research paper on adolescent development

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Dynamics of Identity Development in Adolescence: A Decade in Review

Affiliations.

1 Utrecht University.
2 Erasmus University Rotterdam.
PMID: 34820948
PMCID: PMC9298910
DOI: 10.1111/jora.12678

One of the key developmental tasks in adolescence is to develop a coherent identity. The current review addresses progress in the field of identity research between the years 2010 and 2020. Synthesizing research on the development of identity, we show that identity development during adolescence and early adulthood is characterized by both systematic maturation and substantial stability. This review discusses the role of life events and transitions for identity and the role of micro-processes and narrative processes as a potential mechanisms of personal identity development change. It provides an overview of the linkages between identity development and developmental outcomes, specifically paying attention to within-person processes. It additionally discusses how identity development takes place in the context of close relationships.

Keywords: adjustment problems; adolescence; identity; within-person processes.

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A deep dive into adolescent development

Spearheaded by psychologists, a new long-term study will produce mountains of open-access data on adolescents

By Kirsten Weir

June 2019, Vol 50, No. 6

Print version: page 20

Open Science

In January, the National Institutes of Health (NIH) released the first complete baseline data set from the largest-ever study of adolescent health and development. The Adolescent Brain Cognitive Development (ABCD) Study will follow 11,874 children, starting at ages 9 and 10, for the next decade.

The ABCD Study will collect mountains of data: on neurological development, sociocultural and psychological factors, mental and physical health, environmental exposures, substance use, academic achievement and more. It's a huge undertaking, with huge implications for understanding children's development as they move through adolescence and into early adulthood.

"This is a massive effort, notable for both its scope and its depth," says Sandra Brown, PhD, vice chancellor for research and professor of psychology and psychiatry at the University of California, San Diego, and co-director of the ABCD Coordinating Center.

Because the project looks at so many different aspects of development, researchers will be able to mine the data to understand problems such as substance use and the emergence of mental illness, as well as the normal course of healthy adolescent development, adds Sara Jo Nixon, PhD, a professor of psychology at the University of Florida and a principal investigator of the study. "Often, we're interested in what went wrong, and indeed we'll have data to speak to those problems. But we'll also have data to look at resiliency and the kinds of factors—whether biological, psychological, social or cultural—that really nurture healthy development," she says. "This study is the epitome of what any psychological scientist would love to do."

ABCD basics

Launched in 2016, the ABCD Study is coordinated by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, with support from numerous other NIH institutes and offices as well as the Centers for Disease Control and Prevention. To assist in recruitment, APA provided NIH with a statement encouraging families to consider participating, and an APA staff member serves on the ABCD national liaison board.

The study encompasses 21 research sites across the country and will follow participants for 10 years. It's an interdisciplinary effort, but psychologists Brown and Terry Jernigan, PhD, also at the University of California, San Diego, sit at the helm of the Coordinating Center, and 26 of the 40 principal investigators are psychologists. The study was carefully planned from the start to include a diverse group of adolescents, Brown says.

"We worked with high-quality epidemiologists, so the sample we're bringing to the table is a good reflection of the sociodemographics of the United States," she says.

To manage such a large project, the study's designers included funding for a coordinating center and a data management center. There's also a retention committee that works to ensure that as many of the participants as possible stick it out over the next decade—no small feat, considering the time investment. The project involves neuroimaging, genetic testing and behavioral testing as well as numerous questionnaires for the children, their parents and teachers. Participants will wear sensors 'round-the-clock for several weeks, most likely once a year, to collect data about activity levels, heart rate and sleep patterns. Investigators will even collect hair samples and baby teeth to study exposures to environmental toxins. The study includes more than 2,000 twins and triplets, allowing researchers to begin to tease apart genetic susceptibility from environmental influences.

As the children move into their teenage years, researchers will be able to explore questions about substance use, physical activity, sports injuries, sleep, learning and the emergence of mental health problems—and that's just for starters, says psychologist Susan Tapert, PhD, a professor at the University of California, San Diego, and an associate director of the ABCD Coordinating Center. "There's really an infinite number of questions that can be addressed here."

Principal investigators aren't the only scientists who will be able to answer them. The study was developed with an open-access model, and the data collected are freely available to any qualified researcher who wants to tap into them via the National Institute of Mental Health Data Archive .

The open-science philosophy will drive the science forward faster, while the large sample size and methodologically rigorous study design will ensure that the data are trustworthy, says Raul Gonzalez, PhD, an ABCD principal investigator and professor of psychology at Florida International University. "There is a replication crisis in the sciences, and a lot of that crisis is partially due to small sample sizes and a bias to publish significant results," he says. "With this study, there is an opportunity to assess a lot of questions that are controversial in our field."

Another unique element of the open-access model: Lead investigators won't have preferential access to data before they've been made available to the general public. Whether you're a principal investigator at one of the study sites or a grad student far from the action, you will have the same opportunity to access the same information at the same time through planned data releases. "That says a lot about the commitment of the leadership team to make sure transparency and reproducibility are addressed head-on," says Nixon.

Early findings

Investigators finished recruiting participants only last year, yet they have already begun drawing insights from the study. In one analysis of the baseline data, Aaron Blashill, PhD, and Jerel Calzo, PhD, of San Diego State University, explored differences in mood disorders and suicidality between 9- and 10-year-olds who identified as gay, lesbian or bisexual and those who identified as heterosexual. The rate of mood disorders was 22.5 percent for sexual minority children, compared with 6.9 percent for heterosexual children. Similarly, 19.1 percent of sexual minority children experienced suicidal thoughts, while just 4.6 percent of heterosexual children did ( Journal of Affective Disorders , Vol. 246, No. 1, 2019).

Other groups have pulled from ABCD data to explore a pressing 21st-century problem: the effects of screen time. Jeremy Walsh, PhD, now at the University of British Columbia Okanagan, and colleagues explored physical activity, screen-time behavior and sleep among more than 4,500 of the participants. They found that children who met recommended guidelines for these activities—at least 60 minutes of physical activity, no more than two hours of recreational screen time and 9 to 11 hours of sleep daily—had better cognition than those who did not, as measured by tests of attention, language abilities, episodic memory, working memory, executive function and processing speed. Unfortunately, though, only half of the children in the sample got the recommended amount of sleep, just 36 percent had fewer than two hours of screen time and a mere 17 percent engaged in the recommended amount of daily exercise, the researchers found ( The Lancet Child & Adolescent Health , Vol. 2, No. 11, 2018).

Meanwhile, Tapert and colleagues found a link between screen time and a variety of complex structural brain changes, including cortical thickness, sulcal depth and gray matter volume. Different patterns of structural changes were related to downstream outcomes such as externalizing psychopathology and fluid and crystallized intelligence. But the changes differed depending on the type of screen media—and they weren't all bad (or all good) ( Neuroimage , Vol. 185, No. 1, 2019). "Kids who frequently played video games tended to have poorer mental health profiles and more family conflict, for example, while kids who were engaged in social media tended to have slightly better social and mental health functioning," she says. "It's not just how much screen time a child gets, but what they're doing."

With a single time point of data, it's too soon to make conclusions about the pros and cons of different screen media activities, Tapert notes. But as researchers follow the children in the years to come, they hope to be able to paint a more detailed picture of the effects of screen time on the brain.

A study that evolves

A lot can change in a decade. New social media platforms pop up almost overnight. Drug laws change, and the popularity of certain substances of abuse can wax and wane. New genetic tests and biomarkers may be discovered, new sensor technology could become available and neuroimaging techniques will be refined. The ABCD investigators have designed the study to accommodate such changes, so that new survey questions can be added and new technologies can be incorporated in future waves of data collection. "We have structures within ABCD that allow us to maintain enough continuity, so we can look at change in a systematic way and also augment the study using new methodologies," Brown says.

With its breadth, depth and flexible experimental design, the ABCD Study will serve as a model for other large-scale, long-term projects, investigators say. It also serves to showcase just how much psychology can do. "This is truly team science, led in large part by psychologists," Nixon says. "It speaks to the strength of our science, and the opportunity for psychologists to play a leading role in interdisciplinary research."

The Structure of Cognition in 9 and 10 Year-Old Children and Associations With Problem Behaviors:Findings From the ABCD Study's Baseline Neurocognitive Battery Thompson, W.K., et al. Developmental Cognitive Neuroscience , 2018

A Description of the ABCD Organizational Structure and Communication Framework Auchter, A.M., et al. Developmental Cognitive Neuroscience , 2018

Adolescent Neurocognitive Development and Impacts of Substance Use:Overview of the Adolescent Brain Cognitive Development (ABCD) Baseline Neurocognition Battery Luciana, M., et al. Developmental Cognitive Neuroscience , 2018

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MINI REVIEW article

Understanding the dynamics of the developing adolescent brain through team science.

$\r\nKiki Zanolie,*&#x;$

1 Department of Developmental and Educational Psychology, Institute of Psychology, Leiden University, Leiden, Netherlands
2 Leiden Institute for Brain and Cognition (LIBC), Leiden University, Leiden, Netherlands
3 Erasmus School of Social and Behavioral Sciences, Erasmus University Rotterdam, Rotterdam, Netherlands

One of the major goals for research on adolescent development is to identify the optimal conditions for adolescents to grow up in a complex social world and to understand individual differences in these trajectories. Based on influential theoretical and empirical work in this field, achieving this goal requires a detailed understanding of the social context in which neural and behavioral development takes place, along with longitudinal measurements at multiple levels (e.g., genetic, hormonal, neural, behavioral). In this perspectives article, we highlight the promising role of team science in achieving this goal. To illustrate our point, we describe meso (peer relations) and micro (social learning) approaches to understand social development in adolescence as crucial aspects of adolescent mental health. Finally, we provide an overview of how our team has extended our collaborations beyond scientific partners to multiple societal partners for the purpose of informing and including policymakers, education and health professionals, as well as adolescents themselves when conducting and communicating research.

Introduction

Adolescence is a developmental phase between the ages of 10 and 24 years ( Sawyer et al., 2018 ). Adolescence starts with puberty, setting off a cascade of hormonal changes signaling the start of biological maturation ( Dahl et al., 2018 ), and is characterized by major physical, psychological, and social changes ( Blakemore and Mills, 2014 ). Adolescents navigate an increasingly complex social network in which peer relations become more salient and are an important source for social learning (e.g., learning about, with, and from peers to adjust to changing social environments; Westhoff et al., 2020a ). Both peer relations and social learning have a great impact on mental well-being ( Nelson et al., 2005 , 2016 ; Vitaro et al., 2009 ). Moreover, adolescence is considered a period of heightened sensitivity to mental health problems, with approximately 75% of adult mental health problems first appearing during adolescence ( Kessler et al., 2007 ; Solmi et al., 2021 ). As biological, psychological, and social changes occur concurrently in adolescence, it is crucial to understand how these changes are intertwined and contribute to successful developmental outcomes, such as resilience and mental health, as well as to maladaptive outcomes, such as risky behaviors and psychopathology ( Davey et al., 2008 ; Crone and Dahl, 2012 ; Güroğlu, 2021 ). We further argue that understanding adolescence as a developmental phase with risks and opportunities requires incorporating a transactional perspective with measurements at multiple levels (genetic, hormonal, neural, behavioral) and across different social settings (e.g., school, parent relationships, peer relationships; see Figure 1 ). Considering the multitude of factors influencing development and the interlinked complexity of their corresponding measurement levels, we propose that team science is a fruitful approach to understanding the dynamics of adolescent development.

Figure 1 . Overview of the measures required to chart the complexity of developmental changes during adolescence and their impact. Note: This figure illustrates the richness of measures needed in studies that aim to capture the complexity of developmental changes during adolescence (purple). Findings from such studies will subsequently have a scientific and societal impact (green). Impact on the scientific field and on society are interlinked, as collaborating and communicating with societal stakeholders (e.g., policymakers, teachers, parents, and adolescents) also informs new research questions.

To understand individual differences in optimal conditions for growing up in an increasingly complex social world, we use a variety of neurobiological and behavioral methods. Current influential models of adolescent brain development describe an asynchronous development of the limbic “socio-affective system” and cortical “cognitive control system” during adolescence ( Steinberg, 2008 ; Somerville et al., 2010 ). These models emphasize that faster maturation of the limbic system compared to the slower maturation of the cortical system underlies heightened reward sensitivity and risk-taking tendencies, leading to risky and impulsive behaviors such as alcohol use ( Peters et al., 2017 ). Recent accounts of adolescent development also include the impact of individual differences in hormonal, genetic, behavioral, and neural influences which are intertwined in a social context ( Crone and Dahl, 2012 ; Pfeifer and Allen, 2021 ). Specifically, adolescence is seen as a time for heightened goal flexibility, where social goals can influence pathways for development. Hence, the asynchronous development between the limbic and cortical system, together with increasingly complex and influential social experiences, such as peer relations and social learning, makes adolescence a sensitive window for socio-affective development which can lead to multiple pathways, such as risky behaviors and mental illness, or prosocial behavior and mental resilience ( Crone and Dahl, 2012 ; Güroğlu, 2021 ; see Figure 1 ).

In this article, we highlight the unique position of our highly collaborative multidisciplinary research program and focus on its contributions to the field. We provide an overview of our research focusing on: (1) meso level peer relations; and (2) micro level social learning and next describe their combined influence on mental health. We propose that these two themes are crucial in charting the complexity of the dynamically interlinked biological, psychological, and social changes in adolescence. We provide examples of our research designs with controlled experimental settings at the micro-level and assessments of real-life social relationships at the meso level (see Figure 1 ). Finally, we demonstrate how collaborations can be extended to multiple societal partners to inform and include policy makers, education and health professionals, and adolescents themselves when conducting and communicating research. We conclude that understanding the complex dynamics of adolescent development requires rich measurements and we highlight the promising role of team science in achieving this goal.

Peer Relations

Adolescence is characterized by a significant shift in focus from parents toward peers, also referred to as social reorientation ( Nelson et al., 2005 ). Compared to children, adolescents spend increasingly more time without adult supervision and in the company of their peers, where fitting in the peer group and peers’ opinions become vital for adolescents’ self-identity development ( Laursen and Veenstra, 2021 ). Social goals, such as acceptance by the peer group and forming and maintaining friendships, are particularly important in the school context, as they are consistently linked with markers of positive social adjustment and academic achievement ( Dawes, 2017 ). Recently, evidence from neuroimaging studies corroborate the significance of the peer context for adolescents by finding that adolescents show heightened neural responses during social decision-making in brain regions related to reward and motivation, such as the ventral striatum, and in social cognition, such as dorsomedial prefrontal cortex (for reviews see Van Hoorn et al., 2019 ; Andrews et al., 2021 ). For example, in early- and mid-adolescence, mere peer presence, when being observed by an unfamiliar peer, results in heightened neural activation in the medial prefrontal cortex (mPFC; Somerville et al., 2013 ), and when being observed by a friend, adolescents show increased risk-taking behavior, with heightened activation of the ventral striatum ( Chein et al., 2011 ). In an Event-Related Potential (ERP) study, we have shown that manipulation of participants’ social rank (high vs. low rank) modulated neural responses during social exchanges in mid-adolescents but not in children or adults, signifying that even transient social interactions are particularly salient for mid-adolescents ( Zanolie and Crone, 2021 ). In another study, compared to being alone, the presence of a group of spectators (consisting of adolescent confederate actors) led to increased prosocial behavior which was accompanied by enhanced activation in social brain areas such as mPFC, temporal parietal junction (TPJ), precuneus and superior temporal sulcus (STS; Van Hoorn et al., 2016 ). Taken together, these studies of peer presence illustrate the importance of capturing the peer context when studying adolescents’ social behavior ( Figure 1 , micro level).

Neuroimaging studies aiming to capture real-life peer context ( Figure 1 , meso level), however, face the challenge of bringing peer relationships into the highly controlled experimental laboratory setting, such as in the MRI scanner (see Güroğlu and Veenstra, 2021 for a more extensive review of this research line). In tackling this challenge, sociometric assessments of the peer network provide a useful tool to classify an individual’s peer status within a real-life peer group (see Box 1 ). Combinations of sociometric assessments with neuroimaging and/or economic exchange paradigms assessing social decision-making (see Box 2 ) led to insights into how social interactions and their neural underpinnings may depend on peer context ( Güroğlu et al., 2014 ). For example, we found in adults that interactions with familiar peers relate to heightened activation of brain regions of affect and reward (including the ventral striatum and amygdala) and social cognition (including the mPFC, TPJ, STS, and precuneus; Güroğlu et al., 2008 ). Recently, we showed that the developmental trajectories of ventral striatum responses to rewards are modulated by friendship stability across a 5-year period ( Schreuders et al., 2018 ) and that ventral striatum responses to winning money are also (negatively) related to acceptance by the peer group ( Meuwese et al., 2018 ). We also showed that in young adults ( Schreuders et al., 2018 ) and mid-adolescents ( Schreuders et al., 2019 ), prosocial decisions toward friends compared to disliked or unfamiliar peers, are related to increased activation of the putamen, part of the reward circuitry, and the posterior temporoparietal regions that are involved in social-cognitive processes. Moreover, neural responses to social rejection depend on the excluder’s peer status relative to the adolescent’s own status ( De Water et al., 2017 ). Our longitudinal studies further showed that the history of peer experiences across childhood modulates neural responses to social exclusion and during social decision-making in adolescence ( Will and Güroğlu, 2016 ; Will et al., 2016 , 2018 ; Asscheman et al., 2019 ).

Box 1. Using sociometric assessments to study social experiences.

Sociometric assessments based on nominations of classmates on various criteria (e.g., “who do you like?”, “who do you dislike?”, “who are your friends?”) are most valuable for assessing social experiences, and more specifically for assessing peer relationships, in an efficient manner. Crucially, these social assessments require access to a closed network (e.g., classmates, sports team, an orchestra) where the nominations can be made. These nominations can be used to assess social experiences at two levels. At the dyadic level, they reveal reciprocal relationships, such as mutual friendships between two people who nominate each other as a friend (see, e.g., Güroğlu et al., 2008 ; Schreuders et al., 2019 ). At the group level, they reveal information on the status of the individual within the peer group, such as accepted or rejected status based on the total number of received nominations from like and dislike nominations ( Will et al., 2016 ; Will and Güroğlu, 2016 ). Finally, by applying graph theory, these nominations can be used to calculate social network characteristics that can be used to characterize individuals’ positions in the network, such as centrality, as well as identifying group level characteristics, such as social cohesion ( Van den Bos et al., 2018 ). An increasing number of studies combine assessments of peer relations with neuroscientific designs to investigate how peer relations modulate brain activity (see for review Güroğlu and Veenstra, 2021 ).

Box 2. Using economic games to study social interactions.

Economic games create social contexts that reveal fundamental aspects about the participant’s social preferences in ways that are quantifiable. They have proven highly efficient in assessing various forms of (pro) social behavior both in adults and in development ( Camerer, 2011 ; Will and Güroğlu, 2016 ). These paradigms are based on an economic exchange between at least two players where the participant’s decisions have actual consequences for their own and their interaction partner’s payoff. The simplest example is the Dictator Game in which the first player is given valued goods (e.g., money, toys, candies) and can share a portion of those goods with a second player. While game theoretical models assume that humans are rational players who aim to maximize their own profit, findings consistently show that people typically share some portion of the goods, thereby revealing other-regarding preferences. In the Ultimatum game , the first player (proposer) is a variant where the second player can either accept or reject the share given by the first player. If accepted, the goods are divided as proposed by the first player. If rejected, both players receive nothing. The reward maximizing strategy is to accept any offer greater than zero, but again consistent findings show that offers viewed as unfair are rejected ( Fehr and Schmidt, 1999 ). Offers made by the first player are typically higher in the Ultimatum Game than Dictator Game, revealing strategic considerations to reduce the probability of rejection. Another variant is the Trust Game , in which the first player (investor) can again share a portion of goods with the second player (trustee). The portion received by the trustee is multiplied by the experimenters. The trustee then chooses to either share the profit with the investor (reciprocation; both profit from the exchange) or keep all the profit (betrayal; only the trustee profits, the investor loses the entrusted amount; Berg et al., 1995 ). These paradigms can be presented in a repeated fashion, such that participants play multiple rounds of these games with the same partner(s). Feedback received during these repeated interactions facilitates learning about the social preferences of other individuals or groups. Economic exchange paradigms are simple enough to administer to a wide age range (from 3 years old to adults) and enable studying developmental patterns in social behavior ( Güroğlu et al., 2009 ; Meuwese et al., 2015 ; Zanolie et al., 2015 ; Ma et al., 2017 ). Moreover, their structured nature makes them further suitable for neuroimaging research.

Taken together, increasing evidence shows both current and long-term patterns of social experiences with peers modulate adolescent social behavior and their underlying neural processes ( Güroğlu, 2022 ). In order to understand the developing brain in a social context, future studies need to incorporate measures of social networks with assessments of brain function and structure ( Lamblin et al., 2017 ; Baek et al., 2021 ). Additionally, the complexity of social dynamics has in recent years only been amplified through the addition of the online social layer where young people can have meaningful connections. Future studies aiming to understand the dynamics of adolescent development need to include assessments of both offline and online connections.

Social Learning

Peer relations interact with individual and social learning. Social learning encompasses learning about, with, and from others. In the peer context, it involves learning about the characteristics and preferences of a peer or a peer group, such as their trustworthiness or cooperativeness ( Nelson et al., 2005 ; Blakemore and Mills, 2014 ; Sawyer et al., 2018 ). Adaptive social behavior requires adolescents to learn about these characteristics and adjust their own behavior accordingly, such as learning when to be prosocial and towards whom ( Steinberg and Morris, 2001 ; Van den Bos et al., 2011 ; Lockwood et al., 2016 ; Crone and Fuligni, 2020 ). These social learning processes are crucial for fostering healthy relationships with peers, which are predictive of adolescents’ long-term well-being ( Paus et al., 2008 ; Crone and Dahl, 2012 ; Dahl et al., 2018 ; Sawyer et al., 2018 ).

Social learning is often studied with repeated behavioral economic paradigms, where participants play multiple rounds of an economic game with the same partner or multiple partners from one experimentally selected group (see Box 2 ). Peer characteristics or peer evaluations are typically experimentally manipulated, allowing participants to learn through positive and negative feedback ( Ma et al., 2020 ; Westhoff et al., 2020b ; Zanolie and Crone, 2021 ). Reinforcement learning models can then be used to characterize individual differences in learning strategies, learning speed, and the underlying cognitive processes that cause age differences in learning about others ( Sutton and Barto, 2018 ; Nussenbaum and Hartley, 2019 ; Wilson and Collins, 2019 ). For example, we used an information sampling paradigm in which participants were able to sample information about a peer’s history of trustworthiness before deciding to trust or not trust them ( Ma et al., 2020 ). We found that behavioral adaptation to the gathered evidence improved with age, especially from early to mid-adolescence. In other studies, we manipulated the cooperativeness of groups ( Westhoff et al., 2020b ) and used a probabilistic learning task in which participants could sometimes earn rewards for themselves and sometimes for others ( Westhoff et al., 2021 ). We found that probabilistic learning to benefit others showed age-related improvement across adolescence and was associated with ventromedial prefrontal cortex responses to unexpected outcomes. Learning for the self was stable across adolescence and associated with ventral striatal responses to unexpected outcomes. Together, these findings suggest that adolescents show rapid improvements in behavioral adjustments to the social environment, especially from early to mid-adolescence. These findings are consistent with the idea that learning about the consequences of actions in an interpersonal context is especially salient for adolescents and furthermore highlight early to mid-adolescence as a sensitive period for learning about others ( Blakemore and Mills, 2014 ; Nelson et al., 2016 ; Sawyer et al., 2018 ; Andrews et al., 2021 ).

Considering that learning at school takes place in the peer context (i.e., in classrooms and group assignments), learning about, with, and from peers are also crucial research lines to identify the optimal conditions of learning at school. In ongoing studies, we focus on determining which individuals work well together by combining reinforcement learning or feedback processing paradigms with sociometric assessments. Such studies form the first steps of identifying optimal conditions for learning in the context of peers by informing how peer relationships in classrooms and differences in learning strategies between collaborating students may influence (social) learning.

Social Experiences and Mental Health

It is well-established that social experiences influence mental health and well-being. For example, close friendships during adolescence are a protective factor against mental health problems across adolescence and later in life ( Van Harmelen et al., 2017 , 2021 ). However, being rejected by peers is associated with self-harm ( Esposito et al., 2019 ) and depressive symptoms ( Platt et al., 2013 ). Also, epidemiological studies have shown a peak in the emergence of mental health problems across adolescence ( Dalsgaard et al., 2020 ). Showing symptoms of psychopathology in childhood or adolescence are found to be a key predictor of mental health problems and other adverse outcomes later in life ( Zisook et al., 2007 ; Caspi et al., 2020 ). These findings indicate that there are developmental processes enhancing or bringing about vulnerabilities to develop mental health problems. Theoretical models propose a complex interplay between brain development, hormonal changes, and social development in interaction with environmental factors that may explain the emergence and maintenance of mental health problems across adolescence ( Pfeifer and Allen, 2021 ). So far, only a few studies have directly linked the relationship between social context, brain development, and mental health outcomes. One study showed that greater subgenual anterior cingulate activity (sgACC) during a social exclusion game was associated with an increase in parent-reported depressive symptoms 1 year later ( Masten et al., 2013 ). Social interactions with friends have also been related to activation of the sgACC and the ventral striatum. These brain regions are associated with the reward circuitry, speculatively providing indirect evidence linking positive peer interactions with mental health ( Güroğlu et al., 2008 ; Schreuders et al., 2021 ). Research is needed to elucidate the complex interplay between brain development, social context, and mental health ( Davey et al., 2008 ; Pfeifer and Allen, 2021 ). To better understand mental health and the transition from mental health to mental illness, our ongoing studies aim to contextualize individual differences in relation to social development and genetic factors (e.g., by using twin designs; Crone et al., 2020 ), and their association with mental health outcomes in a developmental context ( Ferschmann et al., 2021 ).

Crucial in contextualizing individual differences in etiology and maintenance of mental health problems is investigating neurobiological mechanisms of psychopathology from a longitudinal perspective. Specifically, non-linear developmental changes in cortical and subcortical structures may explain why cross-sectional developmental neuroimaging studies may find mixed results depending on the age range of the participants ( Wierenga et al., 2014a , b ; Mills et al., 2021 ). With longitudinal designs, we, for example, found that heightened scores on externalizing symptoms were associated with smaller developmental changes in brain structure ( Vijayakumar et al., 2014 ; Oostermeijer et al., 2016 ; Ambrosino et al., 2017 ; Bos et al., 2018a ; but see Ducharme et al., 2011 ). Likewise, for internalizing symptoms, such as depression, longitudinal studies revealed associations with aberrant brain development ( Whittle et al., 2014 ; Luby et al., 2016 ; Bos et al., 2018b ). Together, these studies highlight the importance of longitudinal studies for understanding mental health problems and their development.

Integrating Science and Society

Integrating scientific knowledge about adolescent development into society can be achieved in multiple ways. Popular science books such as “The Adolescent Brain” (Het Puberende Brein, Crone, 2018 ) and “Inventing ourselves” ( Blakemore, 2018 ) help to reach a wider audience, including policymakers (“science for policy”). In our team, we aim to reach adolescents via targeted websites designed for youth 1 and scientific articles for children ( Westhoff et al., 2020a ). We also inform youth professionals by designing educational material for elementary and high schools about the developing brain (e.g., http://www.breinkennisleiden.nl/onderwijs ), and through our contributions to science-translation reports such as those on differences between boys and girls in learning (report Dutch Educational Council), and UNESCO’s International Science and Evidence-based Education Assessment on the social-emotional learning ( Gotlieb et al., 2022 ).

It is particularly important to include adolescents themselves when forming policies and designing interventions in order to make their participation efforts optimal and to contribute to their sense of autonomy which benefits their mental health ( Fuligni, 2019 ). Especially during mid-adolescence interventions typically tend to fail when they do not align with adolescents’ desired feeling to be respected and accorded status ( Yeager et al., 2018 ). Peer-led interventions to generate positive behavioral changes can be powerful when the complexity of peer relations and social networks are taken into account as well as social learning (e.g., imitation, norms, and positive reinforcement; Veenstra and Laninga-Wijnen, 2022 ). The next step toward improving these efforts is setting up projects in which adolescents are involved in co-designing and co-creating research ( Whitmore and Mills, 2021 ). Not only does this enrich the context in which scientific findings can be launched and interpreted, but crucially informs researchers in important ways, helping them to improve their research designs and paradigms. In our current projects, adolescent volunteers are also involved in disseminating knowledge to their peers, thereby increasing the likelihood that the information is relevant and interesting for the target audience (e.g., http://www.instagram.com/breinboost ). Finally, in several innovative projects we involve societal stakeholders (e.g., teachers, adolescents, policymakers) in the research consortium from the start of the project and create research and knowledge dissemination projects together throughout the project (see e.g., http://www.neurolab.nl/startimpuls , Vandenbroucke et al., 2021 ).

Conclusions

In this perspectives article, we provided an overview of ways of characterizing developmental changes during adolescence and their relation to the developing brain. We highlighted the importance of capturing social contextual factors, as social experiences play a crucial role in shaping many developmental trajectories. We further emphasized the importance of longitudinal approaches in developmental studies in identifying predictors of mental health. The social context is increasingly important given that young people today grow up in a highly socially complex environment. The recent COVID-19 pandemic showed how strong the effects of the changing social context are on adolescents’ mental health has been ( Orben et al., 2020 ; Van de Groep et al., 2020 ; Asscheman et al., 2021 ; Breaux et al., 2021 ; Green et al., 2021 ; Klootwijk et al., 2021 ). An increased understanding of the effect of social contextual factors on the development and neurobiological mechanisms underlying mental health will inform high stake policy questions, and find their way to daily practice. Throughout this overview, we illustrated the value of collaborative team science to understand adolescent development and the value of integration of science and society to be able to inform policy and practice.

Author Contributions

All authors co-designed the aims and wrote the article. KZ and IM designed the article aims, outline, figure, and integrated individual author contributions. All authors contributed to the article and approved the submitted version.

KZ was supported by the AXA Research Fund. IM was supported by the National Science Foundation. ES and MB were supported by the Research Council of Norway (RCN; 288083). ES and AV were supported by the The Netherlands Organization for Scientific Research (NWO; NWA 400.17.602 Startimpulse grant). JH was supported by NWO [406-11-019 ResearchTalent Grant]. AD was supported by NWO [464-15-176 Open Research Area (ORA) grant] and the Social Resilience and Security Program (Leiden University). LW was supported by NWO (024.001.003 Gravitation grant). EC was supported by the European Research Council (ERC; StG-263234 Starting grant and CoG-681632 Consolidator grant) and NWO (453-14-001 Vici grant). BG was supported by NWO (VENI 451-10-021 Veni grant).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: adolescence, brain development, social development, mental wellbeing, team science

Citation: Zanolie K, Ma I, Bos MGN, Schreuders E, Vandenbroucke ARE, van Hoorn J, van Duijvenvoorde ACK, Wierenga L, Crone EA and Güroğlu B (2022) Understanding the Dynamics of the Developing Adolescent Brain Through Team Science. Front. Integr. Neurosci. 16:827097. doi: 10.3389/fnint.2022.827097

Received: 01 December 2021; Accepted: 31 January 2022; Published: 22 February 2022.

Reviewed by:

Copyright © 2022 Zanolie, Ma, Bos, Schreuders, Vandenbroucke, van Hoorn, van Duijvenvoorde, Wierenga, Crone and Güroğlu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Kiki Zanolie, [email protected]

† These authors have contributed equally to this work and share first authorship

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Child and Adolescent Development

First Online: 28 January 2017

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research paper on adolescent development

Rosalyn H. Shute 3 &
John D. Hogan 4

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For school psychologists, understanding how children and adolescents develop and learn forms a backdrop to their everyday work, but the many new ‘facts’ shown by empirical studies can be difficult to absorb; nor do they make sense unless brought together within theoretical frameworks that help to guide practice. In this chapter, we explore the idea that child and adolescent development is a moveable feast, across both time and place. This is aimed at providing a helpful perspective for considering the many texts and papers that do focus on ‘facts’. We outline how our understanding of children’s development has evolved as various schools of thought have emerged. While many of the traditional theories continue to provide useful educational, remedial and therapeutic frameworks, there is also a need to take a more critical approach that supports multiple interpretations of human activity and development. With this in mind, we re-visit the idea of norms and milestones, consider the importance of context, reflect on some implications of psychology’s current biological zeitgeist and note a growing movement promoting the idea that we should be listening more seriously to children’s own voices.

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Adolescent Development and the Biology of Puberty: Summary of a Workshop on New Research (1999)

Chapter: new research on adolescent development and the biology of puberty, adolescent development and the biology of puberty.

Adolescence is one of the most fascinating and complex transitions in the life span. Its breathtaking pace of growth and change is second only to that of infancy. Biological processes drive many aspects of this growth and development, with the onset of puberty marking the passage from childhood to adolescence. Puberty is a transitional period between childhood and adulthood, during which a growth spurt occurs, secondary sexual characteristics appear, fertility is achieved, and profound psychological changes take place.

Although the sequence of pubertal changes is relatively predictable, their timing is extremely variable. The normal range of onset is ages 8 to 14 in females and ages 9 to 15 in males, with girls generally experiencing physiological growth characteristic of the onset of puberty two years before boys. Pubertal maturation is controlled largely by complex interactions among the brain, the pituitary gland, and the gonads, which in turn interact with environment (i.e., the social, cultural, and ambient environment). A relatively new area of research related to puberty is that of brain development. Evidence now suggests that brain growth continues into adolescence, including the proliferation of the support cells, which nourish the neurons, and myelination, which permits faster neural processing. These changes in the brain are likely to stimulate cognitive growth and development, including the capacity for abstract reasoning.

Although the biology of physical growth and maturation during pu-

berty is generally understood, available data on the biochemical and physiological mediators of human behavior are extremely primitive, and their clinical applicability remains obscure. Despite the limitations of available data, a substantial body of evidence suggests that variations in the age of onset of puberty may have developmental and behavioral consequences during adolescence. Mounting evidence also suggests that gonadal hormones, gonadotropins, and adrenal hormones influence and are affected by social interactions among groups of experimental animals, and they may also play an important role in regulating human social behavior. Interesting and potentially informative parallels exist between the maturational process in human beings and in other animals, especially those having well-documented social structures.

Research conducted with both humans and nonhuman primates suggests that adolescence is a time for carrying out crucial developmental tasks: becoming physically and sexually mature; acquiring skills needed to carry out adult roles; gaining increased autonomy from parents; and realigning social ties with members of both the same and the opposite gender. Studies of such commonalities underscore the critical importance of this part of the life course in establishing social skills. For many social species, such skills are further developed through peer-oriented interactions that are distinct from both earlier child-adult patterns and later adult pairings.

Adolescence is a time of tremendous growth and potential, but it is also a time of considerable risk. Most people would argue that being an adolescent today is a different experience from what it was even a few decades ago. Both the perceptions of this change and the change itself attest to the powerful influence of social contexts on adolescent development. Many of the 34 million adolescents in the United States are confronting pressures to use alcohol, cigarettes, or other drugs and to initiate sexual relationships at earlier ages, putting themselves at high risk for intentional and unintentional injuries, unintended pregnancies, and infection from sexually transmitted diseases (STDs), including the human immunodeficiency virus (HIV). Many experience a wide range of painful and debilitating mental health problems.

One of the important insights to emerge from scientific inquiry into adolescence in the past decade is the profound influence of settings on adolescents' behavior and development. Until recently, research conducted to understand adolescent behavior, particularly risk-related behaviors, focused on the individual characteristics of teenagers and their families. In 1993, the National Research Council conducted a study that took a critical

look at how families, communities, and other institutions are serving the needs of youth in the United States. This study concluded that adolescents depend not only on their families, but also on the neighborhoods in which they live, the schools that they attend, the health care system, and the workplace from which they learn a wide range of important skills. If sufficiently enriched, all of these settings and social institutions in concert can help teenagers successfully make the transition from childhood to adulthood.

Family income is perhaps the single most important factor in determining the settings in which adolescents spend their lives. Housing, neighborhoods, schools, and the social opportunities that are linked to them are largely controlled by income; a family's income and employment status decide its access to health care services and strongly influence the quality of those services (National Research Council, 1993). Opportunities for advanced education and training and entry into the workforce are also closely linked to family income. Moreover, income is a powerful influence in shaping what is arguably the most important setting, the family. At this point in time, the evidence is clear—persistent poverty exacts a significant price on adolescents' health, development, educational attainment, and socioeconomic potential, even though the causal relationships are not well understood in all cases.

Not only is current research attempting to more fully characterize the physiological mechanisms responsible for initiating and regulating neuroendocrine maturation and somatic growth, but it is also attempting to characterize these environmental and contextual factors that may interact with biological ones to enhance or impede maturation. This research is attempting to address questions that could help to inform the development of policies and the delivery of services for youth. Such questions include: What is the pubertal experience like for teenagers today, and how does it differ from that in the past, both in the United States and in other cultures? How do pubertal experiences, in some circumstances and for some subgroups, trigger maladaptive responses? What role do pubertal processes play in cognitive change? How does puberty, in conjunction with other events that occur during early adolescence, influence the emergence of developmental psychopathology?

CHANGES IN THE STUDY OF ADOLESCENT DEVELOPMENT

Over the last two decades, the research base in the field of adolescent development has undergone a growth spurt. Knowledge has expanded sig-

nificantly. New studies have allowed more complex views of the multiple dimensions of adolescence, fresh insights into the process and timing of puberty, and new perspectives on the behaviors associated with the second decade of life. At the same time, the field's underlying theoretical assumptions have changed and matured.

Researchers of human development have consistently observed that the second decade of life is a time of dramatic change: a period of rapid physical growth, endocrine (hormone) changes, cognitive development and increasing analytic capability; emotional growth, a time of self-exploration and increasing independence, and active participation in a more complex social universe. For much of this century, scientists and scholars studying adolescence tended to assume that the changes associated with adolescence were almost entirely dictated by biological influences. It has been viewed as a time of storm and stress, best contained or passed through as quickly as possible. Adolescence , a 1904 book by G. Stanley Hall, typified this standpoint. It was Hall who popularized the notion that adolescence is inevitably a time of psychological and emotional turmoil (Hall, 1904). Half a century later, psychoanalytic writers including Anna Freud accepted and augmented Hall's emphasis on turmoil (Petersen, 1988). Even today, "raging hormones" continue to be a popular explanation for the lability, aggression, and sexual activity associated with adolescence (Litt, 1995). Intense conflict between adolescents and their parents is often considered an unavoidable consequence of adolescence (Petersen, 1988). However, this assumption is not supported by scientific evidence. The assumption that turmoil and conflict are inevitable consequences of the teenage years may even have prevented some adolescents from receiving the support and services they needed.

Research is now creating a more realistic view of adolescence. Adolescence continues to be seen as a period of time encompassing difficult developmental challenges, but there is wider recognition that biology is only one factor that affects young people's development, adjustment, and behavior. In fact, there is mounting evidence that parents, members of the community, service providers, and social institutions can both promote healthy development among adolescents and intervene effectively when problems arise.

The study of adolescence is now becoming an increasingly sophisticated science. Thanks to powerful new research tools and other scientific and technological advances, today's theories of adolescent development are more likely to be supported by scientific evidence than in the past. Indeed,

there has been sufficient research to allow a reassessment of the nature of adolescent development. At the same time, there is greater recognition that neither puberty nor adolescence can be understood without considering the social and cultural contexts in which young people grow and develop, including the familial and societal values, social and economic conditions, and institutions that they experience. This research has contributed the following to our understanding of adolescence:

The adolescent years need not be troubled years. There is now greater recognition that young people can move through the adolescent years without experiencing great trauma or getting into serious trouble; most young people do. Although adolescence can certainly be a challenging span of years, individuals negotiate it with varying degrees of difficulty, just as they do other periods of life. Moreover, when problems do arise during adolescence they should not be considered as "normal"—i.e., that the adolescent will grow out of it—nor should they be ignored (Petersen, 1988).

Only a segment of the adolescent population is at high risk for experiencing serious problems. Over the past 50 years, studies conducted in North America and Europe have documented that only about a quarter of the adolescent population is at high risk for, or more vulnerable to, a wide range of psychosocial problems (Carnegie Corporation of New York, 1995). These adolescents are not believed to be at increased risk because of biological or hormonal changes associated with puberty, but rather from a complex interaction among biological, environmental, and social factors. Indeed, as discussed by Anne Petersen, there is mounting evidence that most biological changes interact with a wide range of contextual, psychological, social, and environmental factors that affect behavior (Buchanan et al., 1992; Susman, 1997, see also Brooks-Gunn et al., 1994). Researchers are also concluding that behaviors associated with adolescence, including some high risk behaviors, are influenced by the social milieu (Brooks-Gunn and Reiter, 1990). Studies show that, in contrast to children and adults, the most common causes of mortality among adolescents are associated with social, environmental, and behavioral factors rather than genetic, congenital, or biological diseases. Indeed, many of today's adolescents are using alcohol and other drugs, engaging in unprotected sexual intercourse, and are both victims and perpetrators of violence, which puts them at increased risk for a wide range of developmental and health-related problems, including morbidity and mortality. It is important to note that the leading

causes of morbidity and mortality among adolescents are entirely preventable. Although relatively small, a significant number of adolescents also experience morbidity and mortality associated with genetic and congenital disorders (such as cystic fibrosis, muscular dystrophy, cerebral palsy), cancer, and infectious diseases that affect their development, behavior, and well-being.

Adolescent behavior is influenced by complex interactions between the biological and social contexts. In the past, researchers tended to conduct research designed to examine the impact of hormones on adolescent behavior. While this work continues, there is now an appreciation for the complex reciprocal relationship and interaction between biological and social environments, and the interaction between these environments and adolescent behavior (Graber et al., 1997).

Current understanding of adolescent development remains limited. Although the study of adolescence is becoming more sophisticated in nature, researchers also recognize that the current knowledge base on adolescent development and behavior is quite limited. The research conducted to date has predominately been descriptive in nature, relied on cross-sectional data, and been unidimensional in focus. Indeed, few research studies have successfully considered the multiple factors that collectively influence adolescent development. As discussed by Iris Litt, there is now a growing appreciation that new research is needed, including research that employs longitudinal designs; characterizes developmental changes associated with the onset of puberty well before the age of 8; and seeks to characterize growth and development across the life span—i.e., from infancy to adolescence, young adulthood, adulthood, and the senior years. Studying these developmental stages in isolation from one another provides only a partial and incomplete picture.

Researchers from diverse fields, including the biological, behavioral, and social sciences, have developed new techniques to study adolescent development. Use of more rigorous research methods has improved the reliability and validity of the measurement techniques used, and consequently the ability to document the multifaceted dimensions of growth and maturation during adolescence. For example, the development of radioimmunoassay methodology in the late 1960s, and the considerable re-

finement of that process over the decades, have made it possible to study the hormones that control reproductive maturation. The development of neuroimaging technology in the 1970s created exciting new opportunities for studying brain development; these techniques include more sensitive, easy-to-use hormone assay technology and new brain imaging technologies, allowing insight into brain development and function. Moreover, longitudinal studies are increasingly being designed to characterize the interaction among genetic, biological, familial, environmental, social, and behavioral factors (both risk and protective in nature) among children and adolescents. For example, a valuable new source of data that has the potential to significantly advance the knowledge base of physiological and behavioral development among adolescents is the National Longitudinal Study of Adolescent Health (called Add Health). From the collection of longitudinal data, it will be possible to examine how the timing and tempo of puberty influences social and cognitive development among teenagers. This dataset will also permit analyses to examine how family-, school-and individual-level risk and protective factors are associated with adolescent health and morbidity (e.g., emotional health, violence, substance use, sexuality).

An Increasing Number of Disciplines are Beginning to Conduct Research on Adolescent Development. Understanding adolescent development requires answers to a number of difficult questions: how do adolescents develop physically, how do their relationships with parents and friends change, how are young people as a group viewed and treated by society, how does adolescence in our society differ from adolescence in other cultures, and how has adolescence and adolescent development changed over the past few decades. A complete understanding of adolescence, and the potential to answer these questions depends on an integrated approach, and involvement of a wide range of disciplines, including but not limited to endocrinology, psychology, sociology, psychiatry, genetics, anthropology, neuroscience, history, and economics. While each discipline offers its own view point regarding adolescence and adolescent development, the field will not be able to successfully answer these questions without integrating the contributions of different disciplines into a coherent and comprehensive viewpoint. Fortunately, studies of puberty are increasingly drawing on and therefore benefiting from the knowledge base of these diverse fields.

KEY FINDINGS OF RECENT STUDIES

The workshop included a series of panel discussions that focused on adolescence as experienced by both human and nonhuman primates, including neuroendocrine physiology at puberty, the interplay between pubertal development and behavior, and implications for research, policy, and practice. Here we briefly summarize key findings from some of the studies that were discussed at the workshop (also see Crockett and Petersen, 1993; Grumbach and Styne, 1998; Pusey, 1990; Suomi, 1997;1991). As previously noted, this summary is not intended to provide a comprehensive review of the new research in this field; rather, it highlights important new findings that emerged during the workshop presentations and discussions.

In the United States, the Onset of Puberty Occurs Earlier than was Previously Recognized. Over the last 150 years, girls' sexual maturation, as measured by the age of menarche, is occurring at younger ages in all developed countries by at least two to three years. In the mid-nineteenth century, the average age at which girls reached menarche was approximately 15. The trend toward earlier menarche is now being documented in developing countries as well. Improved diets and more effective public health measures are the reasons often cited for this trend (Garn, 1992).

Research conducted during the 1990s greatly enhanced researchers' understanding of the age of puberty among girls. For example, although the onset of menarche is still considered to be a significant indicator of the tempo of maturation, researchers now view menarche as a late event in the pubertal process. At the workshop, Frank Biro presented data from the Growth and Health Study funded by the National Heart, Lung, and Blood Institute. This longitudinal study enrolled a cohort of over 2,000 girls, ages 9 to 10 years in 1987–1988; approximately half of the sample was white and half was black; the sample was recruited from clinics at three clinical centers located in Richmond, California, Cincinnati, Ohio, and metropolitan Washington, D.C. According to the study design, girls' maturation stage and body mass index were assessed annually; data for other variables, such as household income, nutrition, physical activity, cardiovascular risk factors, self-esteem and self-perception, and other psychosocial measures, were collected biennially (Brown et al., 1998). Almost half of the participants had begun puberty before the onset of the study. According to Biro, indicators of pubertal growth have been observed as early as age 7. These findings suggest that as children experience puberty and other develop-

mental changes at earlier ages, there may be the need to consider how to design and deliver age-appropriate interventions during the middle childhood and preteen years, to help them avoid harmful or risky behaviors and develop a health-promoting lifestyle.

There is Significant Variation Among Individuals in the Timing of Puberty. There is variation in both the onset and the tempo of puberty. Research shows that the timing of puberty can affect other aspects of development, especially for girls. Jeanne Brooks-Gunn discussed the findings from a recent study, which recruited a community sample of nearly 2,000 high school students from urban and rural areas of western Oregon. The study found that early-maturing girls and late-maturing boys showed more evidence of adjustment problems than other adolescents (Graber et al., 1997).

Multiple Factors Affect the Age of Puberty. Research now suggests that the timing of puberty can be affected by a wide range of factors, including genetic and biological influences, stress and stressful life events, socioeconomic status, environmental toxins, nutrition and diet, exercise, amount of fat and body weight, and the presence of a chronic illness. Research also shows that the family, the peer group, the neighborhood, the school, the workplace, and the broader society have all been shown to influence adolescent developmental outcomes, although it is less clear if these factors influence pubertal development. With respect to school settings, research suggests that the transition from small elementary schools to larger, more anonymous middle schools can be a stressful event in the lives of children (National Research Council, 1993). Some of the stressful influences or events factors mentioned above have been correlated with pubertal timing, but a causal relationship cannot be assumed.

Stress does not Trigger Puberty, But it does Modulate the Timing of Puberty. In her remarks at the workshop, Elizabeth Susman took note of research correlating stress and the timing of puberty. 1 A review of this literature shows that researchers observe different effects of stress at differ-

For the purposes of this discussion, stress is defined as a physical, mental, or emotional strain or tension. Stress is a normal part of everyone's life and need not be either good or bad; reactions to stress however, can vary considerably, with some reactions being unpleasant and/or undesirable.

ent stages of puberty (Susman et al., 1989). For example, stress appears to delay maturation for young adolescents but to precipitate puberty for older adolescents. According to Susman, it makes sense that stress would delay maturation because stress hormones tend to suppress reproductive hormones (Susman, 1997; Graber and Warren, 1992). She added that her research has not yet resolved the question of directionality: Do environmental stressors affect the reproductive hormones, or does the rate of maturation affect the level of circulating stress hormones? Other participants at the meeting noted that social factors influence this process as well. For example, family conflict appears to be associated with earlier menarche in girls (Graber et al., 1995).

There is some Evidence that, on Average, Girls experience more distress during adolescence than boys. Some researchers have speculated that, for girls, the transition during puberty brings about greater vulnerability to other environmental stressors (Ge et al., 1995). In particular, a growing literature suggests that the early onset of puberty can have an adverse effect on girls' development (Caspi et al., 1993; Ge et al., 1996). It can affect their physical development (they tend to be shorter and heavier), their behavior (they have higher rates of conduct disorders); and emotional development (they tend to have lower self-esteem and higher rates of depression, eating disorders, and suicide). The youngest, most mature children are those at greatest risk for delinquency.

Early-maturing boys also appear to have higher rates of delinquency (Graber et al., 1997; Rutter and Smith, 1995). Generally speaking, however, boys who mature early fare better than late bloomers. Because they are taller and more muscular than their age-mates, they may be more confident, more popular, and more successful both in the classroom and on the playing field. In contrast, late-maturing boys have a poorer self-image, poorer school performance, and lower educational aspirations and expectations (Dorn et al., 1988; Litt, 1995).

Girls from Ethnic Minority Groups may be Reaching Puberty Earlier than White Girls. Data presented at the workshop show that for black girls, the average age of menarche is 12.1 years, compared with 12.9 years for white girls (see Brown et al., 1998). Black girls also begin pubertal development earlier than their white peers do—by 15 months. Interestingly, even though they reach menarche earlier, tempo of the pubertal development is slower. Researchers have also found that self-esteem does not fol-

low the same developmental pattern in black and white girls. It appears that black girls' higher self-esteem may be rooted in cultural differences in attitudes toward physical appearance and obesity (Brown et al., 1998). In general, however, the factors that protect some girls and place others at risk are not well understood. It is important to note that these findings are preliminary in nature, and more research is need to further validate them, as well as determine if these differences apply to girls from other ethnic, and racial groups, such as Hispanics, American Indians, Asians, and Pacific Islanders.

Puberty may be a Better Predictor of Aggression and Problem Behaviors than Age. There is growing evidence to suggest that puberty rather than chronological age may signal the onset of delinquency and problem behaviors among some teenagers (Keenan and Shaw, 1997; Rutter et al., 1998). For example, early maturers—both mate and female—are more likely than other adolescents to report delinquency. Early-maturing females also appear to be at increased risk for victimization, especially sexual assault, and this may partially explain their greater likelihood of problem behaviors (Flannery et al., 1993; Raine et al., 1997). These findings suggest the need for interventions that are targeted to early-maturing adolescents who may be at increased risk for a wide range of behavior problems and associated poor developmental outcomes.

Physical Maturation Appears to have Little Correlation with Cognitive Development. Many developmental psychologists, most notably Jean Piaget, have documented an expanded capacity for abstract reasoning during adolescence. Today's adolescents are often capable of complex reasoning and moral judgment; their capacities frequently astonish parents and teachers. Indeed, IQ tests show an overall gain in cognitive capacities since the 1940s, when military personnel were tested in large numbers and achieved a median score of about 100. However, there appears to be little relationship between physical and cognitive maturation.

Researchers have tested the hypothesis that growth across the developmental spectrum—physical, cognitive, social, and emotional—proceeds on a similar timetable, and they have found little evidence to support this hypothesis. However, the research in this area is relatively weak, in part due to a lack of reliable, valid, easily administered instruments for assessing cognitive development (Litt, 1995). When cognitive development and capacities are not in sync with physical and sexual maturation, young people

are more vulnerable; this also creates special challenges for designing and delivering age appropriate clinical interventions and services. Adults will often assume that adolescents who look older have a better grasp of the consequences of their actions.

Brain Development Appears to Continue During Adolescence. One of most remarkable findings in neurobiology over the last decade is the extent of change that can occur in the brain, even in the adult brain, as a function of the physical, social, and intellectual environment.

Starting in infancy and continuing into later childhood, there is a period of exuberant synapse growth followed by a period of synaptic ''pruning" which is largely completed by puberty. Although, neuroscientists have documented the time line of this synaptic waxing and waning, they are less sure about what it means for changes in childrens' and adolescents' cognitive development, behavior, intelligence, and capacity to learn. Generally, they point to correlations between changes in synaptic density or numbers and observed changes in behavior based on developmental and cognitive psychology. In coming decades, research tools such as positron emission tomography (PET) scans and functional magnetic resonance imaging (MRI) scans should greatly expand researchers' knowledge about adolescent brain development. In particular, functional imaging, if repeated over time, carries the potential for providing a better understanding of the functional connections between brain development and psychological performance (including cognitive development). New insights into brain development may also shed light on some psychopathologies and learning disabilities that affect preteens and adolescents, such as attention deficit/ hyperactivity disorder (ADHD), depressive disorders, and schizophrenia.

Researchers are Also Providing New Insights into the Relationship Between Gender, Hormones, Brain Development, and Behavior. In terms of the onset of puberty, boys generally follow girls by two years. For example, boys typically reach their maximum height velocity two years later than girls. In the realm of neuroscience, there is new evidence of divergent patterns of male and female brain development; these patterns have been observed between the ages of 5 and 7. Case in point: during this period, the amygdala (a part of the limbic system concerned with the expression and regulation of emotion and motivation) increases robustly in males, but not in females; the hippocampus (a part of the limbic system that plays an important role in organizing memories) increases robustly in females, but

not in males. The basal ganglia are larger in females; this appears to be significant, since boys are more likely to have disorders, such as ADHD, that are associated with smaller basal ganglia. Girls may have extra protection against this type of disorder. Although there are clear differences in the path of brain development for girls and boys, it is not yet possible to look at a brain scan and determine whether the subject is male or female.

Pregnancy During Adolescence may Alter the Physiological Development of Girls. During pregnancy, young women at different points in pubertal development show comparable hormone profiles. Pregnancy in very young women may compromise their skeletal growth, preventing them from reaching maximum bone mass. Frank Biro noted that his research team, which followed several hundred adolescent pregnancies, found that, after giving birth, adolescent mothers were on average significantly heavier (by approximately 10 pounds) and fatter (having thicker skin folds) than their counterparts who had not given birth.

RESEARCH CHALLENGES

The final session of the workshop focused on a broad view of the field of puberty and adolescent development, considering the implications of recent advances for the future of research, as well as its effects on current policies and practices. Summarizing the comments made by workshop participants, we outline below a number of challenges that researchers now face in moving this area of inquiry to its next stage of development. Gaps within the current knowledge base of adolescent development that require further research as identified by the presenters are also summarized.

Adolescence Should be Recognized as a Credible Area of Scientific Inquiry. Numerous workshop participants emphasized the need to build the capacity of the field of adolescent research with new funding for longitudinal research and incentives for providing professional training and conducting interdisciplinary research.

The many studies showing that adolescence is not necessarily a time of storm and stress (Elkind, 1992; Hamburg, 1992) represent a significant shift in perspective. However, there has been relatively little research on the affective and attitudinal characteristics often associated with the adolescent period—elation, thrill seeking, excitement, moodiness, shifts in energy, irritability, restlessness. Only recently have studies linked negative emotional

or affective states to the hormonal changes of puberty, particularly in normal children (Buchanan et al., 1992).

Advancing the field's understanding of adolescence requires a focus on research and on the policies that are ideally informed by this research. Existing theoretical models should be expanded to take advantage of advances in the biomedical sciences. As workshop participant Elizabeth Susman observed, "Further integration of physiological processes into models of adolescent development will enable scientists to construct more holistic, integrative models than currently are available" (Susman, 1997).

Research is Needed to Explore the Relationship Among Various Aspects of Pubertal Growth by Creating and Applying more Complex Modeling Procedures. Until quite recently, models of adolescent development tended to be unidirectional, allowing researchers to track either behavior or hormones. Some progress was then made in developing bidirectional analyses, showing the interaction between behavior and hormones. Only recently have investigators looked seriously at physical and social factors that may influence adolescent development. Consequently, existing models do not afford the opportunity to take more than a snapshot of adolescence or, at best, to conduct longitudinal studies that follow the trajectory of one or another variable. Advances in the understanding of adolescence therefore hinge on the development of more complex, multidimensional theoretical and statistical models—i.e., a "global weather map" of puberty. An interdisciplinary effort is needed to develop such models.

Research is Needed to Further Study the Age of Onset of Menarche and Differences Among Girls of Different Racial and Ethnic Groups. According to some researchers, "maturational timing appears to be the same across ethnic groups, provided nutrition is adequate" (Brooks-Gunn and Reiter, 1990). As they acknowledge, however, this assertion is controversial within the field, and many questions remain.

In light of research that suggests that black girls reach menarche earlier than white girls, which factors contribute to the early onset of puberty for black girls? Can we assume that the reasons for differences in the timing of menarche are the same today as they were in the 1960s? If, as discussed earlier, black girls begin puberty approximately 15 months before their white counterparts, but they arrive at menarche only 8 months earlier, what accounts for their slower tempo of pubertal development? What is the relationship between body weight and age of puberty for black and white

girls? Do girls who are heavier have a slower tempo of pubertal development? How important are different cultural attitudes toward body image? What insights might cross-cultural studies provide?

Although much of the current research focuses on the different course of puberty among black and white girls, clearly there is a need for additional research to characterize differences in the timing of puberty and menarche (and outcomes associated with these differences) in an increasingly racially and ethnically diverse adolescent population in the United States. This research must go beyond black-white comparisons to other racial and ethnic groups, such as Hispanics, American Indians, and Asians and Pacific Islanders. Moreover, given the heterogeneity that exists within these groups, within-group comparisons are also needed—e.g., comparisons of African Americans, Nigerians, and Caribbean blacks within black populations; Cubans, Puerto Ricans, Central Americans, and Mexicans within Hispanic populations; and Chinese, Japanese, and Vietnamese within Asian populations. How do genetic and cultural factors affect the timing of pubertal development and the timing of menarche? An anthropologist taking part in the workshop noted that, among the Lumi people of New Guinea, the average age of menarche is significantly later than it is in the United States and other developed countries.

Research is Needed to Investigate the Relationship Between Adrenarche and Puberty. Puberty is now considered to be one event along a continuum of development. It is preceded by adrenarche (the reinitiating of adrenal androgen secretion), which begins about two years before what has traditionally been considered the onset of puberty. Heredity appears to play a major role in determining the onset of adrenarche as well as puberty. Adrenarche is still poorly understood; its function is not entirely clear. Researchers initially thought that adrenarche causes a prepubertal growth spurt between the ages of 5 and 7, but it is difficult to attribute this "blip" to adrenarche, since adrenal androgen secretion continues while growth drops back to its former rate. Are there cross-cultural and cross-national differences with respect to the onset of adrenarche? If so, why?

Research is Needed to Explore Further the Relationship Between Sex Steroids and Behavior. It is commonly thought that pubertal change affects moods and behavior, but the evidence is mixed (Richards and Larson, 1993). Despite decades of speculation, the effects of sex steroids, in particular on moods and behavior, during adolescence remain unclear. What

is the relationship between the adrenal and gonadal systems (or HPA and HPG systems) and their influence on mood and behavior? Many researchers are looking at these relationships, but more research is needed. Reliable and valid measures that will permit examinations with greater specificity are needed to determine how the pubertal rise in hormone concentrations affects cognition, as well as its effect on problem behaviors, such as aggression.

Research is Needed to Study Vulnerability and Resiliency Across the Spectrum of Child and Adolescent Development. Why are some preteens and adolescents more or less vulnerable or resilient given comparable life events and contexts in which they are growing and developing? Are biological systems more or less sensitive to life events and contexts at certain points in time? If so, do genetic influences predispose some youth to be more or less vulnerable, or conversely, more or less resilient? For example, if an adolescent girl develops an eating disorder, does her life trajectory in general, and the biological impact of the disease in particular, depend on the point in her development when it occurs?

Research is Needed to Study the Factors that Promote or Impede Cognitive Development in Adolescence. The field would benefit from a more complex model of adolescent cognitive development. Why does cognitive development proceed on a different timetable than physical and sexual maturation? Researchers focusing on puberty have not detected the effects of steroids on cognitive functioning, but, in menopause, estrogen therapy demonstrably affects cognitive functioning. What accounts for this discrepancy? How is the architecture of the brain related to adolescent cognitive development? Will functional MRI studies enhance knowledge in this area? Moreover, we need to better understand the decision-making processes of adolescents and the factors that motivate them to engage in high risk versus health promoting behaviors.

Research is Needed to Expand the Field's Understanding of the Effects of Stress—both Negative and Positive Forms of Stress—on Adolescent Development. Researchers have just recently begun to establish a connection between stress and the timing of pubertal maturation. New research is needed to identify adverse environmental conditions (such as those associated with poverty) that may affect the long-term suppression or stimula-

tion of endocrine processes that, in turn, may affect normal growth and psychological development (Susman, 1997).

Research is Needed to Further Clarify Developmental Differences According to Gender. Why do girls reach puberty before boys? What are the implications with respect to health promotion and the prevention of risky behaviors? What are the implications of gender differences in brain development?

Research is Needed to Address Key Issues in Adolescent Development in Light of Advances in Genetics. Adolescence is a time when a whole set of genetic influences become more important while another set of genetic factors, which were apparent in early life, become less important. For example, there is clear evidence for a genetic predisposition to schizophrenia, and the onset of schizophrenia typically occurs during the later adolescent years. What interaction between the host and environment signals the onset of schizophrenia during adolescence? Can we with greater specificity account for how and when these as well as other genetic "signals" are turned on or off during childhood as well as adolescence? How are new genetic mechanisms brought into play? What are the factors, both genetic and nongenetic, that can influence the expression of specific genes during adolescence? Increasing knowledge about the interaction of multiple genes, the environment, and behavior will someday help to inform the development of new strategies to promote the healthy development of both children and adolescents.

In summary, as discussed at the workshop, there are a number of challenges for conducting research in this area, as well as clear opportunities for advancing the knowledge base regarding adolescent development, health, behavior, and well-being. The next generation of research studies needs to be interdisciplinary in nature; to integrate cross-sectional and longitudinal research methods with more sophisticated modeling techniques to examine the interrelationship among genetic, biological, social, and environmental influences and their unique and shared contribution to adolescent development; and to be couched within a broader developmental framework.

POLICY CHALLENGES

In discussing the state of research on puberty and adolescent development, workshop participants turned to issues related to policy and practice.

Summarizing their remarks, we outline below some opportunities to inform policy and practice through scientific research.

The Gap Among Research, Policy, and Practice Needs to be Narrowed. As in many other fields of science, in the field of adolescent development more knowledge is available than is put to use. Although there is much more still to learn, the knowledge base is already sufficient to allow reconsideration of many policies now. The communication of research findings to policy makers, service providers, educators, parents, and young people may help them develop more effective strategies for addressing the opportunities and challenges of adolescence, including helping adolescents to learn how to form close, durable human relationships; feel a sense of worth as a person; express constructive curiosity and exploratory behavior; know how to use the support systems available to them; succeed at school; and acquire the technical and analytic capabilities to participate in a world-class economy (Carnegie Corporation of New York, 1995). In particular, parents, educators, health providers, and human service providers need to have a greater awareness that puberty begins earlier than most people imagine (especially for girls), that early-maturing girls may be at higher risk for depression and problem behaviors, that many factors affect the timing and course of pubertal development, and that physical or sexual maturation is most likely on a different schedule than cognitive development. Finally, individuals or groups that make decisions about important legal and social questions need access to such information so they can make the kinds of decisions that protect the health and well-being of youth. For example, research findings should be used to undergird policies and regulations regarding when it is appropriate for adolescents to be treated as adults—by courts, health agencies, sex education programs, and schools.

Research Needs to be Applied to Promote Positive Developmental Outcomes. Studies of the timing of puberty suggest that preventive efforts need to start earlier—particularly interventions designed to prevent problem behaviors, such as violence. Research findings can help policy makers determine when particular interventions are most likely to be effective, and for whom. One workshop participant pointed out that, too often, conduct disorders are not identified until a child reaches adolescence. As the knowledge base expands, it may become more possible to recognize, in advance of puberty, which children are at risk for such disorders and to provide anticipatory guidance. Research can also point to subpopulations (such as chil-

dren born to adolescent mothers) that may be more likely to encounter problems in adolescence (Hardy et al., 1997; Graber and Brooks-Gunn, 1999). A key challenge is to track and anticipate different patterns of maturation before they actually occur and to encourage parents, teachers, health care providers, and other key players to provide primary prevention intervention.

The Focus Needs to Shift to One That Embraces Both Prevention and Health Promotion. A shift in emphasis is needed from simply preventing problems to actively promoting a wide range of healthful behaviors. Policy makers and practitioners need the kind of information that will help them promote healthy development, including information about what is happening at various stages of adolescence; how hormonal changes interact with contextual factors and how they affect sexual arousal; and the risk factors affecting early, middle, and late maturers. For example, preventing unwanted pregnancy and infection with STDs is an urgent concern for all those who raise adolescents or who work with them. Some ethnic or cultural groups look favorably on early marriage and childbirth and, within these groups, young mothers and their children tend to fare well. However, across the United States, most teenage pregnancies are unplanned and unwanted. Fortunately, the nation has made some progress in reducing rates of unintended pregnancies among teenagers in recent years (Institute of Medicine, 1995). After reaching 117 pregnancies per 1000 females ages 15–19 in 1990, the pregnancy rate has fallen a total of 17 percent between 1990 and 1996 to 97 births per 1000 females ages 15–19; these pregnancy data include births, abortions, and miscarriages (Henshaw, 1998). Despite these improvements, these rates remain high thus warranting further attention. Research shows that other nations are doing much better at ensuring the health and well-being of adolescents and helping them avert unwanted pregnancies. Young people in other countries have similar patterns of sexual activity; however, they have access to better information and supports, including sex education and contraception.

Resources Need to be Invested in an Effort to Promote Sound Decision Making Among Adolescents. Adolescents are capable of impressive intellectual feats, but research shows that studies of cognitive capacity in artificial settings (such as laboratories and classrooms) may overestimate what adolescents are able to do in real life, in which stress and time pressure are often intense (Petersen and Leffert, in press). Moreover, a wide range of

factors, such as social coercion and the use of alcohol and other drugs may influence and compromise adolescents' ability to accurately process information to make well-informed choices. For this reason, it is often useful to distinguish between the kind of "cold cognition" described by cognitive scientists—formal operations, the capacity for abstract thought—and "hot cognition"—the capacity to reason and make multiple decisions under conditions of high anxiety and stress. Too little is known about hot cognition. It is clear, however, that adolescents need more help in coping with the kinds of situations in which competent decision making is essential.

Cross-cultural studies raise key questions. What insights can be drawn from studies of other countries, in which youth are engaging in fewer high risk behaviors? Are adolescents in the United States engaging in risky behaviors because they have had too few opportunities to learn how to avoid them and make good decisions? Is there a need for more and better models of responsible adult decision making, both in their communities and in the media? Many other cultures expect youth to take on adult roles earlier, and they lay the groundwork for adult decision making. What kind of policies or programs will strengthen adolescents' capacity for sound decision making? What are the mechanisms underlying changes in cognitive capacities, leading toward adult intellectual functioning? What kinds of experiences and tools can be provided to adolescents that will help them learn to make good decisions? What kinds of settings and experiences will further their moral development?

Cultural Diversity must be Taken into Account when Studying Adolescence and Planning Interventions. In efforts to understand adolescence and promote good outcomes for young people and their families, the importance of cultural context cannot be overstated. The same conditions or circumstances may pose different risks and challenges for different groups. For example, different cultures have different attitudes toward sexual precocity and sexual behavior, including early pregnancy and childrearing. Early puberty poses fewer problems for girls in cultures whose adult women tend to support early maturation; for example, there is limited research suggesting that black girls cope better with early maturation than their white peers. Clearly this research needs to be further replicated, conducted with both girls and boys, and conducted with a diverse group of teens—i.e., with teenagers from a variety of racial and ethnic groups.

These findings have important implications for professionals who work

with adolescents and their parents. Not every early-maturing girl is at high risk. Moreover, research shows that adolescents growing up in different contexts may have different views of their own development. White girls may be more likely than black or Hispanic girls to value a thin body type; they are more likely to restrict their diets and to smoke, affecting their pubertal development. Studies also indicate that young people from different ethnic or cultural groups tend to have different estimations of their own physical and sexual maturity, regardless of the objective evidence.

Adolescents should be Included in Efforts Intended to Improve Outcomes for Them and Their Families. Given access to good schools, access to preventive information, needed services, and strong social supports, young people can control their own behavior through effective cognitive, self-regulatory, and self-management techniques. They can learn to respond to stressful life events and the unpredictable nature of day-to-day life as experienced by most adolescents and adults. They can also serve as positive role models within their schools and communities and encourage their peers to engage in health promoting behaviors.

In summary, as discussed at the workshop, there are a number of opportunities to inform policy through research. Specifically, participants discussed the need to construct policies and design programs that focus on both prevention and health promotion; that seek to promote positive developmental outcomes (not just the absence of problems); that engage adolescents as young adults (rather than talking down to them as if they were children). Moreover, in light of the growing diversity in the adolescent population, policies must ensure that health care and social services are delivered in a culturally relevant and sensitive manner.

IMPROVING PUBLIC UNDERSTANDING

In the course of the workshop discussions, participants identified a number of important findings from research that should be communicated to increase the public's understanding of the reality of adolescence. Summarizing the comments of workshop participants, we lay out below some of the most important messages that can be communicated to parents, teachers, health care providers, and others who live and work with adolescents.

Sexually Transmitted Diseases and other Health Problems Pose a Major Threat to Adolescents. It is clear, from nearly three decades of research, that adolescents are at high risk for infection with STDs, including HIV; rates of infection with STDs are higher among adolescents and young adults than any other age group, and incidence rates of HIV infection remain alarmingly high among teenagers (Institute of Medicine, 1995). All adolescents require the knowledge and skills needed to protect themselves from STDs, HIV, and unintended pregnancy. There remains the need to deliver effective prevention and health promotion interventions to all adolescents, to ensure that they have long, productive, and healthy lives. The public can play a very important role to ensure the health, safety, security, and wellbeing of adolescents. For example, health providers and educators can and should provide adolescents with the knowledge and skills they require to protect themselves from a wide range of public health problems, including STDs, HIV, alcohol and other drug abuse, and violence. Parents can also play an important role by encouraging and facilitating meaningful discussions with their teenagers in an effort to provide them with needed information and skills, as well as to provide them with the opportunity to explore their own values and beliefs. Finally, the media can play a very important role by reinforcing prevention and health promotion messages.

Children Need Health Monitoring and Care During the Elementary and Middle School Years. Puberty begins earlier than most parents and many health professionals realize. And yet, many 5- to 11-year-olds are rarely seen in doctors' offices or health centers unless they have an acute health care need or a serious medical problem. Once the well-baby visits of infancy and toddlerhood are over and a full round of immunizations has been completed, most parents seldom take their children to the doctor. As a result, parents lack the kind of information and guidance they need to help them fully understand and appreciate the developmental changes experienced by the prepubescent child. Some problems that could be addressed in middle childhood (including growth problems and behavioral issues) may go unrecognized or untreated until a later age. Clearly, health care providers, health care institutions, community-based organizations, and other social service agencies can play a very important role by educating parents that their children in the middle childhood, preadolescent, and adolescent years require access to health care and preventive services. Health care delivery systems also need to consider revising their standards of care

and recommendations about needed health care services during the middle childhood and preadolescent years.

Middle childhood is also a good time to address or prevent obesity and eating disorders, such as anorexia and bulimia. Most obese adolescents do not become obese adults, but about 15 percent (well over the chance level) do become obese (Garn, 1992). This statistic merits attention in view of the long-term risks associated with obesity in adolescence, including cardiovascular disease and Type II diabetes. Parents, health professionals, and teachers can introduce or reinforce the importance of regular exercise and a good diet. Neither is sufficient alone for staying healthy throughout the life span; they must be considered together. Again, health care providers, social agencies, educators, and community-based programs can and should be playing an active role to ensure that adolescents know what constitutes a healthful diet and are encouraged to eat well-balanced meals and exercise regularly. They are also often in a unique position to identify children and adolescents who are at high risk for developing an eating disorder before they develop such problems and to ensure that children and adolescents who do have an eating disorder know how to get help.

Storm and Stress are not Inevitable in Adolescence. The developmental milestones of adolescence have often been viewed in terms of pathology, yet decades of research would suggest otherwise. It is important to communicate clearly that adolescence does not inevitably bring on years of storm and stress for young people or their families. A classic epidemiological study of the mental health status of adolescents conducted in Great Britain by Michael Rutter and his colleagues found that half reported sadness or ''misery" on questionnaires, but less than 15 percent of boys or girls were found to be depressed—that is, to have impaired functioning or true mood disturbance—based on in-depth interviews (Rutter et al., 1976).

When Psychological Difficulties Do Occur in Adolescence, They are not Necessarily Outgrown Later. At the same time, there has been a growing recognition from the past decade of research that psychological difficulties during adolescence need and deserve attention from parents and professionals. When adults overlook these problems, assuming that they are an inevitable part of adolescence and will be outgrown, they may be placing young people at risk; there is evidence that difficulties experienced in adolescence often continue into adulthood (Petersen, 1988). Will and com-

mitment on the part of society are needed to screen for and respond to mental health problems experienced by adolescents to ensure that they do not become chronic and debilitating problems in adulthood.

Biology is not Destiny. Although it gives definition to various aspects of development, biology alone does not determine outcomes (positive or negative) for young people. The modern perspective is that behavioral factors also modulate biological systems. It is widely recognized that many factors—including some that parents can influence—affect the course of adolescent development. Genetic differences among individuals and groups are usually influenced by social and cultural contexts. For example, differences in the timing of puberty for black and white girls may relate only partially to genetic factors; nutrition, socioeconomic conditions, and other factors have been shown to influence pubertal development.

Families Matter. Humans are a social species. The regulation of children's biological systems, and their resilience when confronted with day-to-day stress, depend heavily on their interactions with important adults. This is true for adolescents as well as for younger children. Parents need to stay actively involved as their children move through the second decade. And although adolescents need and deserve privacy in some areas of their lives, stable, supportive relationships with parents and other family members are essential to their development, health, and well-being.

Civic Engagement should be Encouraged Among Adolescents. During the past two decades, there has been a growing literature that suggests that as much as 40 percent of young adolescents' time is unstructured, unsupervised, and consequently unproductive; much of this time occurs during the after-school hours when adolescents are frequently alone, watching television. Quite often, there are few after-school activities that provide young people with the opportunity to explore the community, put lessons learned in school and home to practical use, meet peers and adults other than classmates and teachers, and begin to transition to young adulthood (Carnegie Corporation of New York, 1995). Moreover, there are few links between schools and the workforce. Research shows that many factors influence adolescent development. Social institutions, such as schools, the health care delivery system, faith institutions, and community organizations, play an important role in supporting the healthy and productive development

of adolescents. In this regard, adults appear to be missing important opportunities to influence young people's lives. In particular, research suggests, community context influences the developmental processes that can promote positive developmental outcomes among adolescents and discourage them from engaging in problem behaviors, such as substance abuse, precocious sexual activity, and delinquency (National Research Council, 1993, 1996; Petersen et al., 1991).

Other than infancy, no stage in human development results in such rapid or dramatic change than adolescence. During adolescence, a child matures into an adult physically. Within a matter of four to five years, the average child grows nearly a foot taller, assuming adult size, shape, and reproductive status. How can such enormous changes take place during such a compressed period? How does the body initiate, regulate, and time these changes? How do these changes affect behavior, and vice versa? Today, we are in a better position to answer these questions than ever before. Breakthroughs in science and technology have sparked an explosion of new knowledge about the developmental changes that occur during adolescence. Advances in neuroendocrinology and brain imaging are beginning to produce important insights into pubertal growth and adolescent development.

While focusing on the biological mechanisms that underlie adolescent development, workshop participants repeatedly sounded this theme: social ecology is crucial. Physical development is influenced by a broad spectrum of environmental, social, and cultural factors, and both experience and heredity affect the timing of puberty. The evidence for this dual influence is growing rapidly.

The study of adolescence in general, and puberty in particular, is challenging as a result of their complexity. A multitude of factors interact, affecting the timing and trajectory of development in the second decade of life. Which factors interact under which circumstances? Which factors are driving forces in adolescent development, and which have more marginal roles? What is the relationship between the timing of puberty and the progression of hormonal changes? These are some of the issues that will require further investigation as the field of adolescent development itself comes of age.

Adolescence is one of the most fascinating and complex transitions in the human life span. Its breathtaking pace of growth and change is second only to that of infancy. Over the last two decades, the research base in the field of adolescence has had its own growth spurt. New studies have provided fresh insights while theoretical assumptions have changed and matured. This summary of an important 1998 workshop reviews key findings and addresses the most pressing research challenges.

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Ment Health Fam Med
v.6(3); 2009 Sep

A qualitative study on adolescence, health and family

Soroor parvizy.

Assistant Professor, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran

Fazlollah Ahmadi

Associate Professor, Nursing Department, Faculty of Medicine, Tarbiat Modarres University, Tehran, Iran

Family is important to both health and adolescence. Adolescence is a time of peak health, but there are some important family based risk factors. The aim of this study was to explore the perspective of adolescent Iranians on issues of family and their health. We used descriptive, qualitative methodology and purposeful sampling and interviews for collecting the data. Forty‐one participants explained their perspectives on health and family. Data were analysed using qualitative content analysis. Analysis revealed three categories of risk factors: a widening generation gap, effective parenting and family financial situation. To have healthy adolescents, both children and parents need more knowledge and better skills about adolescent health and development and about social trends. To understand adolescents in a more realistic way, parents should develop healthy communication to avoid family health problems.

Introduction

The family is a heavenly or basic unit which has deep roots in both Iranian national culture and religious belief. It has the meaning of loving, belonging, training and coexisting as well as safety, security and unity. As written in the Holy Quran, Sura Rome verse 21: ‘Amongst God's signs for you is this, that He created mates for you from among yourselves for you to dwell with in tranquility. It is He who put love and compassion between you. Verily in these are signs for those who reflect.’ Prophet Mohammad said: ‘Best amongst you is he who treats his family well: and I am kindest of all to my own family’. 1

Family can be a place where both potential resources for health or possible threats to wellbeing may arise. The core functions of family are the exchange of love, affection, comprehension, nurturing and care, economic security, a sense of identity and belonging, raising children and guidance on social values 2 and there are some important interactional effects between family and its members at different developmental stages.

Adolescence is a crucial period of human life and adolescents may encounter problems that may affect them for the rest of their lives. Family has a fundamental role in different aspects of the health of adolescents and examples of this are available from around the world. Seventeen percent of Finnish teenagers frequently reported tiredness and 10% did not experience the joy of life. 3 The protective function of family has been showed to be an important factor in the prevention of risk behaviours in Chilean adolescents 4 and family religiosity was negatively associated with adolescent sexual activity in a US national longitudinal study by Manlove et al . 5 Poor children's health status, parental marital status and family rearing patterns were shown as risk factors for adolescent emotional abuse in a study from China. 6 The overall effect of family interventions in reducing adolescent drinking has been shown in a meta‐analysis. 7

The Iranian context and related studies

Iran, with 15 million adolescents accounting for almost 25% of the total Iranian population, is one of the youngest countries in the world, a situation which can pose many challenges to family co‐hesion. 8 Compared with their western counterparts, Iranian adolescents are less delinquent. Iranian culture expects that adolescents should respect and obey their parents and children usually live with their parents until marriage, no matter how old they are. Even after marriage, they may continue living with their parents independently in the family home. Segregation of the sexes is respected in public places such as schools and the university environment and/or workplace is the first opportunity for the sexes to communicate. Out of wedlock sexual relationships are prohibited by Iranian religion, culture and law. Over the last decade, as a result of the influence of western culture via satellite media, adolescents and their families are experiencing an increase in rates of aggression, parents being insulted, opposite sex relationships, western hair styles, fast food, individualisation and smoking, and this cultural colonisation is in many cases unwelcome.

The Iran National Youth Organization (INYO) is the main formal organisation responsible for adolescent and youth programming and welfare in Iran. This high‐level, well‐organised body plans to develop evidence‐based programmes to improve adolescents' quality of life.

According to INYO research, 66% of adolescents believed that the influence of satellite media will foster western culture and a developing consumerism which are crucial challenging agents for the deep and rich Iranian culture. Adolescents stated that their main needs were to have useful and safe pastimes during adolescence and a future career. 9

Emami et al investigated mental health in Iranian adolescents and found that a considerable proportion of adolescents experienced mental disorders, with girls experiencing such disorders more frequently than boys. 10 Salimi et al studied high school students to assess the effects of parental expectations on students' anxiety about education and career. Analysis yielded a negative correlation between parental self‐esteem and expectations and students' anxiety about education and career. 11 A qualitative content analysis on addiction in Iranian adolescents revealed themes of the causes and prevalence of addiction, unhealthy friendship and communication, increased rates of cigarette smoking, alcohol and drugs, barriers to and factors in addiction and health and family and addiction. 12 A cross‐sectional study carried out on smoking in Iranian adolescents found that the most common reasons youths cited for initiating cigarette smoking were to attract attention from friends, due to family inattention and due to poverty. 13 A cross‐sectional survey to evaluate the extent and potential correlates of sexual risk taking behaviours among adolescent boys in metropolitan Tehran found two factors to be considered as sexual risk taking behaviour: ‘not using condom or, inconsistent condom use in sexual contacts’ and ‘multiple sexual partners in lifetime’. 14 A grounded theory study to develop an identity‐based model for adolescent health in Iran found identity as a core variable and the concepts of friendship and relationships, education, family, lack of limitation and community as main categories. 8

The health status of Iranian adolescents, specifically their psychological profiles combined with evolving social trends, create a unique challenge for them as they struggle to grow up. It is important to understand their health concerns and needs in relation to their families, as this will promote a pathway to a healthier future for adolescents.

This article explores the perspective of Iranian adolescents on issues of family and their health. Knowledge of these perspectives will help both families and health providers to better understand the health of adolescents, and will help with future planning and provide ideas for more helpful future involvement. These data will be of use to parents, advocates and adolescent health activists to enable them to realise the scope of the challenges confronting them and guide them to focus on their potential resources. The purpose of this study was to explore the perspectives of Iranian adolescents on family factors that may facilitate or inhibit health. The main research question was: ‘Which family factors were health bridges and barriers, and what extreme experiences had adolescents had regarding their health and family?’.

Methodology

Research method.

A descriptive, qualitative approach was used to enable the researchers to learn about the perspective of adolescents on health. According to Boswell and Cannon, a qualitative method is suitable for uncovering the complex human issues and what lies behind them. 15 The method used is the analysis of the content of narrative data to identify prominent themes and patterns among the themes 16 and is a method that is useful for studying phenomena about which little is known.

Sample and data collection method

Purposeful sampling was used. Participants were recruited from schools, their homes, parks and cultural houses in Tehran, the capital of Iran. The criterion for participation in this study was simply being an adolescent (between 11 and 19 years old). After the purpose of the study and the research questions had been explained an appointment was made with those adolescents who consented to participate in the study.

At the beginning of each open‐ended, semi‐structured interview, participants were asked to explain their feelings about their health: which factors they considered to be their health bridges and barriers, and what extreme experiences they had encountered regarding their health.

During the first interview, participants indicated what they understood by adolescent health as a general concept. These responses were used by researchers to develop the interview process overtime, focusing on the main factors identified by participants as affecting adolescent health. Interviews were audiotaped, took place over one to three sessions and lasted between 30 minutes and three hours with an average length of 70 minutes.

Each transcribed interview was initially analysed as a unit; subsequently, all interview themes were analysed together, as a whole. The interaction between data collection and data analysis is clear, each providing the direction for the other. Interviews were conducted until data saturation occurred. According to Polit and Beck, data are considered saturated ‘when themes and categories in the data become repetitive and redundant, and when no new data can be gleaned by further data collection’. 16

Ethical considerations

The Nursing Faculty of Tehran University of Medical Sciences (TUMS) gave ethical approval for the research. Adolescents were verbally informed about the aim of the study and were asked to participate voluntarily. Participants were informed that they could refuse to answer a question or withdraw from the study at any time and if a participant asked for his/her tape, it was given to him/her without making use of the data. Consent was also obtained from all principals of the schools which participating adolescents attended. To protect their privacy and confidentiality, interviews were conducted with the participation of only the interviewer and the interviewee and participants were identified by an identification code. Emphasis was placed on creating a relaxed atmosphere during interview through the use of good communication skills. Interviews were continued with those adolescents who were willing to discuss with the researcher their experiences and deep emotions about adolescent health and family. Three adolescents who ceased participation in the study (with a transcript recheck) were permitted to do so.

Data analysis

The interviews were analysed using the qualitative content analysis method. Content analysis has an important place in the wide range of investigative tools valuable to investigators of themes 17 and was therefore selected as an appropriate method for the analysis of the study data.

A theme or code is a single assertion about a subject and it is the most useful unit of content analysis. The unit of analysis for this study was a meaningful statement, ranging in length from a word to one or two complete sentences. The first phase of the analysis was line by line coding; key phrases of the transcripts, in participants' own words, were identified and underlined. The underlined codes were rephrased into a shorter code phrase in the second phase of the analysis. Subsequently, those phrases with similar meanings were brought together and subcategories generated. In the final stage of analysis named categories were generated through further abstraction and grouping of subcategory themes. 17 , 18 The data analysis process is shown in Box 1 .

Box 1 Data analysis process

First phase. Line by line coding

‘Parents should teach us how to live ; they should help us to understand the meaning of life , but every morning they take us to school ; they register our names in extra classes . They will do many things for us , but at last we don't learn how to live , in our future real life ’.

Second phase. Phrasing shorter codes

Parental responsibility in learning how to live

Parental responsibility to explain the meaning of the life

Doing lots of non‐essential daily activities for children

Negligence from the main parental responsibilities

Learning how to live

A sense of not to be healthy regarding communication with parents

Third phase. Generation of sub‐themes

Necessity of being ready for future real life

Fourth phase. Making and naming

Effective parenting

Data credibility

Credibility of data was established through member (participant) rechecking, peer checking and prolonged engagement with participants and data. The maximum variation of sampling was also used to confirm reliability and credibility of the data themes. 19 Five participants were contacted after analysis for member rechecking, and were given a full transcript of their coded interviews with a summary of the themes that had emerged to see whether these reflected their perspective. The researcher's explanations were also added, if needed. Inter‐transcript reliability was established by completing a second review and peer checking, carried out by a number of colleagues who were briefed by the researchers. Transcript and theme rechecking showed acceptable agreement between, and among, different peers and the research team. The results were also checked with five adolescents who had not participated in this research to confirm result ‘fit’. Prolonged engagement with participants and data helped the researcher to obtain the adolescents' trust and to get a better understanding of the research environment. The sampling strategies enabled a maximum variation of sampling to occur and, as a result, a vast range of views and experiences was obtained.

Participant characteristics

Participants consisted of 41 adolescents aged between 11 and 19 years old, 22 of them female and 19 male. The remaining demographic characteristics of the participants are shown in Table 1 .

Demographic characteristics of participants


Demographic characteristic	(%)

Sex
Male	22 (54)
Female	19 (46)
Age
11–13	6 (15)
14–16	11 (27)
17–19	24 (58)
Grade
Secondary school	14 (34)
High school	18 (44)
University	5 (12)
Others	4 (10)
Total	41 (100)

Themes and sub‐themes

Content analysis of the transcripts revealed the following three main themes, each of which embraces two to three sub‐themes. The participants identified family adolescent health factors as consisting of:

a widening generation gap
effective parenting in adolescent health promotion

Box 2 Emerged themes and sub‐themes

A widening generation gap

Parental knowledge deficit about adolescents' health risk factors and characteristics
Non‐friendly and humiliating parental relationship with their children
Traditional parents
Parental responsibility in adolescents' health promotion
Abstinence from drinks and cigarettes in their parents' presence
Parental conflicts as an inhibiting factor of adolescents' health

Family financial situation

Parents' joblessness
Parents' overload

Theme1: The widening generation gap

The first main theme was the widening generation gap, with three sub‐themes: parental lack of knowledge about adolescent health risk factors and characteristics; an unfriendly and humiliating parental relationship with their children; and traditional parents.

PARENTAL LACK OF KNOWLEDGE ABOUT ADOLESCENT HEALTH RISK FACTORS AND CHARACTERISTICS

A parental lack of knowledge about adolescent health risk factors and characteristics was emphasised by most participants. Adolescents mentioned that this could create communication problems with their parents and this was caused by the widening gap between the two generations.

Participants stated that adolescent developmental changes were usually ignored and normal adolescent changes were interpreted as deviation or stubbornness by parents because of their lack of knowledge about adolescent health risk factors and characteristics. Becoming independent is one of the developmental changes in adolescence and an inappropriate environment to enable this change could be a barrier for adolescent development. Adolescents hoped that parents would learn to appreciate how important it is to have a deeper understanding of them and their changing situation. As one 19‐year‐old female described: ‘We are very different from our parents; there is a wide gap between us. In the past, the girls were similar to their moms and the boys to their dads, but now we can't understand mutual needs and expectations’.

AN UNFRIENDLY AND HUMILIATING PARENTAL RELATIONSHIP WITH THEIR CHILDREN

An unfriendly and humiliating parental relationship with their children was a special issue for adolescents and it formed the second theme. Participants explained that this kind of relationship caused a sense of loneliness, of not being understood, of not having been guided by parents and resulted in decreased participation in family activities. ‘Becoming depressed’ and ‘feeling unhealthy’ were revealed as consequences of an unfriendly and humiliating relationship. As one of the participants, a 14‐year‐old male described: ‘I feel that I am collapsed and crushed when they [my parents] punish me, I'm completely unhealthy when they yell at me.’

TRADITIONAL PARENTS

Some of the participants complained about parents who held traditional values. Participants revealed that they experienced more change, sometimes unwanted change related to use of the internet and satellite media. Adolescents explained that the more they used the internet, the more their pseudo‐needs developed, the more their interest in fashion grew, the more challenges evolved and the wider the gap between adolescents and their parents became.

Adolescents believed that traditional parents could not understand social changes and modernity, which was important from the adolescent perspective. As one 19‐year‐old female described: ‘parents don't understand changes; they should know that everything is changing, so we shouldn't be like them; we shouldn't do the same things they did’.

Theme 2: Effective parenting

Effective parenting was the second main category with three sub‐categories: parental responsibility in adolescent health promotion; abstinence from alcohol and smoking in parents' presence; and parental conflict as an inhibiting factor of adolescent health.

PARENTAL RESPONSIBILITY IN ADOLESCENT HEALTH PROMOTION

Parental responsibility in adolescent health promotion was described as an important factor in adolescent health according to all participants. Participants believed that parents are responsible for the protection and promotion of their children's health. Adolescents stated that they expected the following from their parents: good communication; teaching life skills; identity development; nurturing of self‐esteem and provision of comfort and peace. These themes are clearly revealed in the following quotations: ‘parents should help us to understand the meaning of life, but every morning they take us to school; they register our names in extra classes. They do many things for us, but ultimately we don't know how to live.’ An 18‐year‐old male participant stated ‘If I had a daughter, I would never push her to do this or that; I would teach her how to live; I would make her free to make decisions – even wrong ones – these would be useful for her development’.

Our participants pointed out that parents are responsible for making a safe, warm environment for their children so that they would prefer being at home to being elsewhere. Adolescents complained about their parents repetitious dos and don'ts; as one 19‐year‐old female described: ‘We are fed up with our parents telling us to study, to think of university entrance exams; we never played or watched cartoons. They think that our school status is all our future’.

ABSTINENCE FROM ALCOHOL AND CIGARETTES IN THEIR PARENTS' PRESENCE

Abstinence from alcohol and cigarettes in their parents' presence, because of a sense of shame and out of respect for their parents, has been revealed as an imposed health promotion factor. Although adolescents often complain about limitations imposed by their families, some have had good experiences of such family limitations. Many adolescents speak of travelling and picnicking with their family as a turning point in their teenage life, due to self‐limitation out of respect for their family. As one 18‐year‐old male stated: ‘The time when I was completely healthy was when travelling, because I was with my family, and I couldn't smoke or drink in their presence’.

PARENTAL CONFLICT AS A NEGATIVE FACTOR IN ADOLESCENT HEALTH

The adolescents studied held the views that family has a fundamental supportive role in the psychological aspect of adolescent health and that parental conflict was a negative factor in adolescent health. Participants believed that children are usually the ‘blameless victims’ of parental conflict, which may create many difficulties in adulthood. As one 14‐year‐old male said: ‘My mother and father are fighting with each other so they cannot be kind to me. I failed school last year because of their constant conflicts at home. But they don't see their own problems, only mine’.

Theme 3: The family financial situation

The last category was the family financial situation, which contains the two sub‐categories of parental overload and parental unemployment.

PARENTAL OVERLOAD

Parental overload as a consequence of their financial situation was an important factor in adolescent health as parental stress was generated by overwork. According to the participants, the financial situation as well as the inflation rate, which forced parents to have several jobs, had major implications for both adolescent and family health. Challenges presented themselves as families experienced an ‘imposed modernity’ as mothers changed their role and entered into paid employment. This change in role meant that they could not integrate the family in the same way as they could when they were solely in the homemaker role, nor could they answer the emotional needs of their adolescent children as effectively. These challenges regarding the strong supportive and caring role of the family are, and will be, more important in an oriental culture such as that of Iran.

Participants perceived that fatigued parents, who had several jobs, did not know about their teenagers' developmental needs and were completely out of reach, could limit the potential for adolescent health, and this could also be the case for unemployed parents. Adolescents expected emotional and psychological support more than a nurturing and physiological role from their parents and participants believed that the more parents worked the less the emotional attention they would pay to their children. ‘Now both of our parents have to work; there won't be anyone to talk to, even a short chat; they have no more time and energy to pay attention to their children’. An 18‐year‐old male and 16‐year‐old girl added: ‘they don't know that we need their individual affection and care more than the money they give us’.

Parental unemployment and inflation was another aspect of financial problems identified as important to both adolescent and family health. As one 15‐year‐old male participant put it: ‘I think poverty and a bad financial family situation will cause family problems’.

The main themes and some of the sub‐themes will be developed further in the discussion.

In general, qualitative research methods search for answers from the broader social context. The closer we get to the natural state in which health research data are collected, the fewer the limitations that will exist in translating the findings into real‐life applications. According to the participants in this study, the family has a vital role to play in adolescent health.

Methodological considerations

While this study was conducted in a qualitative manner, potential limitations still exist. The naturalistic paradigm of the study and the deeper meaning of health can limit the generation of the findings. The researchers in this study asked about the health of the participants without considering which of the three stages of adolescence – early, middle or late – participants were negotiating. In order to gain a clearer and deeper understanding of adolescent health beliefs, participants' developmental stage could have been considered.

The study also has the limitation that the same female researcher (SP) interviewed both male and female adolescents. Although there were rich data extracted from male participants, in a traditional and religious culture such as that in Iran, males might have had fewer cultural inhibitions and less sense of shyness with a same‐sex interviewer, especially regarding the topics of health and sexual behaviour.

No data were collected for those adolescents who declined to participate, or who asked for their tapes or their transcripts, because of the informed consent process.

Strengths of the study design were that transcripts and codes were reviewed by a variety of people including participants, non‐participant adolescents, colleagues and researchers. As a result of this thorough process the results may be transferable to groups and contexts similar to those represented by the adolescents in this study. Prolonged engagement with participants, maximum variation of sampling and good communication skills have contributed to the deep and rich data gathered in this research.

Theme 1: The widening generation gap

As our participants stated, the widening generation gap can affect both family and adolescent health. The widening gap between generations, social trends, modernity and more virtual communication along with socialisation will increasingly aggravate the problems of the adolescents' traditional families. Our female participants disagreed more with the family's functions and the traditional role of their parents because of the greater limitations and narrower restrictions which they have experienced. Adolescent–parent challenges have also been emphasised in other studies. Independence is important to adolescents, but it is family consistency that matters to parents. The challenges are in these areas: housing, rules and regulations, nutrition and sleep patterns, as well as same‐sex and opposite sex friendships. 20 Moreover, troubled relationship with parents and siblings were significant predictors of smoking in Iranian adolescents, notably in girls. 13

Parents can have an influence on promoting beneficial adolescent health behaviours and reducing risky behaviours. 2 Open and responsive communication, the provision of an appropriate level of supervision and keeping involved in children's lives are associated with better adolescent outcomes in identity formation. 20 , 21 Participants revealed that both they and their parents need more knowledge and better practices to pass through this unstable stormy developmental period. From the adolescents' point of view, schools and media should teach them, though this is already happening. Health care activists, family and school health nurses can be effective in these areas. Community health nurses should have a better understanding of the family changes as they are familiar with the transactions between adolescents and families. According to Allender and Spradley this understanding can help them to develop more appropriate models and thus to solve family problems. 22

Unfriendly communication is a challenging issue for both children and parents. The less the parents know about the characteristics of adolescence, the more communication conflicts they will experience. This may be because of the traditional supervisory role of the parents on the one hand, and adolescents' need for independence and for a supportive and informative parental relationship on the other hand.

Changing social norms affects adolescent health in different ways. Traditional parents were targets of complaint because of the limitations that they imposed on adolescents. Because of the sense of limitation, these challenges between adolescents and parents are common in research literature on adolescents. 20 , 21

According to Tsai and Wong, in their qualitative study on adolescent pregnancy in Taiwan, weakening family bonds, cultural changes and a widening generation gap could increase the risk of adolescent pregnancy. 23

With regard to education, the imposition of study and majors was another specific issue mentioned by a number of adolescents. Participants claimed that parents tried to enact their own unachieved desires through their children and failed to respect their children's inclinations and talents. The imposed study and majors could also worsen the communication challenges between the two generations. As a result of worry about drug availability, parents push their children to study in order for them to remain protected; a fact which, in turn, creates additional tensions in the families. In one qualitative study, a specific concern mentioned by a number of parents was that of their children's education. 24

The importance of an effective parental role and a warm home environment were emphasised by the participants. The findings of Mollahasani's research on Iranian adolescents showed that adolescents needed their parents to play an active parental role or else they would search for this support outside their home. 25 This would indirectly increase the probability of drug addiction. This is an important point as Iran is a high‐risk country for illicit substance misuse as it is a transit path for drug traffickers because of its geographical location. So an effective family and conscientious parents will both be important in preventing adolescent addiction. The mentioned study supports our participants' claims that parents care for adolescents' physical needs, but that psychological needs are more important from the adolescent perspective. 25 As our participants said, parents were responsible for ‘preparing a secure, free, warm and relaxed atmosphere at home’, ‘avoiding family conflicts’ and ‘being kind to their children’. Community health nurses can help both adolescents and their parents by teaching them communication skills. 26

According to another study, respondents who perceived the parental relationship in the family to be moderate or poor felt lower satisfaction as well as a more negative attitude towards life; they had lower self‐esteem, and experienced a more depressed mood than those who reported a good parental relationship. 27 Adolescents who have maternal warmth and attachment, who have caring parents and who are expected by their parents to have high academic achievement are at a lower risk of becoming addicted to drugs. Having appropriate familial relationships and living in an effective family could also decrease the risk of adolescent addiction problems. Parental availability during special times when family members assemble together, for example at dinner time, will help to protect adolescents from addiction 28 , 29 and better family support is associated with lower levels of risk behaviour in adolescents. 30

The importance of the family's financial situation was emphasised by the participants. We make the supposition that the consequences of financial problems, which resulted in parents caring more for the physiological rather than the emotional needs of children, received more criticism from adolescents than the economic problems themselves. Participants perceived that both unemployed parents and fatigued parents who had several jobs frequently did not know about their teenagers' developmental needs, and were completely out of reach of their adolescents so could negatively impact upon their children's health. Some of our participants talked about ‘adolescent health’ and ‘economic justice’ as being inextricably linked. Adolescents' social sensitivity, idealism and comparison with peers contributes to a sense that their health is dictated by divisions in society. Social welfare and adolescents' participation in part‐time jobs can increase their income, enhance their self‐esteem and improve their health perception.

Families change in response to economic conditions. 31 Many studies have recognised the central role of socioeconomic factors in determining both adolescent and family health. The physical and mental health of adolescents is related to the structure of their families, their educational attainment, current economic conditions and personal allowances. 27 , 32 Furthermore, perceived family functioning was concurrently related to measures of adolescent psychological wellbeing (existential wellbeing, mastery, life satisfaction, self‐esteem and general psychiatric morbidity) and problem behaviour (substance abuse and delinquency) in Shek's longitudinal study. 33

Nurse educators, especially in developing countries that are experiencing a transitional trend, could incorporate the findings of this study into family health nursing education programmes for both public health nurses and students in order to help families develop a better understanding of adolescent health needs. Community and public health nurses should be encouraged to periodically orientate others about adolescent interaction with peers, family and health and the interaction with social factors. Family and school health services should be encouraged to improve both parental and adolescent health by enhancing parental and adolescent communication skills and by keeping parents informed about adolescent changes related to emerging social trends.

Further research is necessary to test which of these interventions is more effective. Other research questions that might be helpful include the following:

What are the effective factors in attaining optimal adolescent health?
Which familial and sociocultural changes might be helpful in enhancing adolescent health outcomes?
What are the experiences and the processes of being and remaining healthy in different adolescent groups?

The family has a fundamental role to play in adolescent health. The participants of this study emphasised three main categories associated with health outcomes: a widening generation gap, effective parenting and family financial situation.

Both adolescents and parents need to know more about how to participate in a healthy family that will train healthy adolescents with more effective social responsibility based on their own realistic plans for their future lives.

ACKNOWLEDGEMENTS

We gratefully acknowledge the very helpful participation of adolescents as well as school staff without whose contribution this study would not have been completed.

The authors also gratefully acknowledge Professor Helena Leino‐Kilpi (Nursing Department, Turku University, Finland) for her very helpful comments.

Our special thanks are dedicated to Mr Ahmadreza Farzaneh Nejad (TUMS) and Mr Damon Tringham (Turku University, Finland) who proofread the earlier manuscript and edited the English version of the article.

This article is written based on the investigator's PhD dissertation at the faculty of Nursing and Midwifery, TUMS; therefore, the official support of TUMS is also acknowledged.

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Soroor Parvizy, Assistant Professor, Nursing and Midwifery Faculty, Iran University of Medical Sciences, Tehran, Iran.

Fazlollah Ahmadi, Associate Professor, Nursing Department, Faculty of Medicine, Tarbiat Modarres University, Tehran, Iran.

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Adolescent Development and the Biology of Puberty: Summary of a Workshop on New Research (1999)

CHANGES IN THE STUDY OF ADOLESCENT DEVELOPMENT

KEY FINDINGS OF RECENT STUDIES

RESEARCH CHALLENGES

POLICY CHALLENGES

IMPROVING PUBLIC UNDERSTANDING

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Child and Adolescent Development

A qualitative study on adolescence, health and family

Fazlollah Ahmadi

Introduction

The Iranian context and related studies

Methodology

Sample and data collection method

Ethical considerations

Data analysis

Box 1 Data analysis process

Data credibility

Participant characteristics

Themes and sub‐themes

Box 2 Emerged themes and sub‐themes

Theme1: The widening generation gap

PARENTAL LACK OF KNOWLEDGE ABOUT ADOLESCENT HEALTH RISK FACTORS AND CHARACTERISTICS

AN UNFRIENDLY AND HUMILIATING PARENTAL RELATIONSHIP WITH THEIR CHILDREN

TRADITIONAL PARENTS

Theme 2: Effective parenting

PARENTAL RESPONSIBILITY IN ADOLESCENT HEALTH PROMOTION

ABSTINENCE FROM ALCOHOL AND CIGARETTES IN THEIR PARENTS' PRESENCE

PARENTAL CONFLICT AS A NEGATIVE FACTOR IN ADOLESCENT HEALTH

Theme 3: The family financial situation

PARENTAL OVERLOAD

Methodological considerations

Theme 1: The widening generation gap

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