بسم الله الرحمن بسم الله الرحمن الرحيمالرحيم

AdolescenceAdolescenceThe Bottle NeckThe Bottle Neck

Menan Abd-El-Maksoud Rabie, MDMenan Abd-El-Maksoud Rabie, MDMBBch, Msc, MD, Arab BoardMBBch, Msc, MD, Arab Board

Psychiatry ConsultantPsychiatry Consultant

Associate Professor of Psychiatry, Ain Shams UniversityAssociate Professor of Psychiatry, Ain Shams University

Associate Member of the International Federation of Associate Member of the International Federation of Psychiatric Epidemiology (IFPE)Psychiatric Epidemiology (IFPE)

ParentingParenting and and growing upgrowing up are are both very stressful things to be doingboth very stressful things to be doing

And when a family tries to do them And when a family tries to do them both at the both at the same timesame time, it, it’’s s inevitable that somewhere along the inevitable that somewhere along the line there is going to be line there is going to be …………………… frictionfriction

Dr David FongDr David Fong

The familyThe familyFamily life exists on a continuum. Family life exists on a continuum. Sometimes, itSometimes, it’’s absolutely great and s absolutely great and sometimes, well, it really isnsometimes, well, it really isn’’t.t.

Furthermore, bear in mind that Furthermore, bear in mind that where a family stands on this where a family stands on this continuum varies acc. to stresses & continuum varies acc. to stresses & strains they are under.strains they are under.

A huge interaction between a family, A huge interaction between a family, its members and their environment its members and their environment are changing all the time.are changing all the time.

Successful familiesSuccessful families

The idea of typical family has The idea of typical family has changed, but what a family needs to changed, but what a family needs to do hasndo hasn’’t changed that much (not in t changed that much (not in terms of earning money or living in terms of earning money or living in luxury, but in terms of contentment, luxury, but in terms of contentment, adjustment and coping)adjustment and coping)

Family tasks are to fulfill:Family tasks are to fulfill:

* Physical needs * Psychological needs* Physical needs * Psychological needs

* Emotional needs * Spiritual needs* Emotional needs * Spiritual needs

Family tasksFamily tasksPhysical needsPhysical needs

Food, shelter, warmth, clothingFood, shelter, warmth, clothing

Psychological needsPsychological needs

Safety, length and durability of the Safety, length and durability of the bond bond ““elastic bandelastic band”” dangerous if too dangerous if too loose and crippling if too tight,loose and crippling if too tight,

Emotional needsEmotional needs

Allow emotions, behavioral thermostatAllow emotions, behavioral thermostat

Spiritual needsSpiritual needs

Dream, be ambitiousDream, be ambitious

a developmental period of dramatic change.a developmental period of dramatic change.

Adults on the outside Adults on the outside more more misunderstandings misunderstandings && ignorance of what a ignorance of what a teenager is trying to understand, do, feel, or teenager is trying to understand, do, feel, or be.be.

Adult response is shaped by adult Adult response is shaped by adult expectations, understanding and feelings. expectations, understanding and feelings. ranging from delight, admiration & interest ranging from delight, admiration & interest to disapproval, disgust & fear.to disapproval, disgust & fear.

ADOLESCENCE

AdolescenceAdolescence

A long transitional developmental A long transitional developmental period between childhood and period between childhood and adulthood.adulthood.

A maturational developmental process A maturational developmental process involving major physical, psychological, involving major physical, psychological, cognitive, and social transformations.cognitive, and social transformations.

Its onset marked by puberty. Its onset marked by puberty.

AdolescencAdolescencee

AdolescencAdolescenceeNormal adolescence is a Normal adolescence is a

universal & extreme universal & extreme internal & external internal & external stress: stress: marked emotional marked emotional reactivityreactivityvolatile behavioral volatile behavioral unpredictability unpredictability dramatic separations dramatic separations from family tiesfrom family tiessevere disruptions in the severe disruptions in the personal sense of self, personal sense of self, leading to separation and leading to separation and autonomyautonomy

AdolescenceAdolescenceA A time of reordering, realignment, time of reordering, realignment, and transformation leading to and transformation leading to

physical physical && cognitive development cognitive development

relational transformations relational transformations

psychological differentiationpsychological differentiation

interdependence interdependence

greater self coherence.greater self coherence.

STAGES OF STAGES OF ADOLESCENCEADOLESCENCE

Adolescence is usually Adolescence is usually divided into phases of divided into phases of early (12 to 14 years) early (12 to 14 years) middle (14 to 17 years) middle (14 to 17 years) late adolescence (17 to late adolescence (17 to 19 years) 19 years) described in terms of described in terms of physical, cognitive, physical, cognitive, psychological, and social psychological, and social changes changes

Concrete self descriptionConcrete self description

Tortuous course Tortuous course

Definition of self portraitDefinition of self portrait

I- Physical I- Physical ChangesChanges

Growth spurtGrowth spurtSecondary sex characteristics begin to appear Secondary sex characteristics begin to appear about a year after the onset of the growth spurt about a year after the onset of the growth spurt (pubic hair & breast development in girls & pubic (pubic hair & breast development in girls & pubic hair &genital development in boyshair &genital development in boys(( Menarche (8-13 ys)Menarche (8-13 ys)Spermache (9-14 ys)Spermache (9-14 ys)The nose and mouth widen & the jaw juts out. The The nose and mouth widen & the jaw juts out. The chin is the last chin is the last Body hair darkens and lengthens Body hair darkens and lengthens Sweat glands become active Sweat glands become active body odor body odorVoice quality changesVoice quality changesComplexion and acne problems Complexion and acne problems Endurance and strengthEndurance and strength

Thought experimentThought experimentImagine that over the next 3-4days Imagine that over the next 3-4days

You sprout hair allover your bodyYou sprout hair allover your body……Your voice changes completely Your voice changes completely ……Your body odor changes Your body odor changes ……You canYou can’’t judge distance because your t judge distance because your limbs are growing limbs are growing ……You have strange new urges You have strange new urges ……You canYou can’’t control your mood t control your mood ……Your sexual organs behave in a Your sexual organs behave in a strange way and there are fluids strange way and there are fluids coming out coming out ……

II- Cognitive II- Cognitive ChangesChanges

abstract thoughtabstract thought, , integrate concrete experiences, integrate concrete experiences, possible scenarios, historical facts, and remembered possible scenarios, historical facts, and remembered experiences into an abstract generalization experiences into an abstract generalization information-processing skillsinformation-processing skills, selective , selective attentionattention, , better short- and long-term better short- and long-term memorymemory, and , and organizationalorganizational strategies strategies knowledgeknowledge base, and base, and decision-making decision-making future or future or ideal possibilitiesideal possibilities; A teenager can be ; A teenager can be inspired by the "what ifs" inspired by the "what ifs" self-reflectionself-reflection new dimensions of personal or moral new dimensions of personal or moral categorizations.categorizations.multidimensional appreciationmultidimensional appreciation more complex more complex understanding of causality in academic, personal, and understanding of causality in academic, personal, and interpersonal matters (but not everyday)interpersonal matters (but not everyday)to becometo become relative relative rather than absolute rather than absolute

dendrites

dendritic tree

cell body

axon

1-21 Stahl S M, Essential Psychopharmacology (2000)

التغيرات المعرفيةالتغيرات المعرفيةCognitive ChangesCognitive Changes

1-22 Stahl S M, Essential Psychopharmacology (2000)

growth factor (protein)

undeveloped neuron

dendrites in need of “pruning”

1-23 Stahl S M, Essential Psychopharmacology (2000)

normal “pruning”

BIRTH AGE 6 AGE 14-20

1-20 Stahl S M, Essential Psychopharmacology (2000)

These new capacities lead to These new capacities lead to preoccupation with the self, preoccupation with the self, periods of private introspection, periods of private introspection,

self-consciousnessself-consciousness..

""the imaginary audiencethe imaginary audience""

falsely assume that others are as falsely assume that others are as preoccupied with their behavior preoccupied with their behavior && appearance as they are appearance as they are themselvesthemselves..

The ability to separate one's thinking from that of others The ability to separate one's thinking from that of others enhances the capacity for perspective taking and enhances the capacity for perspective taking and interpersonal empathyinterpersonal empathy

Cognitive ChangesCognitive Changes ةةالتغيرات المعرفيالتغيرات المعرفي

Adolescence begins when children Adolescence begins when children stop asking questions-because they stop asking questions-because they know all the answers.know all the answers.

Evan EsarEvan Esar

III-Psychological changesIII-Psychological changesChanges in adolescent Changes in adolescent

internal world:internal world:Choice and Choice and consequenceconsequenceAdolescents are Adolescents are making decisions for making decisions for the first time without the first time without an experience base, an experience base, they find information they find information with peers, TV or with peers, TV or media.media.Adolescents try on Adolescents try on personalities personalities to see which is the to see which is the best fit best fit

III-Psychological changesIII-Psychological changes

Separation and individuationSeparation and individuation

Development of a stable internal Development of a stable internal worldworld

Emotional regulationEmotional regulation

How parents can helpHow parents can help… …

Parents need to be honest and Parents need to be honest and availableavailable

Parents need to set boundariesParents need to set boundaries

* realistic boundaries* realistic boundaries

* enforceable boundaries* enforceable boundaries

* beneficial for the family* beneficial for the family

III-Psychological changesIII-Psychological changes

How parents can helpHow parents can help……

Remember how it was for youRemember how it was for you

Give them spaceGive them space

Remember the boundariesRemember the boundaries

Be rational and calmBe rational and calm

CULTURE

HISTORICAL ERA &TECHNOLOGY

Adolescent development is Adolescent development is shaped byshaped by

Gender dif

self-esteem,

Paths ofSeparating from parents

relations

Timing of

puberty

SOCIO ECONOMIC CLASS

PARENT-CHILD DIALOGUE

QOL 2

Adolescent development is shaped Adolescent development is shaped byby

Individual differencesIndividual differences

dialoguedialogue

Context Context (environment)(environment)

TimingTiming

Arrested ego Arrested ego developmentdevelopment

Steady conformitySteady conformity

Progressive ego Progressive ego developmentdevelopment

Accelerated ego Accelerated ego developmentdevelopment

Stuart Hauser and colleaguesStuart Hauser and colleagues

Healthy adolescence results from Healthy adolescence results from healthy ego development that healthy ego development that generates an extensive and generates an extensive and flexible repertoire of responses flexible repertoire of responses and a healthy balance of and a healthy balance of autonomy & involvement with autonomy & involvement with othersothers

PARENT-PARENT- CHILD CHILD DIALOGUEDIALOGUE

Conflict-resolution strategiesConflict-resolution strategies

Conflict starts with behaviors that deviate Conflict starts with behaviors that deviate from from expectationsexpectations. .

Children and parents argue more at the Children and parents argue more at the onset of pubertyonset of puberty, ,

Parents and children argue more often Parents and children argue more often aboutabout such issues as curfews, chores, such issues as curfews, chores, schoolwork, and personal hair and clothing schoolwork, and personal hair and clothing styles styles

positive outcomespositive outcomes

Parent-child conflicts yield Parent-child conflicts yield positive positive

outcomesoutcomes when they are: when they are:

temporary, temporary,

take place in the context of warm take place in the context of warm close relationships, and close relationships, and

proceed with mature conflict proceed with mature conflict resolution strategies resolution strategies

end in negotiated compromises.end in negotiated compromises.

negative outcomesnegative outcomesThe inevitable troubles may result in The inevitable troubles may result in negative outcomesnegative outcomes when they when they become pervasive, become pervasive, occur with a backdrop of shaky emotional occur with a backdrop of shaky emotional relationships, relationships, involve parents or children who may be involve parents or children who may be temperamentally or psychiatrically more temperamentally or psychiatrically more vulnerable, and vulnerable, and escalate regularly to devaluing and hostile escalate regularly to devaluing and hostile interactions interactions end in withdrawal or disengagement end in withdrawal or disengagement

Adolescent development is better in Adolescent development is better in parent-child relationship ccc byparent-child relationship ccc by::

Secure attachmentSecure attachment

Well-worn styles of discussionWell-worn styles of discussion

Supportive communicationSupportive communication

Adaptive strategies for conflict Adaptive strategies for conflict resolutionresolution

Parents with Parents with mature ego mature ego developmentdevelopment who have (self who have (self awareness, appreciation of individual awareness, appreciation of individual differences, reasonable approaches differences, reasonable approaches to adolescent experimentation)to adolescent experimentation)

Balanced authoritative parentingBalanced authoritative parenting

Limit setting vs negotiationLimit setting vs negotiation

Respect autonomous expression vs Respect autonomous expression vs disciplined conformitydisciplined conformity

Emotional responsiveness vs mature Emotional responsiveness vs mature conflict resolutionconflict resolution

Stereotyped expectations vs newly Stereotyped expectations vs newly encountered ideas and conceptsencountered ideas and concepts

From the Adult Side increased feelings of inadequacy around parentingincreased feelings of inadequacy around parenting

greater anxietygreater anxiety

greater marital tensiongreater marital tension

Middle-age parents may be confronting diminished Middle-age parents may be confronting diminished physical attractiveness physical attractiveness && life opportunities life opportunities

dialogue dialogue adaptive responses to the adolescent's adaptive responses to the adolescent's

emotional distancingemotional distancing

body changesbody changes

increased questioning of family rules and increased questioning of family rules and conventionsconventions

different tastes in clothes and musicdifferent tastes in clothes and music

search for privacy and extrafamily relationships. search for privacy and extrafamily relationships.

From the Adolescent SideFrom the Adolescent SideAdolescent fashion, behaviors, Adolescent fashion, behaviors, and tastes are not merely and tastes are not merely "rebellious" alternatives to "rebellious" alternatives to parental values and behaviors. parental values and behaviors. Teenagers are learning and Teenagers are learning and making serious life choices making serious life choices when they do the varied and when they do the varied and sometimes extreme things they sometimes extreme things they do.do.For the teenager they are For the teenager they are explorations into who I have explorations into who I have been, am, or could be.been, am, or could be.Badges of membership in some Badges of membership in some peer groups and non-peer groups and non-membership in others.membership in others.

RٍRٍself-discovery involves self-discovery involves discomfort, confusion, anxiety, discomfort, confusion, anxiety, and unhappiness especially in and unhappiness especially in Early adolescence Early adolescence

Peer PressurePeer Pressure“The blind leading the blind“The blind leading the blind””

When teenagers pick a peer group with When teenagers pick a peer group with behaviors and values more similar to behaviors and values more similar to those of their parents, the teenagers and those of their parents, the teenagers and parents have a more harmonious journey. parents have a more harmonious journey. Teenagers with ability in academic, Teenagers with ability in academic, athletic or arts are accepted by these peer athletic or arts are accepted by these peer groups. groups. If teenagers are rejected by more-If teenagers are rejected by more-competent peer groups, they seek out competent peer groups, they seek out groups who will accept and validate their groups who will accept and validate their level of competence.level of competence.

Peer PressurePeer Pressure Why peers can helpWhy peers can help……

Peers act as a mirrorPeers act as a mirror

Peers act as a testing Peers act as a testing groundground

Peers provide social Peers provide social support and safetysupport and safety

Peers donPeers don’’t live in the t live in the same house, they are same house, they are separate and private separate and private from the family, they from the family, they are precious and are precious and important.important.

Peer PressurePeer Pressure“The blind leading the blind“The blind leading the blind””

How to deal with the peer How to deal with the peer pressurepressure

Offer your servicesOffer your services

Be interestedBe interested

DonDon’’t label or judget label or judge

DonDon’’t worry about your child going to t worry about your child going to an irreversible path, this feeling is an irreversible path, this feeling is usually amplified in the presence of a usually amplified in the presence of a peer grouppeer group

Milestones of self developmentMilestones of self development– generation of components of the selfgeneration of components of the self– differentiation and exploration of these differentiation and exploration of these

componentscomponents– valuing of some parts and devaluing of valuing of some parts and devaluing of

others (self-esteem regulation) others (self-esteem regulation) – dropping of devalued and development dropping of devalued and development

of valued partsof valued parts– reconciling of contradictory self images reconciling of contradictory self images – integration of self components.integration of self components.

Susan HarterSusan Harter

Process of Identity FormationProcess of Identity Formation

Identity diffusionIdentity diffusion: period of exploration of : period of exploration of alternative selves toward a period of choice, alternative selves toward a period of choice, commitment, and consolidation. commitment, and consolidation. ForeclosureForeclosure: premature commitment Teenagers : premature commitment Teenagers who foreclose the process adopt identities who foreclose the process adopt identities prescribed by parents or other authority figures prescribed by parents or other authority figures without ever experiencing tension or exploring without ever experiencing tension or exploring options. options. identity confusionidentity confusion: failure to commit : failure to commit appropriate in early adolescence, in later appropriate in early adolescence, in later adolescence adolescence a maladaptive inability to seek a maladaptive inability to seek decisions and make commitments.decisions and make commitments.

You should be concerned ifYou should be concerned if……

The problem persists for a period of The problem persists for a period of months (become chronic)months (become chronic)

The problem is snowballingThe problem is snowballing……

The behavior is markedly different The behavior is markedly different from that of a peer groupfrom that of a peer group

Pathological outcomes in identity Pathological outcomes in identity formation lead to turning against the formation lead to turning against the self (e.g., depression, eating self (e.g., depression, eating disorders, and suicidality) or turning disorders, and suicidality) or turning against others or society (e.g., against others or society (e.g., delinquent behaviors).delinquent behaviors).

External ProblemsExternal Problems

Domestic violenceDomestic violence

DivorceDivorce

BereavementBereavement

Being part of a single parent familyBeing part of a single parent family

Being part of a stepfamilyBeing part of a stepfamily

Healthier teenagers can see how they can Healthier teenagers can see how they can be both smart and dumb, kind and mean, be both smart and dumb, kind and mean, capable and incompetent, lovable or capable and incompetent, lovable or unpopular depending upon the unpopular depending upon the contextcontext..

Older adolescents integrate past, current, Older adolescents integrate past, current, and future selves coordinating them into and future selves coordinating them into self-knowledge & acceptance. They will self-knowledge & acceptance. They will refuse to participate in an activity with refuse to participate in an activity with reasons such as "That's not me."reasons such as "That's not me."

Finding Finding the real methe real me is a stable, is a stable, comfortable sense of self with continuity comfortable sense of self with continuity to childhood identities and confidence in to childhood identities and confidence in future roles. future roles.

Guidelines for the ParentGuidelines for the Parent

What teenagers want from their familyWhat teenagers want from their family

BoundariesBoundaries

Compromise and negotiationCompromise and negotiation

Appropriate levels of responsibility for Appropriate levels of responsibility for decisionsdecisions

Open communicationOpen communication

Adult reactions to adolescent problemsAdult reactions to adolescent problems

ConsistencyConsistency

To know where they standTo know where they stand

Guidelines for the ParentGuidelines for the Parent

BE SENSITIVEBE SENSITIVE

Stay available showing love, support, Stay available showing love, support, commitment, and interest in your commitment, and interest in your teenager.teenager.

Offer affection and protection with Offer affection and protection with challenges acc to what they can handlechallenges acc to what they can handle

ListenListen

Search for and find opportunities to Search for and find opportunities to congratulate, and praisecongratulate, and praise

Avoid labeling, judging, devaluingAvoid labeling, judging, devaluing

Support emerging mature, autonomous Support emerging mature, autonomous behaviorbehavior

Guidelines for the ParentGuidelines for the Parent

BE INFORMEDBE INFORMEDHelp them ask and explore important Help them ask and explore important questionsquestionsMake it possible for them to call for help Make it possible for them to call for help verbally rather than by acting upverbally rather than by acting upPermit conflict and guide discussionsPermit conflict and guide discussionsValue stimulating conversations with Value stimulating conversations with different points of viewdifferent points of viewEncourage them to adopt a personal value Encourage them to adopt a personal value systemsystemHelp them learn from their mistakes Help them learn from their mistakes through self-reflection and discussionthrough self-reflection and discussionAsk questionsAsk questions

Guidelines for the ParentGuidelines for the ParentNORMALISENORMALISERemember and remind them that Remember and remind them that adolescence is a processadolescence is a processFoster a sense of "comfortable" Foster a sense of "comfortable" continuitycontinuityRemind teenagers that they are going to Remind teenagers that they are going to school, working, and loving for school, working, and loving for themselves and not for youthemselves and not for youGive them some slack for moodiness, Give them some slack for moodiness, distancingdistancingRemember teenagers have a lot of inside Remember teenagers have a lot of inside work to do that does not relate to youwork to do that does not relate to you

Don't take interactions personallyDon't take interactions personally

Guidelines for the ParentGuidelines for the ParentBE PREPAREDBE PREPARED

Promote greater differentiation while not Promote greater differentiation while not disrupting enduring family connectionsdisrupting enduring family connections

Help adolescents develop disciplined Help adolescents develop disciplined conformity to society's necessary rules conformity to society's necessary rules and expectationsand expectations

Respect (you don't have to like) their peer Respect (you don't have to like) their peer choiceschoices

Low-key, accepting, calm parents hear Low-key, accepting, calm parents hear more. . . . Kids keep talking to themmore. . . . Kids keep talking to them

Validate and encourage child's own Validate and encourage child's own capacity to copecapacity to cope

Guidelines for the ParentGuidelines for the ParentBE OPEN AND ACCEPTINGBE OPEN AND ACCEPTINGBe firm and flexible about guidelines, Be firm and flexible about guidelines, allowing for increased negotiating allowing for increased negotiating powerspowersSupport their dreams, while helping Support their dreams, while helping them to plan, organize, and follow them to plan, organize, and follow activities to completionactivities to completionAsk if something is wrong when Ask if something is wrong when behavior changesbehavior changesLet them set the pace and timing of Let them set the pace and timing of close and distant interactionsclose and distant interactions

Let your child be the teenager he Let your child be the teenager he wants to be, not the adolescent wants to be, not the adolescent you were or wish you had beenyou were or wish you had been

Laurence SteinbergLaurence Steinberg