescent's ability to attend to incoming stimuli, respond to social cues, and
modulate behavior to achieve goals and regulate impulsive actions. Neuroimaging studies provide evidence
suggesting that during late adolescence and even into adulthood, the prefrontal cortex neural networks
continue to facilitate working memory, prospective memory (the ability to keep in mind an intention to do
something in the near future while multitasking), perspective taking (understanding another person's point
of view), and responding to others while keeping one's feelings in mind. This phase of adolescence is an
exciting time for the development of finely tuned cognitive abilities, social skills, and enduring
relationships.
Nick, a little more than 18 years old, was in his second semester of his first year of
college and living away from home. The novelty of being away from home was wearing
off, and he was feeling that he needed to make a decision about his major and what he
wanted to do with his life. He reflected on the fact that he was no longer a minor and
could make many decisions regarding his fate without his parents being at all involved.
This was a liberating feeling, yet, now that he had his freedom, he was not really sure
what he wanted to do with his life. Nick had made many friends at school, and he
wanted to pursue something academic that he could potentially use in a future career.
This semester, he had signed up for a variety of liberal arts classes, ranging from art
history to architectural drafting to sociology, philosophy, and music. He had been
influenced in a positive way by his friends, who told him that it was too early to make a
final decision about what he wanted to do, but nevertheless he felt a pressure to decide.
Lisa, a friend, challenged his goal to figure out the rest of his life right now. Instead, she
suggested that he take at least two more semesters of classes in the liberal arts
curriculum before making a decision about which career was the best match for him.
Nick realized that Lisa's approach to life was very different than the one in which he had
grown up, in which his parents had always pressed him to plan ahead, make choices and
commitments early, and then see them through. He had been influenced to believe that
quitting or changing can be a sign of weakness. Lisa's approach left more room for
basing decisions on experiences rather than on what one was supposed to do. Nick
took her advice and decided to allow himself another year to decide what to major in and
what to pursue as a career.
Components of Adolescence
Physical Development
Physical growth, along with the onset of sexual development, is identified as the hallmark of
adolescence. Puberty is the process by which adolescents develop physical and sexual maturity, along with
reproductive ability. Pubertal development begins in response to a surge of gonadotropin-releasing
hormone from the hypothalamus. The hypothalamus is influenced by a multitude of physiological and
psychological factors, and the onset of puberty may be delayed or altered in situations of severe nutritional
deprivation. Gonadotropin-releasing hormone acts on the pituitary gland to release the gonadotropin-
luteinizing hormone and follicle-stimulating hormone. These two hormones, in turn, act to stimulate the
production of a variety of androgens, testosterone, estradiol, and other peptides. Physical development
during puberty is also regulated by two additional hypothalamic peptides, growth hormone-releasing
hormone and somatostatin, both of which promote the release of growth hormone from the pituitary gland.
Puberty unfolds over time in conjunction with the pulses and feedback loops of these gonadotropins. The
first signs of the pubertal process are an increased rate of growth in both height and weight. This process
begins in girls by approximately 10 years of age. By the age of 11 or 12 years, many girls noticeably tower
over their male classmates, who do not experience a growth spurt, on average, until their 13th year. Even
more striking are the differences in the development of secondary sexual characteristics in girls versus boys
approximately 13 years old. By age 13 years, many girls have experienced menarche, and the majority have
developed breasts and pubic hair. The initial appearance of pubic hair in both genders may occur before
puberty, during adrenarche, which is dependent on hormones secreted by the adrenal glands, rather than
by gonadal development. Some components of pubertal development are identical in boys and girls and
include an increase in height, weight, muscle, and fat, whereas others, such as breast development or
growth of facial hair, are specific to only one gender. There is wide variation in the normal range of onset
and timing of pubertal development and its components. There is a set sequence, however, in the order in
which pubertal development proceeds. Thus, secondary sexual characteristics in boys, such as increased
length and width of the penis, for example, will occur after the release of androgens from developed
enlarged testes.
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Table 32.3-1. Sexual Maturity Rating (SMR) of Girls and Boys
SMR Girls Boys
Stage Preadolescent, papilla elevated Penis, testes, scrotum preadolescent

1
No pubic hair No pubic hair
Stage Breast bud, small mound; areola Penis size same, testes and scrotum
2 diameter increased enlarged, with scrotal skin reddened
Sparse, long pubic hair, mainly along

labia
Sparse, long pubic hair, mainly at the

base of the penis
Stage Breast and areola larger; no separation Penis elongated, with increased size
3 of contours of testes and scrotum
Pubic hair darker and coarser; spread Pubic hair darker and coarser; spread
over pubic area over pubic area
Stage Breast size increased Penis increased in length and width

4
Areola and papilla raised Testes and scrotum larger
Pubic hair coarse and thickened; Pubic hair coarse and thickened;
covers less area than in adults, does covers less area than in adults, does
not extend to thighs not extend to thighs
Stage Breasts resemble adult female breast; Penis, testes, scrotum appear mature
5 areola has recessed to breast contour
Pubic hair increased in density; area

extends to thighs
Pubic hair increased in density, area;

extends to thighs
Sexual maturity rating (SMR), also referred to as Tanner stages, range from SMR 1 (prepuberty) to SMR 5
(adult). The SMR ratings include stages of genital maturity in boys and breast development in girls, as well
as pubic hair development. Pubic hair development is a less reliable measure of sexual maturity, however,
because it may emerge in response to androgens from the adrenal glands before the pubertal process has
actually begun. Table 32.3-1 outlines SMRs for boys and girls.
The primary female sex characteristic is ovulation, or the release of eggs from ovarian follicles
approximately once every 28 days. When adolescent girls reach SMR 3 to 4, ovarian follicles are producing
enough estrogen to result in menarche, the onset of menstruation. When adolescent girls reach SMR 4 to 5,
an ovarian follicle matures on a monthly basis and ovulation occurs. Estrogen and progesterone promote
sexual maturation, including further development of fallopian tubes and breast development.
For adolescent boys, the primary sex characteristic is the development of sperm by the testes. In boys,
sperm development occurs in response to follicle-stimulating hormone acting on the seminiferous tubules
within the testes. The pubertal process in boys is marked by the growth of the testes stimulated by
luteinizing hormone. There is no discrete sign of the formation of viable sperm, but it must be assumed
that at the time that ejaculatory capacity occurs, viable sperm are likely to be present. An adolescent
boy's ability to ejaculate generally emerges within 1 year of reaching SMR 2. Secondary sexual
characteristics in boys include thickening of the skin, broadening of the shoulders, and the development of
facial hair.
In general, the majority of adolescents adjust well to the changes in their physical growth and maturation.
Inasmuch as overall identity formation is a gradual process, adolescents incorporate their developing
physical identities into their evolving adult selves.
Cognitive Maturation
Cognitive maturation in adolescence encompasses a wide range of expanded abilities that fall within the
global category of executive functions of the brain. These include the transition from concrete thinking
to more abstract thinking; an increased ability to draw logical conclusions in scientific pursuits, with peer
interactions, and in social situations; and new abilities for self-observation and self-regulation. These result
in an adolescent's capacity to develop hypotheses, express altruism, create idealistic scenarios, and
develop hopes and dreams for the future. Adolescents acquire increased awareness of their intellectual,
artistic, and athletic gifts and talents, yet it often takes many more years into young adulthood for them to
establish a practical application for these abilities.
The cognitive developmental theorist Jean Piaget has been a central influence on the way in which
clinicians and researchers understand the cognitive strategies of children throughout development and the
changes that occur during adolescence. The central cognitive change that occurs gradually during
adolescence is the shift from concrete thinking (concrete operational thinking, according to Piaget) to the
ability to think abstractly (formal operational thinking, in Piaget's terminology). This evolution occurs,
according to Piaget, as an adaptation to stimuli that demand an adolescent to produce hypothetical
responses, as well as in response to the adolescent's expanded abilities to provide generalizations from
specific situations. Recent magnetic resonance imaging (MRI) studies showing evidence of a preadolescent
increase in cortical gray matter in the brain, possibly due to a wave of increased production of synapses,
may be a physical correlate of the adolescent's ability for expanded abstract reasoning. The development
of abstract thinking is not a sudden epiphany but, rather, a gradual process of expanding logical deductions
beyond concrete experiences and achieving the capacity for idealistic and hypothetical thinking based on
everyday life. Younger adolescents may be able to verbalize an understanding of complex abstract
constructs and still react to situations in rigid and concrete ways. For example, a young adolescent may be
able to verbalize an understanding of the link between drug and alcohol use and health risks but cannot
imagine it happening to himself or herself. Similarly, adolescents often believe that they can beat the
odds, even when they understand the mathematical meaning of the probability of an event occurring.
Adolescents often use an omnipotent belief system that reinforces their sense of immunity from danger,
even when confronted with logical risks. Some degree of child-like magical thinking continues to coexist
with more mature abstract thinking in many adolescents. Despite the persistence of magical thinking into
adolescence, adolescent cognition departs from that of younger children with regard an increased ability
for self-observation and the development of strategies to promote strengths and compensate for
weaknesses. For example, an adolescent who becomes aware of a weakness in completing academic work
or tests during the time allotted in school may realize that he or she knows the material but cannot
perform well in timed examinations and will make a request of the teacher to receive additional time on
examinations. The ability to develop strategies for survival and use proactive methods of making them
happen increases during the period of adolescence. One of the important cognitive tasks in adolescence is
to identify and gravitate toward those pursuits that seem to match the adolescent's cognitive strengths in
academic courses and in thinking about future aspirations. Piaget believed that cognitive adaptation in
adolescence was profoundly influenced by social relationships and the dialogue between adolescents and
peers, making social cognition an integral part of cognitive development in adolescence.
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Socialization
Socialization in adolescence encompasses the ability to find acceptance in peer relationships and in turn
the development of more mature social cognitions enabling the adolescent to accept others. It is common
knowledge that, for early adolescents, the skills for developing a sense of belonging to a peer group, along
with the ability to conform with the activities of that group, are of central importance to a sense of well-
being. Being viewed as socially competent by peers is a critical component in building good self-esteem for
most early adolescents. Peer influences are powerful and can foster positive social interactions, as well as
apply a pressure in less socially accepted behaviors or even high-risk behavior. Belonging to a peer group is,
in general, a sign of adaptation and a developmentally appropriate step in separating from parents and
turning the focus of loyalty toward friends. Social cognitionthe way in which adolescents use logic and
reason in their assumptions about peers and in their peer interactionshas been explored by Robert
Selman. After interviewing children and adolescents with respect to their interpretation of various social
interactions, he identified stages of social cognition. In school-aged children and preadolescents, Selman
described social cognitions as fair weather cooperation. That is, the friendships are characteristically on-
again/off-again, depending on the level of affiliation or disagreement in the last social interaction. Thus,
children between the ages of 6 and 12 years are able to engage in exchanges of ideas and opinions and
acknowledge feelings of peers, but the relationships often wax and wane in a discontinuous way on the
basis of altercations and good times. Friendships deepen with repeated good times, but, for some school-
aged children, a variety of peers are often interchangeablethat is, a companion is sought when a given
child has free time, rather than out of a desire to spend time with a specific friend. As adolescence ensues,
friendships become more individualized, and personal secrets are likely shared with a friend rather than a
family member. A comfort level is achieved with one or several early adolescent peers, and the group may
stick together, spending most free time together. In early adolescence, a blend of these two social
modes may emerge, small cliques may arise, and, even within the cliques, competition and jealousies
regarding which dyads are preferred or higher ranked within the clique may result in some discontinuities
in the relationships. In later adolescence, the peer group solidifies, leading to increased stability in the
friendships and a greater mutuality in the quality of the interactions.
Moral Development
Moral reasoning among adolescents depends on the maturation of cognitive strategies for problem solving,
societal conventions, exposure to familial attitudes, and personal values adopted. Morality is a set of
values and beliefs about codes of behavior that conform to those shared by others in society. Adolescents,
like younger children, tend to develop patterns of behaviors characteristic of their family and educational
environments and by the imitation of specific peers and adults whom they admire. Moral development is
not strictly tied to chronological age but, rather, is an outgrowth from cognitive development. Piaget
described moral development as a gradual process parallel to cognitive development, with expanded
abilities in differentiating the best interests for society from those of individuals occurring during late
adolescence. The development of trends in moral judgment has been divided into levels by Lawrence
Kohlberg, who posed moral dilemmas to children and adolescents and subsequently characterized their
responses. According to Kohlberg, morality can be divided into preconventional, conventional, and
postconventional. Before adolescence, decisions regarding actions that are loosely defined as right and
wrong are dependent on the anticipated consequence to those actions. School-aged children, for
example, denoted as using level 1 of preconventional morality, may define actions that result in a negative
consequence or punishment as wrong simply due to the consequence that may ensue. The most
important defining feature of right then becomes being able to get away with it, and it only becomes
wrong if there is punishment associated with it. Some young adolescents, still functioning within the
category of preconventional morality but one level higher (level 2), may define right and wrong as
synonymous with what is perceived as fair and reciprocal. Thus, the philosophy of an eye for an eye, and a
tooth for a tooth may prevail in this stage of morality. During adolescence, conventional morality, level 3,
becomes prevalent, with the view that there is a right and a wrong determined by society, often
without the possibility of mitigating or extenuating circumstances. Adolescents espousing this level of
morality are often rigid in their concept of good and bad and unable to find a role for motivation in
their judgment of behaviors. Thus, adolescents may often take the viewpoint of applying the harshest
punishments that society can offer when asked to judge complex moral situationsfor example, a poor man
robbing a pharmacy to obtain a life-saving medication for his child. Later in adolescence, at level 4, a
greater understanding of societal rules may be espoused within the context of conventional morality. It is
generally not until late adolescence or early adulthood that the complexities of moral decision making are
recognized and incorporated into their thinking. Postconventional morality (level 5), according to Kohlberg,
implies the ability to interpret complex moral dilemmas in which the best moral decisions of an individual
may come into conflict with the moral standards of society. At this level of thinking, adolescents are more
flexible in their understanding of right and wrong. The concept of extenuating circumstances is
understood at this level of moral thinking, allowing exceptions to rules that are ordinarily followed.
Kohlberg postulated a final, higher level of postconventional moral development that he labeled level 6, in
which an individual is able to recognize a universal moral imperative that might take priority over standard
societal moral values.
Although Kohlberg's and Piaget's notions of moral development focus on a unified theory of cognitive
maturation for both sexes, Carol Gilligan emphasizes the social context of moral development leading to
divergent patterns in moral development. Gilligan points out that, in women, compassion and the ethics of
caring are dominant features of moral decision making, whereas for men, predominant features of moral
judgments are related more to a perception of justice, rationality, and a sense of fairness.
Self-Esteem
Epidemiological surveys suggest that the majority of adolescents rise to the challenges of their physical and
emotional development with optimism and solid self-esteem. Self-esteem is a conglomerate measure of
one's sense of self-worth based on perceived success and achievements, as well as a perception of how
much one is valued by peers, family members, teachers, and society in general. The most important
correlates of good self-esteem are one's perception of positive physical appearance and high value to peers
and family. Secondary features of self-esteem relate to academic achievement, athletic abilities, and
special talents. Adolescent self-esteem is mediated, to a significant degree, by positive feedback received
from a peer group and family members, and adolescents often seek out a peer group that offers
acceptance, regardless of negative behaviors associated with that group. There are also developmental
factors that influence adolescents'
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cognitions about themselves that affect global ratings of self-esteem in this age group. Studies comparing
reported self-esteem across the lifespan indicate that there are trends in self-esteem ratings that are age
related. Starting in adolescence, there are also gender differences in reported self-esteem. A recent report
investigating global measures of self-esteem in school-aged childrenadolescents, 13 to 17 years old, and
older teens to young adults, 18 to 22 years oldfound group differences depending on age. Overall
reported self-esteem was found to be highest in school-aged children as compared to adolescents and
young adults, and boys and girls were identical in their self-reports. During adolescence, global reports of
self-esteem decreased throughout, with adolescent girls experiencing a drop twice that of adolescent boys.
Self-esteem, at a group level, continued to drop during the high school years, rose in young adulthood
during the college years, and continued to rise in early to mid-adulthood. Girls continued to rate
themselves with generally lower self-esteem into adulthood. The question arises as to how most
adolescents surveyed report relative good adjustment and yet, at the same time, experienced a drop in
self-esteem. These data appear to reflect the inflated self-esteem of school-aged children, who may be
seeing themselves as better, smarter, and more capable than they really are. During adolescence, it is
quite possible that even well-adjusted individuals realize that they are not as exceptional as they used to
believe they were. Adolescents seem to be more aware of their shortcomings and, therefore, had lower
self-reported scores on self-esteem measures. In young adulthood, however, and into mid-adulthood, along
with expanded cognitive abilities for self-regulation, reported self-esteem increases and continues to
increase well into mid-adult life.
Adolescent Brain Development: Correlations with Emotional, Social,

and Cognitive Changes
During the course of adolescence significant qualitative changes in thinking are demonstrated in greater
ability to discriminate emotional cues, increased self-awareness, selective attention to information, and
increased response inhibition. Perhaps the most dramatic changes in cognitive abilities are an increased
capacity for abstract reasoning, planning, and affect modulation. Recent neuroimaging studies provide
evidence for structural and functional brain development in adolescence that are believed to correlate
with changes in cognitive abilities and social responses.
It is well known from studies of postmortem brains of children and adolescents that after puberty increased
myelinization occurs in the axons in the frontal cortex, which serves to speed transmission in that brain
area. In addition, although synapses are known to increase in density over time as children grow, in
adolescent brains, synaptic proliferation (synaptogenesis) in the prefrontal cortex is followed by significant
synaptic pruning, leading to a net decrease in synapse density (gray matter) in the frontal lobes, which is
believed to be essential for the fine tuning of the synaptic circuits during adolescence.
Over the past decade, MRI and functional MRI (fMRI) have become important modalities for studying both
the structure and the function of adolescent brains. MRI, for example, has been able to provide evidence of
a relative linear increase in white matter in the frontal and parietal cortexes of adolescents, whereas gray
matter has been found to have a nonlinear decrease in density in adolescents. That is, at puberty, gray
matter volume is at its peak, followed by a plateau after puberty and then a decline throughout
adolescence. This coincides with the synaptic reorganization believed to underlie the surge in higher-level
cognitive and social functioning observed in adolescents. Two areas of the brain consistently shown by MRI
to evidence structural changes during adolescence are the prefrontal cortex and the parietal cortex.
Neuroimaging studies indicate that the prefrontal cortex matures more slowly than other areas of the brain
and that its development is correlated with increased capacity in adolescents to inhibit behavioral
responses. The prefrontal cortex is known to mediate executive function, that is, skills involving working
memory, selective attention, and voluntary response inhibition. In addition to executive function, the
prefrontal cortex is believed to be involved in social and cognitive abilities such as self-awareness and the
development of an understanding of another person's perspective. Recent studies have provided evidence
of a linear improvement in performance by age on certain tasks within executive function, such as those
involving selective attention, working memory, and problem solving. This lends support for an increase in
performance in these tasks as a function of the pruning and synaptic reorganization of the prefrontal
cortex.
Social cognitionin particular, recognition of facial expressions of emotionhas been studied recently in
healthy adolescents. The amygdala, a region of the brain known to be associated with emotion processing,
was found by functional MRI to be activated in adolescents shown fearful facial expressions and in response
to happy faces compared to neutral faces. Among adolescents, left amygdala activity when presented with
fearful faces decreased in girls but not in boys. Female adolescents also demonstrated greater activation of
the dorsolateral prefrontal cortex, whereas male adolescents did not show this pattern. It was
hypothesized that the pattern of diminished amygdala and increased prefrontal activation in female
adolescents reflects increased maturity in the regulation of emotional experiences in them compared to
male adolescents.
Overall, both structural and functional MRI studies implicate puberty as a period of synaptic reorganization
in the prefrontal and parietal cortex, which may place the adolescent brain in a sensitized state with
respect to the development of executive functions and social cognitive skills. Clearly the adolescent brain
continues to develop structurally, and the relationships of these structural changes to behavioral and
emotional responses warrant further investigation.
Current Environmental Influences and Adolescence
Adolescent Sexual Behavior

Sexual interest and experimentation are critical components of adolescent development for boys and girls.
Sexual experimentation in adolescents often begins with fantasy and masturbation in early adolescence,
followed by genital touching with the opposite sex or, in some cases, same-sex partners, oral sex with
partners, and initiation of sexual intercourse at a later point in development. In one study of urban
adolescents, at least one third reported some form of genital sexual activity in the last year with a partner,
and approximately 10 percent reported oral sexual behavior with a partner. The balance between healthy
adolescent sexual experimentation and emotionally and physically safe sexual practices has been one of
the major challenges for society in the new millennium.
Trends in adolescent sexual activity are monitored by the YRBSS, which measures the self-reported
prevalence of health-risk behaviors, including sexual activity. Surveys obtained for the years 2004 to 2006
provide detailed information regarding sexual activity in adolescents and risks associated with these
behaviors. Among high school students across the nation, 46.8 percent reported that they had had sexual
intercourse during their life, and 33.9 percent of high school students reported that they were currently
sexually active. Among those who were currently sexually active, 62.8 percent reported that they or their
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partner had used a condom during their last sexual intercourse. The prevalence of having had sexual
intercourse at least once was higher among black males (74 percent) than Hispanic males (57.6 percent),
followed by black females (61.2 percent) and Hispanic females (44.4 percent). The overall rate of having
had sexual intercourse in high school among white students was 43 percent, with white females (43.7
percent) reporting it slightly more frequently than white males (42.2 percent). A total of 14.3 percent of
students report that they had had sexual intercourse with at least four persons during their lifetime. Among
the 33.9 percent of currently sexually active students nationwide, 17.6 percent reported that either they
or their partner had used birth control pills as a contraceptive before their last sexual intercourse.
Close to 90 percent of high school students had received instruction that includes information about
acquired immunodeficiency syndrome (AIDS) or HIV infection. Nationwide, 11.9 percent of students had
been tested for HIV.
Factors That Influence Adolescent Sexual Behavior

Factors impacting sexual behavior in adolescents include psychosocial factors, temperamental and
personality traits, externalizing and internalizing psychiatric symptoms, gender, cultural and religious
background, racial factors, family attitudes, and sexual education and prevention programs.
A recent longitudinal study of predictors of sexual initiation and high-risk sexual behaviors in young
adolescents indicated that externalizing factors, specifically a history of violent delinquency in middle
school and substance use, were associated with sexual initiation in early adolescence.
A survey of more than 400 female adolescents of varied racial backgrounds found that higher levels of
impulsivity were associated with a younger age at first experience of sexual intercourse; a higher number
of sexual partners; sexual intercourse without the use of contraception, including condoms; and a history
of sexually transmitted disease (chlamydia). The level of impulsivity was not found to be significantly
associated with age, race, or education. Although this investigation focused only on girls, it is likely that
similar results might be obtained for boys.
Historically, male adolescents have initiated sexual intercourse at a younger age than female adolescents,
and current data suggest that approximately 10 percent of girls and 20 percent of boys report age of first
experience of sexual intercourse to be less than age 15 years. In general, adolescents who initiate sexual
intercourse at younger ages are also more likely to have a greater number of sexual partners.
There is a suggestion from recent surveys of urban adolescents that early initiation of sexual intercourse,
before age 15 years, is more frequent among African-American boys than in Hispanic boys and more
frequent in Hispanic boys than in white boys.
The additive effects of more highly educated families, social and religious youth groups, and school-based
educational programs can be credited with a decline in high-risk sexual behavior among adolescents in the
1990s. Responsible sexual behavior among adolescents has been determined as one of the ten leading
health indicators for the next decade. One urban schoolbased intervention designed to promote sexual
abstinence in middle schoolers and support safe sexual practices in those students who continue to be
sexually active reported that successful abstinence was only possible in those students who had not
initiated sexual intercourse by the time of the intervention.
Risk-Taking Behavior
Reasonable risk taking is a necessary endeavor in adolescence, leading to confidence in forming new
relationships and competence in sports and in social situations. However, high-risk behaviors among this
generation of adolescents are associated with serious negative consequences and can take many forms,
including drug and alcohol use, unsafe sexual practices, self-injurious behaviors, and reckless driving.
Alcohol is the most commonly used substance among adolescents and is associated with a multitude of
coexisting high-risk behaviors, such as motor vehicle accidents resulting in injury and death, academic
deterioration, fighting, and criminal behaviors. According to a recent National Institutes of Health survey,
heavy drinking (defined as at least five consecutive drinks at one time) was reported by almost one third of
high school seniors. Rates of alcohol use have been stable over the last few years among adolescents, with
more than one third of male high school seniors and approximately one fourth of female high school seniors
reporting heavy drinking. A recent longitudinal study of alcohol use in adolescents followed into adulthood
confirmed the high level of continuity of this behavior. Adolescent frequent and heavy use of alcohol was
associated with future antisocial behavior, as well as increased levels of depression. Furthermore, even
lower levels of alcohol use predicted similar problems as teens entered young adulthood. This implies the
need for preventive interventions during adolescence for those teens who use alcohol, even if drinking
behavior does not appear to be frequent or serious.
Illicit drugs, including marijuana, cocaine, heroin, hallucinogens, ecstasy, and amphetamines, also pose
a serious health risk among adolescents. A recent National Institute on Drug Abuse survey indicated that, in
young adolescents, more than 10 percent used an illicit substance in a given month, and, in older
adolescents, approximately 25 percent used illicit drugs in a given month. In younger adolescents, boys and
girls had similar rates of drug use, whereas older adolescent boys had slightly higher rates. Although there
are vast differences between adolescents who had experimented on rare occasions with marijuana and
adolescents who engaged in daily drug use, the large numbers of adolescents engaged in these behaviors at
every level is cause for public health concern. Furthermore, use of illicit substances is also associated with
youth crimes and violent behaviors. In the last few years, rates of violent crime victimization, including
aggravated assault, robbery, rape, and homicide, according to the U.S. Department of Justice statistics,
are in the range of 20 crimes per 1,000 adolescents per year. This rate is approximately twice the rate of
crime victimization in adults. Male adolescents are approximately twice as likely as female adolescents to
be the victims of serious violent crimes, with younger adolescents, 12 to 14 years old, just as likely to be
victims as older adolescents, 15 to 17 years old. These grave statistics indicate a need to identify risk
factors and to find protective factors for today's youth.
Adolescents who regularly engage in high-risk behaviors are likely to be those with inadequate parental
supervision, low levels of investment in academic pursuits, and little involvement in structured
extracurricular activities. Prosocial behavior among adolescents has been shown to be associated with
youth participation in school-based clubs, athletic teams, and community organizations that sponsor
supervised social activities.
Identifying adolescents with high-risk behavior is not always feasible until the high-risk behaviors have
resulted in academic or legal consequences. Once this occurs, a given adolescent can be identified as being
at high risk for future difficulties and, optimally, should be monitored by a counselor through school, an
outside therapist, and, in some cases, through the legal system. It is not always easy for an outsider, at
first glance, to separate adolescents engaging in normal experimentation from those embroiled in high-risk
behaviors. When there is evidence that an adolescent is engaged in frequent alcohol or drug use, reckless
behavior, or criminal activities, urgent psychosocial interventions are needed. In less obvious cases,
adolescents who
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have ongoing academic difficulties, do not participate in any athletic or other extracurricular structured
activities, and are socially isolated may also be in need of psychiatric evaluation.
A recent survey of high-risk behaviors in adolescents in a primary care medical clinic setting found that the
presence of tattoos and body piercings was associated with a higher probability of high-risk behavior. In the
general population, approximately 10 to 13 percent of adolescents have tattoos, compared to 5 percent of
the total population, including all ages. Body piercings have also become more prevalent among
adolescents since the 1980s. Of the more than 500 adolescents surveyed in this study, 13.2 percent
reported at least one tattoo, and 26.9 percent reported at least one body piercing, other than in their ear
lobe, at some point in their lives. Both tattoos and body piercings were more common in girls than in boys
(16.6 vs. 8.1 percent for tattoos, 36.7 vs. 10.1 percent for body piercing). Adolescents who endorsed
possession of at least one tattoo or body piercing were more likely to endorse the use of gateway drugs
(cigarettes, alcohol, marijuana), as well as experience with hard drugs (cocaine, crystal
methamphetamine, and ecstasy). Female adolescents who had tattoos or body piercings, especially
younger adolescents, were more likely to endorse a history of suicidal ideation or behaviors. Male
adolescents with tattoos and female adolescents with body piercings were more likely to report a history of
involvement in physical fights, carrying a weapon, or bodily injury as a result of physical fighting.
Adolescents with tattoos or piercings were more frequently sexually active than were adolescents without
them and at greater risk for unsafe sexual behavior.
Overall, the presence of tattoos or body piercings does not necessarily indicate high-risk behaviors in
adolescents but is associated with a higher risk among adolescents of engaging in these behaviors.
Conversely, many adolescents with serious high-risk behaviors do not possess tattoos or body piercings.
Given the serious consequences of alcohol and drug use and violence among adolescents, inquiry into these
behaviors should be an integral part of every health care evaluation.
Adolescent Use of the Internet

The Internet is a ubiquitous form of communication and information sharing, affecting all aspects of life for
today's adolescents. Recent reports indicate that about 90 percent of children and adolescents use the
Internet in myriad ways, including instant messaging, visiting social networking sites, blogging, chatting in
chat rooms, posting photos, videos, and stories, and obtaining information by visiting numerous websites.
Positive effects of the Internet identified for adolescents in this generation include exponentially increased
communication with both friends and family that is likely to influence their intellectual and social
development. Use of the Internet for accessing academic information, seeking knowledge on a broad range
of topics, from recreational activities to psychological concerns, and corresponding with peers through
messages, chat rooms, and games is pervasive among the current generation of adolescents. In addition to
the casual uses of the Internet for communication, a recent survey investigated the notion that some
adolescents may use it to learn about health-related issues and for self-help. In this regard, several health-
related, adolescent-friendly websites are available that provide information on a variety of psychological
and medical topics. One such site is http://www.CyberIsle.org, originally conceived of by the Department
of Public Health Sciences at the University of Toronto, which was created with the direct collaboration of
adolescents and is fully geared toward an adolescent population. It consists of seven rooms in which
adolescents can chat and obtain health information. Not-2-Late.com, run by the Office of Population
Research at Princeton University, maintains a narrow focus on providing practical information about various
contraceptives and guidance for adolescents who wish to obtain contraception without involving their
parents. The current investigation surveyed two samplesthe first, 145 inner-city adolescents who came to
a health center, and the second, a community sample of students attending a private high school in an
urban city. Practically all (99 percent) of the students attending private high school endorsed use of the
Internet in one or more settings, and 83 percent of the urban adolescents surveyed at the health center
reported using the Internet. Forty-two percent of the urban adolescents surveyed at the health center and
43 percent of the students attending private high school endorsed use of the Internet to obtain health
information. This study provided confirmation of the pervasive use of the Internet by adolescents across
socioeconomic classes. It further suggested that almost half of adolescents have used the Internet at times
to seek out information related to health and social behavior.
This study highlights the importance of available health information on the Internet and points out the
need for this information to be accurate, reliable, and a potential opportunity to guide responsible
behavior among adolescents.
In addition to clear benefits of the Internet for youth, there are also significant risks associated with
Internet use, especially for adolescents who share personal information and communicate with strangers on
line. According to the recent Second Youth Internet Safety Survey, a national telephone survey that
sampled 1,500 Internet users between the ages of 10 and 17 years who used the Internet at least once per
month for the previous 6 months, 9 percent of youth who used the Internet were found to be targets of
some type of online harassment within the previous year. Other sources report that approximately 13
percent of youth online are the targets of unwanted sexual solicitation. Approximately half (45 percent) of
the youth who were the victims of the harassment incidents knew the harasser in person before the events.
Half of the harassers (50 percent) were male and half of them (51 percent) were adolescents. Twenty-five
percent of targets reported an aggressive offline incident that involved either a telephone call or in-person
contact. Those youth who were victimized had higher rates of harassing another youth online. Those youth
who were the targets of adult harassment were often asked to send pictures of themselves or received a
telephone call or a visit in person from the adult. Approximately 39 percent of youth who reported that
they were harassed online experienced distress related to it. Internet safety programs urge youth to avoid
sharing personal information and not to communicate with strangers online.
Massively Multiplayer Online Role-Playing Games among

Adolescents
Massively multiplayer online role-playing games (MMORPGs) are highly sophisticated multiplayer universes
in which players create an individualistic character (avatar). In this medium millions of adolescents along
with children and adults immerse themselves in a graphic virtual environment and can interact with each
other through their avatars on a daily basis. Researchers have questioned the potential dangers of such
gaming among adolescents with regard to their social development, self-esteem, and aggressive behavior.
A recent study investigated the social interactions that occurred within such games. The most popular of
this genre of game is World of Warcraft, with City of Heroes, Ultima Online, Everquest, Lineage II, and
RuneScape less often played. Based on an online questionnaire, it was reported by players that 76.2
percent of male and 74.7 percent of female players had made good friends within the context of the game,
and that the vast
P.3365
majority of players were also playing with real-life friends or family. Another study investigating
adolescents who played video games compared to those who did not play these games found no differences
between gamers and nongamers in time spent with their parents or friends or in sports or leisure activities;
however, gamers were found on average to spend less time with reading and on homework.
Suggested Cross-References
The ideas of Jean Piaget are explained in Section 3.2 and of those Erik Erikson in Section 6.2. Normal
human sexuality is discussed in Section 18.1a, eating disorders are discussed in Chapter 19, and normal
child development is outlined in Section 32.2, family therapy in Sections 30.5, mood disorders and suicide
in Chapter 48, and psychiatric treatment of adolescents in Section 48.10.
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Ovid: Kaplan & Sadock's Comprehensive Textbook of Psychiatry Page 1 of 21

Editors: Sadock, Benjamin J.; Sadock, Virginia A.; Ruiz, Pedro

Copyright 2009 Lippincott Williams & Wilkins

Caroly S. Pataki M.D.

Adolescence is a critical period characterized by neurobiological and physical maturation leading to

What is Normal Adolescence?

Table 32.3-1. Sexual Maturity Rating (SMR) of Girls and Boys

SMR Girls Boys

Stage Preadolescent, papilla elevated Penis, testes, scrotum preadolescent

No pubic hair No pubic hair

Sparse, long pubic hair, mainly along

Sparse, long pubic hair, mainly at the

Stage Breast size increased Penis increased in length and width

Areola and papilla raised Testes and scrotum larger

Pubic hair increased in density; area

Pubic hair increased in density, area;

Adolescent Brain Development: Correlations with Emotional, Social,

Current Environmental Influences and Adolescence

Adolescent Sexual Behavior

Factors That Influence Adolescent Sexual Behavior

Adolescent Use of the Internet

Massively Multiplayer Online Role-Playing Games among

Caminis A, Henrich C, Ruchkin V, Schwab-Stone M, Martin A: Psychosocial predictors of sexual

*Erikson EE: Childhood and Society. Middlesex, England: Penguin; 1950.

Heavside S, Riggins T, Farris E: Advanced Telecommunications in U.S. Public Elementary and

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