Ethical And Professional Issues In Psychology Testing

Ethical And Professional Issues In Psychology Testing

Create a PowerPoint presentation with 16 to 20 slides (not including the title and reference slides) entitled Ethical and Professional Issues in Psychological Testing. Your presentation must provide 2 to 3 slides for each of the required topics and include appropriate citations of your referenced sources. Separate reference slides, which follow APA formatting guidelines for a References page, must be included at the end of the presentation. You must create your own template and organize your presentation in the sequence provided. Do not use a font smaller than 20 pt. You are encouraged to insert relevant figures and graphics. Make sure to appropriately cite any images you use. If you include a table or figure from a journal article, cite it according to APA guidelines. The notes section of each slide must include the text for oral comments you would make while presentating the materials to a live audience.

References must be cited according to APA. For assistance with creating a visually engaging and readable presentation, you may review Garr Reynolds’s tips for creating presentations (Links to an external site.).

The presentation must cover each of the following topics in the order presented below.

The Ethical and Social Implications of Testing

  • Provide an overview and brief evaluation of the ethical and social implications of psychological assessment.

Professional Responsibilities

  • Describe the responsibilities of both test publishers and test users.

Testing Individuals Representing Cultural and Linguistic Diversity

  • Analyze and describe issues related to the testing of cultural and linguistic minorities.

Reliability

  • Explain the common sources of measurement error and how measurement error can impact reliability.

Validity 

  • Create a diagram or figure to compare the types of validity discussed in the textbook.
  • Describe the extravalidity concerns related to testing.
  • Review the articles by Fergus (2013), Kosson, et al. (2013) and Mathieu, Hare, Jones, Babiak, & Neumann (2013). Analyze the information presented in these articles on factor analysis and describe how it is used to validate the constructs of the instruments.

Clinical Versus Statistical Prediction

  • Compare clinical and statistical prediction of mental health decisions based on the work of Ægisdóttir, et al. (2006) and Grove & Lloyd (2006).

Application One: An Ethical and Professional Quandry

Application Two: Evidence-Based Medicine

  • Summarize Youngstrom’s (2013) recommendations for linking assessment directly to clinical decision making in evidence-based medicine.
  • Elaborate on each of Youngstrom’s recommendations by providing practical examples that illustrate the relevance of the recommendations in a clinical setting.

Application Three: Selecting Valid Instruments

  • Create a research hypothesis or brief clinical case scenario in which you must select an instrument to measure intolerance for uncertainty.
  • Use the information in the Fergus (2013) article to support which measure to use.

The presentation

  • Must consist of 16 to 20 slides (not including title and reference slides) that are formatted according to APA style
  • Must include a separate title slide with the following:
    • Title of presentation
    • Student’s name
    • Course name and number
    • Instructor’s name
    • Date submitted
  • Must use the assigned chapters in the course text, Standard 9 from the American Psychological Association’s Ethical Principles of Psychologists and Code of Conduct, and the 3 required peer-reviewed articles assigned for Week One.
  • Must document all sources in APA style
  • Must include separate reference slides formatted according to APA style
 
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Psychology SOCW 6311 & 6070 Wk 3 Responses homework help

Psychology SOCW 6311 & 6070 Wk 3 Responses homework help

RESPONSE 1

Respond to at least two colleagues by doing all of the following:

  • Offer an analysis of their evaluations and subsequent      recommendation. Note both strengths and areas that could be improved. 
  • Identify areas where your own original recommendations or      evaluation was similar to or different from your colleagues’ original      evaluation and explain why.

Colleague 1: Kamran

Chris the social worker and her team of caseworkers are using a strategy that blends elements of geriatric case management with short-term treatment methods, they are primarily using the solution-focused and task-centered models. As part of their continuous practice, the team regularly conducts practice evaluations.  To evaluate its practice approach, the team used a multiple-baseline, single-subject design. Each of the full-time case managers on the team selected one client new to the caseload to participate in the study. The research project is explained to clients by their respective case manager and sign informed consent paperwork in order to participate. As part of the practice process, the case manager uses clinical rating scales that are adapted from the task-centered model. At the beginning of each client meeting, the case manager and client collaboratively evaluate how well the practice steps or tasks that are undertaken by the client and/or case manager were completed using a 10-point clinical scale. While concurrently, they evaluated changes to the respective client problems, also using a 10-point clinical scale (Plummer Makris & Brocksen, 2014b).

The outcome of Chris’s study with her client George would lead me to adopt this model of case management with solution focused and task-centered approaches because the basic logic underlying single subject research (SSR) is straightforward. Data on the behavior of interest which is collected over a period of time until the baseline rate is clearly established.  The intervention then introduced as data continue to be collected. Repeated measurement of the dependent variables over a period of time, is central to SSR. being accurate with high levels of control and validity (Mattaini, 2010). Also, Chris and her team met many quality indicators, that must be present and adequately addressed for a study to be a credible example of single-subject research which includes a description of participants and setting, dependent variable, independent variable, baseline, experimental control/internal validity, external validity, and social validity (Tankersley, Cook, & Cook, 2008). Chris and her team are doing clinical practice research by using a single-subject design because they are fairly easy to implement and can provide very useful information on a case level. While their empirical strength is often considered weak, their applicability and usefulness make them a good method for clinical practice and, if following multiple baseline designs, they can provide good research data as well (Plummer, Makris & Brocksen, 2014b).

I believe that Chris and her team’s research and the data that they recorded in the study and outcomes are adequate to be considered as evidenced-based research in order to support some types of programs. If Chris and her coworkers wanted to submit the study to an evidence-based practice registry, they may be required to develop and add an evaluation segment to their documentation. Other factors that Chris’s team should consider is how individuals with certain characteristics will respond to the intervention, and how the sampling variability was done. The study Chris and her colleagues conducted is I believe is sufficient to state that it is a form of evidence-based practice. The study might have met their needs for their organization, although it could use more detail in many aspects of their research process to be considered an actual program in an evidenced-based registry (Dudley, 2010).

References

Dudley, J. R. (2014). Social work evaluation: Enhancing what we do. (2nd ed.) Chicago, IL: Lyceum Books. Chapter 9, “Is the Intervention Effective?” (pp. 226-244)

Mattaini, M. A.(2010). Single-system studies. In B. Thyer (Ed.). The handbook of social research methods (2nd ed., p.241-273). Thousand Oaks, CA: SAGE. (PDF)

Plummer, S.-B., Makris, S., & Brocksen S. (Eds.). (2014b). Social work case studies: Concentration year. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader]. Social Work Research: Single Subject (pp. 70–72)

Tankersley, M., Cook, B. G., & Cook, L. (2008). A preliminary examination to identify the presence of quality indicators in single-subject research. Education & Treatment of Children, 31(4), 523–548.

Colleague 2: Rachel

Chris is a MSW for a geriatric case management program that wants to evaluate the effectiveness of short-term treatment approach, combining case management was solution-focused and task-centered goals with a practice approach of a multiple-baseline, single-subject design.  Chris is client, George enter the program after he was hospitalized for fainting in public. There was no medical reasoning for his feet other than signs of slight cognitive impairments and dementia.  The caseworker did an assessment of needs for the client which included personal care, decrease in mobility, and longer-term planning around living arrangement and home safety. At the beginning of each session, the client and social worker evaluated the task-centered approach on a 10 point scale.  The results showed that most needs were at least partially addressed and some task were completed.  The outcome of Chris’s study with her client George would lead me to adopt the model of case management which solution focused on task centered approach is because it is a collaborative approach including the client. The client is able to generate task with the social worker that are measurable and reachable.  George previously lost his wife two years ago, so the task centered model would help to keep him busy with a smaller chance of depression symptoms.  Also, the social worker and client are collaboratively scoring the task at the beginning of each session which allows the client to review his progress.  One recommendation for improvement Chris could consider is treatment for his slight cognitive impairments and dementia. These factors could greatly improve his scores each session. Due to these factors, he could be doing great at completing tasks at home, but may not be able to recall during his sessions.  Although I would personally adopt this model, if Chris wanted to submit their intervention to an evidence-based registry, she would have to provide more research (Plummer, Makris, & Brocksen, 2014).

Reference:

Plummer, S.-B., Makris, S., & Brocksen S. (Eds.). (2014b). Social work case studies: Concentration year. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader].“Social Work Research: Single Subject” (pp. 70–72)

 

RESPONSE 2

Respond to at least two colleagues by addressing an example in each colleague’s post in at least one of the following ways:

  • Suggest a strategy for addressing a situation that your      colleague described in one of his or her examples. 
  • Offer additional thoughts regarding the impact of the interaction      described in the example.

Colleague 1: MaShunda

How a social work administrator’s personal leadership philosophy style may influence a human service organization culture

The culture of an organization can affect how business if being completed with stakeholders, clients, workers and the community. Leadership philosophy style can dictate and affect the culture of an organization. If the culture of administration is Authoritarian, others may find that while the administration is well organized,  it can also be controlling and individuals are not allowed to have a say in what is taking place within the organization which can diminish how a person views his or goals within the organization (Northhouse, 2018). Example, when I worked for the Department of Social Services we were not allowed to socialize with colleagues, we had to always share with our supervisor what we were doing (even share when we were going to the restroom), we had a set quota of work that needed to be completed each day (even if you were the person that was doing intake for the day), and workers were never given the opportunity to share their concerns. This made for a very stressful work environment and a high turnover rate within the department. On the other hand, this could be the perfect administration for someone just starting out in the human service field, due to the authoritarian style being more structure it will a good learning environment (Northhouse, 2018).

In a Democratic organization, administration shows a willingness to assist each other and work together to complete a common goal. This organization may not be as organized as an authoritative organization but does give individuals that opportunity to grow, is goal orientated, and work with followers (Northhouse, 2018). Example, in the organization that I currently work for I am a community-based worker so supervision is minimal most of the time. The company is very knowledgeable about staff goals and always attempts to assist staff in reaching their goals.   Workers make their own schedules but meet with supervisors weekly to discuss how administration challenges impact their work. Although I am in the field, I still feel as if I am apart of the organization and that may need are being met. Most of the individuals that I have met while working with this organization have been there for years due to the administration often hiring from within and learning staff goals and strengths. The downside is that there is no real structure because you are by yourself most of the time and the individuals have to be task-oriented to ensure that agency and client expectation are met.

Explain how the organization’s culture might influence a social worker administrators personal leadership style

An administrator leadership style is often times dictated by the culture of the organization. As an administrator, I have found that my personal leadership style is more on the Democratic side so working within an organization that has a totally authoritative culture is a little difficult for me at times. I like to take into consideration what is taking place with followers, learn the strengths of staff and make adjustments accordingly and in an authoritative culture, this is not always acceptable behavior. Also, I come from an educational career path so I love teachable moments and to assist individuals with reaching goals. I do believe in meeting the needs of the agency but in my opinion, you don’t have to be authoritative to get the job done. I feel as if I cannot share my thoughts or creative side then I am doing the agency or organization and injustice and stifling the chances of growth.

Explain how interactions with stakeholders may ultimately impact the organization’s treatment of clients

In dealing with stakeholders that sway more to towards the Theory X way of doing business, the organization may not take into consideration how the client feels or if client needs are always being met. Theory X stakeholder may only see the bottom line which could take away the human side of dealing with a client in the community or office setting. Stakeholders taking on this style may not have much communication with clients because they are only sharing with organization how they need to address clients.

If stakeholders are more of the Theory Y type, then the client may be apart of addressing how the organization does business. In this setting, stakeholders may take the time to build relationships with the clients and become aware of personal and environmental needs. These stakeholders may be very in tune with the needs of the client by may be less in tune as to how the company should be structured to meet such needs.

Reference

Northhouse, P. G. (2018). Introduction To Leadership Concepts and Practice. Fourth Edition. Washington, D.C: Sage.

Colleague 2: Daneilia

Personal Leadership Philosophy and Style

A social work administrator’s leadership philosophy and style may influence a human services organization’s culture by the nature and behavior of the work executed (Northouse, 2018).  The social work administrator can be influential through one’s demeanor and thought process.  For example, as an administrator, I believe that individuals will work if I am motivated and can do the things I ask others to do.  Therefore, emphasizing I understand the job, or I am willing to learn the job, and I am open to suggestions or opinions.

The Organization’s Culture Influence Leadership Style

The organization’s culture can be an influential component in one’s leadership style.  If the organization’s focus is on interaction with people, then the leader may take on a relationship style.  Relationship style is defined by the moment when interacting with another individual or group (Northouse, 2018).  The leader might not be an extremely social person, but because of the work environment, the leader might socially project themselves.  Alternatively, depending on the agency, the culture may lean on laissez-faire, and it is a to each their own and everyone is self-sufficient.  A leader in this situation might have to take down a high functioning style to a relaxed, laid-back style.

Interactions with Stakeholders Are Influential

Interactions with stakeholders such as community members are influential to the impact on the treatment of clients.  If community members feel that there may be the unjust treatment of clients or that a policy needs to be reformed to give more efficient coverage, the delivery of services may need altering.  There is a possibility of missing something during a client’s session that is dominantly seen in a majority of the clients’ sessions.  The organization’s staff may have issues with the practices used to treat clients.  The staff might have findings of the specific practices used by the organization not efficient for the use of the population in which one treats.  Therefore, the request to use various other practices or incorporating other resources during therapy may be encouraged or demanded.

Reference

Northouse, P. G. (2018). Introduction to leadership: Concepts and practice (4th ed.). Washington, DC: Sage.

 
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Discussion: Intervention Strategies

Discussion: Intervention Strategies

Free Mental Health Case Study: Case 1

Li was an 18-year-old high school student. He had always been an average student, hardworking and honest. Recently, however, his mother had noticed that Li had been staying out till late at night, his school grades had been falling, and he was spending more money. The previous week, his mother noticed that some money was missing from her purse. She was worried that Li might have stolen it. She had also noticed that Li was spending less time with his old friends and family, and seemed to be hanging around with a new group of friends, whom he did not introduce to his parents. His mother had suggested to him that he should see a counsellor, but he refused. The health worker decided to visit Li at home. Li was very reluctant to discuss anything at first. However, as he became more trusting of the health worker, he admitted that he had been using heroin regularly for several months, and now he was ‘hooked’. He had tried to stop on many occasions, but each time he felt so sick that he just went back to the drug. He said he wanted help but did not know where to turn.

What’s the problem? Li had become dependent on heroin. Because of his dependence, his school performance had suffered and he had been seeing new friends who also use drugs. He had been stealing things to pay for the drug.

Free Mental Health Case Study: Case 2

Ismail was a 25-year-old college student who was brought by past year and had started locking himself in his room. Ismail used to be a good student but had failed his last exams. His mother said that he would often spend hours staring into space. Sometimes he muttered to himself as if he were talking to an imaginary person. Ismail had to be forced to come to the clinic by his parents. At first, he refused to talk to the nurse. After a while he admitted that he believed that his parents and neighbors were plotting to kill him and that the Devil was interfering with his mind. He said he could hear his neighbors talk about him and say nasty things outside his door. He said he felt as if he had been possessed, but did not see why he should come to the clinic since he was not ill.

What’s the problem? Ismail was suffering from a severe mental disorder called schizophrenia. This made him hear voices and imagine things that were not true.

Free Mental Health Case Study: Case 3

Maria was a 31-year-old who has been brought to the clinic by her husband because she had started behaving in an unusual manner a week previously. She was sleeping much less than usual and was constantly on the move. Maria had stopped looking after the house and children as efficiently as before. She was talking much more than normal and often said things that were unreal and grand. For example, she had been saying that she could heal other people and that she came from a very wealthy family (even though her husband was a factory worker). She had also been spending more money on clothes and cosmetics than was normal for her. When Maria’s husband tried to bring her to the clinic, she became very angry and tried to hit him. Finally, his neighbors had helped him to force her to come.

What’s the problem? Maria was suffering from a severe mental disorder called mania. This made her believe grand things and made her irritable when her husband tried to bring her to the clinic.

From Mental health articles post Free Mental Health Case Study

 

 
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Developmental Psychology homework help

Developmental Psychology homework help

section six

 

In no order of things is adolescence the simple time of life.

—Jean Erskine Stewart

American Writer, 20th Century

Adolescence

Adolescents try on one face after another, seeking to find a face of their own. Their generation of young people is the fragile cable by which the best and the worst of their parents’ generation is transmitted to the present. In the end, there are only two lasting bequests parents can leave youth—one is roots, the other wings. This section contains two chapters: “Physical and Cognitive Development in Adolescence” and “Socioemotional Development in Adolescence.”

Page 337

chapter 11
PHYSICAL AND COGNITIVE DEVELOPMENT IN ADOLESCENCE
chapter outline

1 The Nature of Adolescence

Learning Goal 1  Discuss the nature of adolescence.

2 Physical Changes

Learning Goal 2  Describe the changes involved in puberty, as well as changes in the brain and sexuality during adolescence.

Puberty

The Brain

Adolescent Sexuality

3 Issues in Adolescent Health

Learning Goal 3  Identify adolescent problems related to health, substance use and abuse, and eating disorders.

Adolescent Health

Substance Use and Abuse

Eating Disorders

4 Adolescent Cognition

Learning Goal 4  Explain cognitive changes in adolescence.

Piaget’s Theory

Adolescent Egocentrism

Information Processing

5 Schools

Learning Goal 5  Summarize some key aspects of how schools influence adolescent development.

The Transition to Middle or Junior High School

Effective Schools for Young Adolescents

High School

Extracurricular Activities

Service Learning

image1 ©Image Source/Getty Images

Fifteen-year-old Latisha developed Page 338a drinking problem, and she was kicked off the cheerleading squad for missing too many practice sessions—but that didn’t make her stop drinking. She and her friends began skipping school regularly so they could drink.

Fourteen-year-old Arnie is a juvenile delinquent. Last week he stole a TV set, struck his mother and bloodied her face, broke some streetlights in the neighborhood, and threatened a boy with a wrench and hammer.

Twelve-year-old Katie, more than just about anything else, wanted a playground in her town. She knew that the other kids also wanted one, so she put together a group that generated funding ideas for the playground. They presented their ideas to the town council. Her group attracted more youth, and they raised money by selling candy and sandwiches door-to-door. The playground became a reality, a place where, as Katie says, “People have picnics and make friends.” Katie’s advice: “You won’t get anywhere if you don’t try.”

Adolescents like Latisha and Arnie are the ones we hear about the most. But there are many adolescents like Katie who contribute in positive ways to their communities and competently make the transition through adolescence. Indeed, for most young people, adolescence is not a time of rebellion, crisis, pathology, and deviance. A far more accurate vision of adolescence is that it is a time of evaluation, decision making, commitment, and carving out a place in the world. Most of the problems of today’s youth are not with the youth themselves, but with needs that go unmet. To reach their full potential, adolescents need a range of legitimate opportunities as well as long-term support from adults who care deeply about them (Miller & Cho, 2018; Ogden & Haden, 2019).

image2 Katie Bell (front) and some of her volunteers.  ©Ronald Cortes

topical connections looking back

In middle and late childhood, physical growth continues but at a slower pace than in infancy and early childhood. Gross motor skills become much smoother and more coordinated, and fine motor skills also improve. Significant advances in the development of the prefrontal cortex occur. Cognitive and language skills also improve considerably. In terms of cognitive development, most children become concrete operational thinkers, long-term memory increases, and metacognitive skills improve, especially if children learn a rich repertoire of strategies. In terms of language development, children’s understanding of grammar and syntax increases, and learning to read becomes an important achievement.

preview

Adolescence is a transitional period in the human life span, linking childhood and adulthood Page 339. We begin the chapter by examining some general characteristics of adolescence and then explore the major physical changes and health issues of adolescence. Next, we consider the significant cognitive changes that characterize adolescence and conclude the chapter by describing various aspects of schools for adolescents.

1 The Nature of Adolescence

LG1 Discuss the nature of adolescence.

As in development during childhood, genetic/biological and environmental/social factors influence adolescent development. During their childhood years, adolescents experienced thousands of hours of interactions with parents, peers, and teachers, but now they face dramatic biological changes, new experiences, and new developmental tasks. Relationships with parents take a different form, moments with peers become more intimate, and dating occurs for the first time, as do sexual exploration and possibly intercourse. The adolescent’s thoughts become more abstract and idealistic. Biological changes trigger a heightened interest in body image. Adolescence has both continuity and discontinuity with childhood.

There is a long history of worrying about how adolescents will “turn out.” In 1904, G. Stanley Hall proposed the “storm-and-stress” view that adolescence is a turbulent time charged with conflict and mood swings. However, when Daniel Offer and his colleagues (1988) studied the self-images of adolescents in the United States, Australia, Bangladesh, Hungary, Israel, Italy, Japan, Taiwan, Turkey, and West Germany, at least 73 percent of the adolescents displayed a healthy self-image. Although there were differences among them, the adolescents were happy most of the time, they enjoyed life, they perceived themselves as able to exercise self-control, they valued work and school, they felt confident about their sexual selves, they expressed positive feelings toward their families, and they felt they had the capability to cope with life’s stresses—not exactly a storm-and-stress portrayal of adolescence.

Public attitudes about adolescence emerge from a combination of personal experience and media portrayals, neither of which produces an objective picture of how normal adolescents develop (Feldman & Elliott, 1990). Some of the readiness to assume the worst about adolescents likely involves the short memories of adults. Many adults measure their current perceptions of adolescents by their memories of their own adolescence. Adults may portray today’s adolescents as more troubled, less respectful, more self-centered, more assertive, and more adventurous than they were.

image3Growing up has never been easy. However, adolescence is not best viewed as a time of rebellion, crisis, pathology, and deviance. A far more accurate vision of adolescence describes it as a time of evaluation, of decision making, of commitment, and of carving out a place in the world. Most of the problems of today’s youth are not with the youth themselves. What adolescents need is access to a range of legitimate opportunities and to long-term support from adults who care deeply about them. What might be some examples of such support and caring?  ©Regine Mahaux/The Image Bank/Getty Images

However, in matters of taste and manners, the young people Page 340of every generation have seemed unnervingly radical and different from adults—different in how they look, in how they behave, in the music they enjoy, in their hairstyles, and in the clothing they choose. It would be an enormous error, though, to confuse adolescents’ enthusiasm for trying on new identities and enjoying moderate amounts of outrageous behavior with hostility toward parental and societal standards. Acting out and boundary testing are time-honored ways in which adolescents move toward accepting, rather than rejecting, parental values.

Negative stereotyping of adolescence has been extensive (Jiang & others, 2018; Petersen & others, 2017). However, much of the negative stereotyping has been fueled by media reports of a visible minority of adolescents. In the last decade there has been a call for adults to have a more positive attitude toward youth and emphasize their positive development. Indeed, researchers have found that a majority of adolescents are making the transition from childhood through adolescence to adulthood in a positive way (Seider, Jayawickreme, & Lerner, 2017). For example, a recent study of non-Latino White and African American 12- to 20-year-olds in the United States found that they were characterized much more by positive than problematic development, even in their most vulnerable times (Gutman & others, 2017). Their engagement in healthy behaviors, supportive relationships with parents and friends, and positive self-perceptions were much stronger than their angry and depressed feelings.

image4 ©RubberBall Productions/Getty Images

Although most adolescents negotiate the lengthy path to adult maturity successfully, too large a group does not. Ethnic, cultural, gender, socioeconomic, age, and lifestyle differences influence the actual life trajectory of each adolescent (Green & others, 2018; Hadley, 2018; Kimmel & Aronson, 2018; McQueen, 2017; Ruck, Peterson-Badali, & Freeman, 2017). Different portrayals of adolescence emerge, depending on the particular group of adolescents being described. Today’s adolescents are exposed to a complex menu of lifestyle options through the media, and many face the temptations of drug use and sexual activity at increasingly young ages (Johnston & others, 2018). Too many adolescents are not provided with adequate opportunities and support to become competent adults (Bill & Melinda Gates Foundation, 2018; Edalati & Nicholls, 2018; Lo & others, 2017; Loria & Caughy, 2018; Miller & Cho, 2018; Umana-Taylor & Douglass, 2017).

Recall that social policy is the course of action designed by the national government to influence the welfare of its citizens. Currently, many researchers in adolescent development are designing studies that they hope will lead to wise and effective social policy decision making (Duncan, Magnuson, & Votruba-Drzal, 2017; Galinsky & others, 2017; Hall, 2017).

Research indicates that youth benefit enormously when they have caring adults in their lives in addition to parents or guardians (Frydenberg, 2019; Masten, 2017; Masten & Kalstabakken, 2018; Ogden & Hagen, 2019; Pomerantz & Grolnick, 2017). Caring adults—such as coaches, neighbors, teachers, mentors, and after-school leaders—can serve as role models, confidants, advocates, and resources. Relationships with caring adults are powerful when youth know they are respected, that they matter to the adult, and that the adult wants to be a resource in their lives. However, in a survey, only 20 percent of U.S. 15-year-olds reported having meaningful relationships with adults outside their family who were helping them to succeed in life (Search Institute, 2010).

Review Connect Reflect

LG1 Discuss the nature of adolescence.

Review

· What characterizes adolescent development? What especially needs to be done to improve the lives of adolescents?

Connect

· In this section you read about how important it is for adolescents to have caring adults in their lives. In previous chapters, what did you learn about the role parents play in their children’s lives leading up to adolescence that might influence adolescents’ development?

Reflect Your Own Personal Journey of Life

· Was your adolescence better described as a stormy and stressful time or as one of trying out new identities as you sought to find an identity of your own? Explain.

Page 341

2 Physical Changes

LG2 Describe the changes involved in puberty, as well as changes in the brain and sexuality during adolescence.

Puberty

The Brain

Adolescent Sexuality

One father remarked that the problem with his teenage son was not that he grew, but that he did not know when to stop growing. As we will see, there is considerable variation in the timing of the adolescent growth spurt. In addition to pubertal changes, other physical changes we will explore involve sexuality and the brain.

PUBERTY

Puberty is not the same as adolescence. For most of us, puberty ends long before adolescence does, although puberty is the most important marker of the beginning of adolescence.

Puberty  is a brain-neuroendocrine process occurring primarily in early adolescence that provides stimulation for the rapid physical changes that take place during this period of development (Berenbaum, Beltz, & Corley, 2015; Shalitin & Kiess, 2017; Susman & Dorn, 2013). Puberty is not a single, sudden event. We know whether a young boy or girl is going through puberty, but pinpointing puberty’s beginning and end is difficult. Among the most noticeable changes are signs of sexual maturation and increases in height and weight.

Sexual Maturation, Height, and Weight Think back to the onset of your puberty. Of the striking changes that were taking place in your body, what was the first to occur? Researchers have found that male pubertal characteristics typically develop in this order: increase in penis and testicle size, appearance of straight pubic hair, minor voice change, first ejaculation (which usually occurs through masturbation or a wet dream), appearance of kinky pubic hair, onset of maximum growth in height and weight, growth of hair in armpits, more detectable voice changes, and, finally, growth of facial hair.

What is the order of appearance of physical changes in females? First, either the breasts enlarge or pubic hair appears. Later, hair appears in the armpits. As these changes occur, the female grows in height and her hips become wider than her shoulders.  Menarche —a girl’s first menstruation—comes rather late in the pubertal cycle. Initially, her menstrual cycles may be highly irregular. For the first several years, she may not ovulate every menstrual cycle; some girls do not ovulate at all until a year or two after menstruation begins. No voice changes comparable to those in pubertal males occur in pubertal females. By the end of puberty, the female’s breasts have become more fully rounded.

Marked weight gains coincide with the onset of puberty. During early adolescence, girls tend to outweigh boys, but by about age 14 boys begin to surpass girls. Similarly, at the beginning of the adolescent period, girls tend to be as tall as or taller than boys of their age, but by the end of the middle school years most boys have caught up or, in many cases, surpassed girls in height.

As indicated in  Figure 1 , the growth spurt occurs approximately two years earlier for girls than for boys. The mean age at the beginning of the growth spurt in girls is 9; for boys, it is 11. The peak rate of pubertal change occurs at 11½ years for girls and 13½ years for boys. During their growth spurt, girls increase in height about 3½ inches per year, boys about 4 inches. Boys and girls who are shorter or taller than their peers before adolescence are likely to remain so during adolescence; however, as much as 30 percent of an individual’s height in late adolescence is unexplained by his or her height in the elementary school years.

image5 FIGURE 1 PUBERTAL GROWTH SPURT. On average, the peak of the growth spurt during puberty occurs two years earlier for girls (11½) than for boys (13½). How are hormones related to the growth spurt and to the difference between the average height of adolescent boys and that of girls?

Is age of pubertal onset linked to how tall boys and girls will be toward the end of adolescence? One study found that for girls, earlier onset of menarche, breast development, and growth spurt were linked to shorter height at 18 years of age; however, for boys, earlier age of growth spurt and slower progression through puberty were associated with being taller at 18 years of age (Yousefi & others, 2013).

Hormonal Changes Behind the first whisker in boys and the widening of hips in girls is a flood of  hormones , powerful chemical substances secreted by the endocrine glands and carried through the body by the bloodstream.

The concentrations of certain hormones Page 342increase dramatically during adolescence (Berenbaum, Beltz, & Corley, 2015; Herting & Sowell, 2017; Nguyen, 2018; Piekarski & others, 2017). Testosterone is a hormone associated in boys with genital development, increased height, and deepening of the voice. Estradiol is a type of estrogen that in girls is associated with breast, uterine, and skeletal development. In one study, testosterone levels increased eighteenfold in boys but only twofold in girls during puberty; estradiol increased eightfold in girls but only twofold in boys (Nottelmann & others, 1987). Thus, both testosterone and estradiol are present in the hormonal makeup of both boys and girls, but testosterone dominates in male pubertal development, estradiol in female pubertal development (Benyi & Savendahl, 2017). A study of 9- to 17-year-old boys found that testosterone levels peaked at 17 years of age (Khairullah & others, 2014).

The same influx of hormones that grows hair on a male’s chest and increases the fatty tissue in a female’s breasts may also contribute to psychological development in adolescence (Berenbaum, Beltz, & Corley, 2015; Wang & others, 2017). In one study of boys and girls ranging in age from 9 to 14, a higher concentration of testosterone was present in boys who rated themselves as more socially competent (Nottelmann & others, 1987). However, a research review concluded that there is insufficient quality research to confirm that changing testosterone levels during puberty are linked to mood and behavior in adolescent males (Duke, Balzer, & Steinbeck, 2014). And hormonal effects by themselves do not account for adolescent development (Susman & Dorn, 2013). For example, in one study, social factors were much better predictors of young adolescent girls’ depression and anger than hormonal factors (Brooks-Gunn & Warren, 1989). Behavior and moods also can affect hormones (DeRose & Brooks-Gunn, 2008). Stress, eating patterns, exercise, sexual activity, tension, and depression can activate or suppress various aspects of the hormonal system (Marceau, Dorn, & Susman, 2012). In sum, the hormone-behavior link is complex (Susman & Dorn, 2013).

Timing and Variations in Puberty In the United States—where children mature up to a year earlier than children in European countries—the average age of menarche has declined significantly since the mid-nineteenth century (see  Figure 2 ). Also, recent studies in Korea and Japan (Cole & Mori, 2018), China (Song & others, 2017), and Saudi Arabia (Al Alwan & others, 2017) found that pubertal onset has been occurring earlier in recent years. Fortunately, however, we are unlikely to see pubescent toddlers, since what has happened in the past century is likely the result of improved nutrition and health.

image6 FIGURE 2 AGE AT MENARCHE IN NORTHERN EUROPEAN COUNTRIES AND THE UNITED STATES IN THE NINETEENTH AND TWENTIETH CENTURIES. Notice the steep decline in the age at which girls experienced menarche in four northern European countries and the United States from 1845 to 1969. Recently the age at which girls experience menarche has been leveling off.

Why do the changes of puberty occur when they do, and how can variations in their timing be explained? The basic genetic program for puberty is wired into the species (Day & others, 2017; Kiess & others, 2016). Weight also is linked to pubertal onset. A cross-cultural study in 29 countries found that childhood obesity was linked to early puberty in girls (Currie & others, 2012). And a study of Chinese girls confirmed that childhood obesity contributed to an earlier onset of puberty (Zhai & others, 2015).

Experiences that are linked to earlier pubertal onset include nutrition, an urban environment, low socioeconomic status, adoption, father absence, family conflict, maternal harshness, child maltreatment, and early substance use (Bratke & others, 2017). For example, a recent study found that child sexual abuse was linked to earlier pubertal onset (Noll & others, 2017). In many cases, puberty comes months earlier in these situations, and this earlier onset of puberty is likely explained by high rates of conflict and stress in these social contexts.

image7 What are some of the differences in the ways girls and boys experience pubertal growth?  ©Fuse/Getty Images

For most boys, the pubertal sequence may begin as early as age 10 or as late as 13½, and it may end as early as age 13 or as late as 17. Thus, the normal range is wide enough that, given two boys of the same chronological age, one might complete the pubertal sequence before the other one has begun it. For girls, menarche is considered within the normal range if it appears between the ages of 9 and 15. An increasing number of U.S. girls are beginning puberty at 8 and 9 years of age, with African American girls developing earlier than non-Latino White girls (Herman-Giddens, 2007; Selkie, 2018; Sorensen & others, 2012).

Body Image One psychological aspect of physical Page 343change in puberty is universal: Adolescents are preoccupied with their bodies and develop images of what their bodies are like (Senin-Calderon & others, 2017; Solomon-Krakus & others, 2017). Preoccupation with body image is strong throughout adolescence but is especially acute during early adolescence, a time when adolescents are more dissatisfied with their bodies than in late adolescence.

The recent dramatic increase in Internet and social media use has raised concerns about their influence on adolescents’ body images. For example, a recent study of U.S. 12- to 14-year-olds found that heavier social media use was associated with body dissatisfaction (Burnette, Kwitowski, & Mazzeo, 2017). Also, in a recent study of U.S. college women, spending more time on Facebook was related to more frequent body and weight concern comparisons with other women, more attention to the physical appearance of others, and more negative feelings about their own bodies (Eckler, Kalyango, & Paasch, 2017), In sum, various aspects of exposure to the Internet and social media are increasing the body dissatisfaction of adolescents and emerging adults, especially females.

Gender differences characterize adolescents’ perceptions of their bodies (Hoffman & Warschburger, 2017; Mitchison & others, 2017). In general, girls are less happy with their bodies and have more negative body images than boys throughout puberty (Griffiths & others, 2017). In a recent U.S. study of young adolescents, boys had a more positive body image than girls (Morin & others, 2017). Girls’ more negative body images may be due to media portrayals of the attractiveness of being thin and the increase in body fat in girls during puberty (Benowitz-Fredericks & others, 2012). One study found that both boys’ and girls’ body images became more positive as they moved from the beginning to the end of adolescence (Holsen, Carlson Jones, & Skogbrott Birkeland, 2012).

Early and Late Maturation You may have entered puberty earlier or later than average, or perhaps you were right on schedule. Adolescents who mature earlier or later than their peers perceive themselves differently (Lee & others, 2017; Wang & others, 2018). In the Berkeley Longitudinal Study some years ago, early-maturing boys perceived themselves more positively and had more successful peer relations than did their late-maturing counterparts (Jones, 1965). When the late-maturing boys were in their thirties, however, they had developed a stronger sense of identity than the early-maturing boys had (Peskin, 1967). This identity development may have occurred because the late-maturing boys had more time to explore life’s options, or because the early-maturing boys continued to focus on their advantageous physical status instead of on career development and achievement. More recent research confirms, though, that at least during adolescence it is advantageous to be an early-maturing rather than a late-maturing boy (Graber, Brooks-Gunn, & Warren, 2006).

Early and late maturation have been linked with body image. In one study, in the sixth grade, early-maturing girls showed greater satisfaction with their figures than did late-maturing girls, but by the tenth grade late-maturing girls were more satisfied (Simmons & Blyth, 1987) (see  Figure 3 ). A possible reason for this is that in late adolescence early-maturing girls are shorter and stockier, whereas late-maturing girls are taller and thinner. Thus, late-maturing girls in late adolescence have bodies that more closely approximate the current American ideal of feminine beauty—tall and thin. Also, one study found that in the early high school years, late-maturing boys had a more negative body image than early-maturing boys (de Guzman & Nishina, 2014).

image8 FIGURE 3 EARLY- AND LATE-MATURING ADOLESCENT GIRLS’ PERCEPTIONS OF BODY IMAGE IN EARLY AND LATE ADOLESCENCE. The sixth-grade girls in this study had positive body image scores if they were early maturers but negative body image scores if they were late maturers (Simmons & Blyth, 1987). Positive body image scores indicated satisfaction with their figures. By the tenth grade, however, it was the late maturers who had positive body image scores.

An increasing number of researchers have found that early maturation increases girls’ vulnerability to a number of problems (Selkie, 2018). Early-maturing girls are more likely to smoke, drink, be depressed, have an eating disorder, engage in delinquency, struggle for earlier independence from their parents, and have older friends; and their bodies are likely to elicit responses from males that lead to earlier dating and earlier sexual experiences (Ibitoye & others, 2017; Pomerantz & others, 2017; Wang & others, 2018). In a recent study, onset of menarche before 11 years of age was linked to a higher incidence of distress disorders, fear disorders, and externalizing disorders in females (Platt & others, 2017). Another study found that early maturation predicted a stable higher level of depression for adolescent girls (Rudolph & others, 2014). Further, researchers recently found that early-maturing girls had higher rates of depression and antisocial behavior as middle-aged adults, mainly because their difficulties began in adolescence and did not lessen over time (Mendle & others, 2018). Further, early-maturing girls tend to have sexual intercourse earlier and to have more unstable sexual relationships, and they are more at risk for physical and verbal abuse in dating (Chen, Rothman, & Jaffee, 2017; Moore, Harden, & Mendle, 2014). And early-maturing girls are less likely to graduate from high Page 344school and tend to cohabit and marry earlier (Cavanagh, 2009). Apparently as a result of their social and cognitive immaturity, combined with early physical development, early-maturing girls are easily lured into problem behaviors, not recognizing the possible long-term negative effects on their development.

In sum, early maturation often has more favorable outcomes in adolescence for boys, especially in early adolescence. However, late maturation may be more favorable for boys, especially in terms of identity and career development. Research increasingly has found that early-maturing girls are vulnerable to a number of problems.

THE BRAIN

Along with the rest of the body, the brain changes during adolescence, but the study of adolescent brain development is still in its infancy. As advances in technology take place, significant strides are also likely to be made in charting developmental changes in the adolescent brain (Cohen & Casey, 2017; Crone, Peters, & Steinbeis, 2018; Sherman, Steinberg, & Chein, 2018; Steinberg & others, 2018; Vijayakumar & others, 2018). What do we know now?

The dogma of the unchanging brain has been discarded, and researchers are mainly focused on context-induced plasticity of the brain over time (Romeo, 2017; Steinberg, 2017; Zelazo, 2013). The development of the brain mainly changes in a bottom-up, top-down sequence with sensory, appetitive (eating, drinking), sexual, sensation-seeking, and risk-taking brain linkages maturing first and higher-level brain linkages such as self-control, planning, and reasoning maturing later (Zelazo, 2013).

Using fMRI brain scans, scientists have recently discovered that adolescents’ brains undergo significant structural changes (Aoki, Romeo, & Smith, 2017; Crone, Peters, & Steinbeis, 2018; Goddings & Mills, 2017; Rudolph & others, 2017). The  corpus callosum , where fibers connect the brain’s left and right hemispheres, thickens in adolescence, and this improves adolescents’ ability to process information (Chavarria & others, 2014). We have described advances in the development of the prefrontal cortex—the highest level of the frontal lobes involved in reasoning, decision making, and self-control. However, the prefrontal cortex doesn’t finish maturing until the emerging adult years, approximately 18 to 25 years of age, or later (Cohen & Casey, 2017; Juraska & Willing, 2017; Sousa & others, 2018).

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Brain Development

Although the prefrontal cortex shows considerable development in childhood, it is still not fully mature even in adolescence. Connect to “Physical and Cognitive Development in Middle and Late Childhood.”

At a lower, subcortical level, the  limbic system , which is the seat of emotions and where rewards are experienced, matures much earlier than the prefrontal cortex and is almost completely developed in early adolescence (Mueller & others, 2017). The limbic system structure that is especially involved in emotion is the  amygdala .  Figure 4  shows the locations of the corpus callosum, prefrontal cortex, and the limbic system.

image9 FIGURE 4 THE CHANGING ADOLESCENT BRAIN: PREFRONTAL CORTEX, LIMBIC SYSTEM, AND CORPUS CALLOSUM

With the onset of puberty, the levels of neurotransmitters change (Cohen & Casey, 2017). For example, an increase in the neurotransmitter dopamine occurs in both the prefrontal cortex and the limbic system during adolescence (Cohen & Casey, 2017). Increases in dopamine have been linked to increased risk taking and the use of addictive drugs (Webber & others, 2017). Researchers also have found that dopamine plays an important role in reward seeking during adolescence (Dubol & others, 2018).

Earlier we described the increased focal activation that is linked to synaptic pruning in a specific region, such as the prefrontal cortex. In middle and late childhood, while there is increased focal activation within a specific brain region such as the prefrontal cortex, there are limited connections across distant brain regions. As adolescents develop, they have more connections across brain areas (Lebel & Deoni, 2018; Quinlin & others, 2017; Sousa & others, 2018; Tashjian, Goldenberg, & Galvan, 2017). The increased connectedness (referred to as brain networks) is especially prevalent across more distant brain regions. Thus, as children develop, greater efficiency and focal activation occurs in close Page 345-by areas of the brain, and simultaneously there is an increase in brain networks connecting more distant brain regions. In a recent study, reduced connectivity between the brain’s frontal lobes and amygdala during adolescence was linked to increased depression (Scheuer & others, 2017).

Many of the changes in the adolescent brain that have been described here involve the rapidly emerging fields of developmental cognitive neuroscience and developmental social neuroscience, in which connections between development, the brain, and cognitive or socioemotional processes are studied (Lauharatanahirun & others, 2018; Mueller & others, 2017; Romer, Reyna, & Sattherthwaite, 2017; Sherman, Steinberg, & Chein, 2018; Steinberg & others, 2018). For example, consider leading researcher Charles Nelson’s (2003) view that, although adolescents are capable of very strong emotions, their prefrontal cortex hasn’t adequately developed to the point at which they can control these passions. It is as if their brain doesn’t have the brakes to slow down their emotions. Or consider this interpretation of the development of emotion and cognition in adolescents: “early activation of strong ‘turbo-charged’ feelings with a relatively unskilled set of ‘driving skills’ or cognitive abilities to modulate strong emotions and motivations” (Dahl, 2004, p. 18).

Of course, a major question is which comes first, biological changes in the brain or experiences that stimulate these changes (Lerner, Boyd, & Du, 2008; Steinberg, 2017). In a longitudinal study, 11- to 18-year-olds who lived in poverty conditions had diminished brain functioning at 25 years of age (Brody & others, 2017). However, the adolescents from poverty backgrounds whose families participated in a supportive parenting intervention did not show this diminished brain functioning in adulthood. Another study found that the prefrontal cortex thickened and more brain connections formed when adolescents resisted peer pressure (Paus & others, 2007). Scientists have yet to determine whether the brain changes come first or whether they result from experiences with peers, parents, and others (Lauharatanahirun & others, 2018; Webber & others, 2017). Once again, we encounter the nature-nurture issue that is so prominent in an examination of development through the life span. Nonetheless, there is adequate evidence that environmental experiences make important contributions to the brain’s development (Cohen & Casey, 2017; Crone, 2017; Sherman, Steinberg, & Chein, 2018).

In closing this section on the development of the brain in adolescence, a further caution is in order. Much of the research on neuroscience and the development of the brain in adolescence is correlational in nature, and thus causal statements need to be scrutinized (Steinberg & others, 2018). This caution, of course, applies to any period in the human life span.

ADOLESCENT SEXUALITY

Not only is adolescence characterized by substantial changes in physical growth and the development of the brain, but adolescence also is a bridge between the asexual child and the sexual adult (Diamond & Alley, 2018; Savin-Williams, 2017, 2018). Adolescence is a time of sexual exploration and experimentation, of sexual fantasies and realities, of incorporating sexuality into one’s identity. Adolescents have an almost insatiable curiosity about sexuality. They are concerned about whether they are sexually attractive, how to do sex, and what the future holds for their sexual lives. Although most adolescents experience times of vulnerability and confusion, the majority will eventually develop a mature sexual identity.

In the United States, the sexual culture is widely available to adolescents. In addition to any advice adolescents get from parents, they learn a great deal about sex from television, videos, magazines, the lyrics of popular music, and the Internet (Bleakley & others, 2017; Kinsler & others, 2018; van Oosten & Vandenbosch, 2017). In some schools, sexting is common, as indicated in a recent study of 656 high school students at one school in which 15.8 percent of males and 13.6 percent of females reported sending and 40.5 percent of males and 30.6 percent of females reported receiving explicit sexual pictures on cell phones (Strassberg, Cann, & Velarde, 2017). And in another recent study of 13- to 21-year-old Latinos, engaging in sexting was linked to engaging in penetrative sex (oral, vaginal, and anal sex) (Romo & others, 2017).

Sexual arousal emerges as a new phenomenon in adolescence and it is important to view sexuality as a normal aspect of adolescent development.

—Shirley Feldman

Contemporary Psychologist, Stanford University

Developing a Sexual Identity Mastering emerging sexual feelings and forming a sense of sexual identity are multifaceted and lengthy processes (Diamond & Alley, 2018; Savin-Williams, 2017, 2018). They involve learning to manage sexual feelings (such as sexual arousal and attraction), developing new forms of intimacy, and learning how to regulate sexual behavior to avoid undesirable consequences.

An adolescent’s sexual identity involves activities Page 346, interests, styles of behavior, and an indication of sexual orientation (whether an individual has same-sex or other-sex attractions, or both) (Goldberg & Halpern, 2017). For example, some adolescents have a high anxiety level about sex, others a low level. Some adolescents are strongly aroused sexually, others less so. Some adolescents are very active sexually, others not at all (Hyde & DeLamater, 2017). Some adolescents are sexually inactive in response to their strong religious upbringing; others go to church regularly and yet their religious training does not inhibit their sexual activity.

It is commonly thought that most gays and lesbians quietly struggle with same-sex attractions in childhood, do not engage in heterosexual dating, and gradually recognize that they are a gay or lesbian in mid- to late adolescence. Many youth do follow this developmental pathway, but others do not (Diamond & Alley, 2018; Savin-Williams, 2017, 2018). For example, many youth have no recollection of early same-sex attractions and experience a more abrupt sense of their same-sex attraction in late adolescence. The majority of adolescents with same-sex attractions also experience some degree of other-sex attractions (Carroll, 2018). Even though some adolescents who are attracted to individuals of their same sex fall in love with these individuals, others claim that their same-sex attractions are purely physical (Diamond & Alley, 2018; Savin-Williams, 2017, 2018).

Further, the majority of sexual minority (gay, lesbian, and bisexual) adolescents have competent and successful paths of development through adolescence and become healthy and productive adults. However, in a recent large-scale study, sexual minority adolescents did engage in a higher prevalence of health-risk behaviors (greater drug use and sexual risk taking, for example) compared with heterosexual adolescents (Kann & others, 2016b).

The Timing of Adolescent Sexual Behaviors What is the current profile of sexual activity of adolescents? In a U.S. national survey conducted in 2015, 58 percent of twelfth-graders reported having experienced sexual intercourse, compared with 24 percent of ninth-graders (Kann & others, 2016a). By age 20, 77 percent of U.S. youth report having engaged in sexual intercourse (Dworkin & Santelli, 2007). Nationally, 46 percent of twelfth-graders, 33.5 percent of eleventh-graders, 25.5 percent of tenth-graders, and 16 percent of ninth-graders recently reported that they were currently sexually active (Kann & others, 2016a).

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Sexuality

What characterizes the sexual activity of emerging adults (18 to 25 years of age)? Connect to “Physical and Cognitive Development in Early Adulthood.”

What trends in adolescent sexual activity have occurred in recent decades? From 1991 to 2015, fewer adolescents reported any of the following: ever having had sexual intercourse, currently being sexually active, having had sexual intercourse before the age of 13, and having had sexual intercourse with four or more persons during their lifetime (Kann & others, 2016a) (see  Figure 5 ).

image10 FIGURE 5 SEXUAL ACTIVITY OF U.S. ADOLESCENTS FROM 1991 TO 2015

Sexual initiation varies by ethnic group in the United States (Kann & others, 2016a). African Americans are likely to engage in sexual behaviors earlier than other ethnic groups, whereas Asian Americans are likely to engage in them later (Feldman, Turner, & Araujo, 1999). In a more recent national U.S. survey of ninth- to twelfth-graders, 48.5 percent of African Americans, 42.5 percent of Latinos, and 39.9 percent of non-Latino Whites said they had experienced sexual intercourse (Kann & others, 2016a). In this study, 8 percent of African Americans (compared with 5 percent of Latinos and 2.5 percent of non-Latino Whites) said they had their first sexual experience before 13 years of age.

Research indicates that oral sex is now a common occurrence among U.S. adolescents (Fava & Bay-Cheng, 2012; Song & Halpern-Felsher, 2010). In a national survey, 51 percent of U.S. 15- to 19-year-old boys and 47 percent of girls in the same age range said they had engaged in oral sex (Child Trends, 2015). Researchers have also found that among female adolescents who reported having vaginal sex first, 31 percent reported having a teen pregnancy, whereas among those who initiated oral-genital sex first, only 8 percent reported having a teen pregnancy (Reese & others, 2013). Thus, how adolescents initiate their sex lives may have positive or negative consequences for their sexual health.

Risk Factors in Adolescent Sexual Behavior Many adolescents are not emotionally prepared to handle sexual experiences, especially in early adolescence (Cai & others, 2018; Donenberg & others, 2018; Ihongbe, Cha, & Masho, 2017). Early sexual activity is linked with risky behaviors Page 347such as drug use, delinquency, and school-related problems (Boisvert, Boislard, & Poulin, 2017; Rivera & others, 2018). A recent study of more than 3,000 Swedish adolescents revealed that sexual intercourse before age 14 was linked to risky behaviors such as an increased number of sexual partners, experience of oral and anal sex, negative health behaviors (smoking, drug and alcohol use), and antisocial behavior (being violent, stealing, running away from home) at 18 years of age (Kastbom & others, 2016). Further, a recent study found that early sexual debut (first sexual intercourse before age 13) was associated with sexual risk taking, substance use, violent victimization, and suicidal thoughts/attempts in both sexual minority (in this study, gay, lesbian, and bisexual adolescents) and heterosexual youth (Lowry, Robin, & Kann, 2017). And in a recent study of Korean adolescent girls, early menarche was linked with earlier initiation of sexual intercourse (Kim & others, 2018).

In addition to having sex in early adolescence, other risk factors for sexual problems in adolescence include contextual factors such as socioeconomic status (SES) and poverty, immigration/ethnic minority status, family/parenting and peer factors, and school-related influences (Simons & others, 2016; Warner, 2018). The percentage of sexually active young adolescents is higher in low-income areas of inner cities (Morrison-Beedy & others, 2013). One study revealed that neighborhood poverty concentrations predicted 15- to 17-year-old girls’ and boys’ sexual initiation (Cubbin & others, 2010). Also, a national survey of 15- to 20-year-olds found that Spanish-speaking immigrant youth were more likely to have a sexual partner age difference of 6 or more years and less likely to use contraception at first sexual intercourse than their native Latino, non-Latino White, and English-speaking Latino immigrant counterparts (Haderxhanaj & others, 2014).

image11 What are some risks associated with early initiation of sexual intercourse?  ©Stockbyte/PunchStock

A number of family factors are associated with sexual risk-taking (Ashcraft & Murray, 2017; Ruiz-Casares & others, 2017). For example, a recent study revealed that adolescents who in the eighth grade reported greater parental knowledge and more family rules about dating were less likely to initiate sex from the eighth to tenth grade (Ethier & others, 2016). Also, a recent study revealed that of a number of parenting practices the factor that best predicted a lower level of risky sexual behavior by adolescents was supportive parenting (Simons & others, 2016). Further, one study found that difficulties and disagreements between Latino adolescents and their parents were linked to the adolescents’ early sex initiation (Cordova & others, 2014). Also, having older sexually active siblings or pregnant/parenting teenage sisters placed adolescent girls at higher risk for pregnancy (Miller, Benson, & Galbraith, 2001).

Peer, school, sport, and religious contexts provide further information about sexual risk taking in adolescents (Choukas-Bradley & Prinstein, 2016). One study found that adolescents who associated with more deviant peers in early adolescence were likely to have more sexual partners at age 16 (Lansford & others, 2010). Also, a research review found that school connectedness was linked to positive sexuality outcomes (Markham & others, 2010). A study of middle school students revealed that better academic achievement was a protective factor in preventing boys and girls from engaging in early sexual intercourse (Laflin, Wang, & Barry, 2008). Also, a recent study found that adolescent males who play sports engage in a higher level of sexual risk taking, while adolescent females who play sports engage in a lower level of sexual risk taking (Lipowski & others, 2016). And a recent study of African American adolescent girls indicated that those who reported that religion was of low or moderate importance to them had a much earlier sexual debut that their counterparts who said that religion was very important or extremely important to them (George Dalmida & others, 2018).

image12Psychologists are exploring ways to encourage adolescents to make less risky sexual decisions. Here an adolescent participates in an interactive video session developed by Julie Downs and her colleagues at the Department of Social and Decision Making Sciences at Carnegie Mellon University. The videos help adolescents evaluate their responses and decisions in high-risk sexual contexts.  ©Michael Ray

Cognitive and personality factors are increasingly implicated in sexual risk taking in adolescence. Weak self-regulation (difficulty controlling one’s emotions and behavior) and impulsiveness are two such factors. Another longitudinal study found that weak self-regulation at 8 to 9 years of age and risk proneness (tendency to seek sensation Page 348and make poor decisions) at 12 to 13 years of age set the stage for sexual risk taking at 16 to 17 years of age (Crockett, Raffaelli, & Shen, 2006). Also, a meta-analysis indicated that the link between impulsivity and risky sexual behavior was likely to be more characteristic of adolescent females than males (Dir, Coskunpinar, & Cyders, 2014).

Contraceptive Use Too many sexually active adolescents still do not use contraceptives, use them inconsistently, or use contraceptive methods that are less effective than others (Chandra-Mouli & others, 2018; Diedrich, Klein, & Peipert, 2017; Fridy & others, 2018; Jaramillo & others, 2017). In 2015, 14 percent of sexually active adolescents did not use any contraceptive method the last time they had sexual intercourse (Kann & others, 2016a). Researchers have found that U.S. adolescents are less likely to use condoms than their European counterparts (Jorgensen & others, 2015).

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Conditions, Diseases, and Disorders

What are some good strategies for protecting against HIV and other sexually transmitted infections? Connect to “Physical and Cognitive Development in Early Adulthood.”

Recently, a number of leading medical organizations and experts have recommended that adolescents use long-acting reversible contraception (LARC). These include the Society for Adolescent Health and Medicine (2017), the American Academy of Pediatrics and American College of Obstetrics and Gynecology (Allen & Barlow, 2017), and the World Health Organization (2017). LARC consists of the use of intrauterine devices (IUDs) and contraceptive implants, which have a much lower failure rate and are more effective in preventing unwanted pregnancy than birth control pills and condoms (Diedrich, Klein, & Peipert, 2017; Fridy & others, 2018; Society for Adolescent Health and Medicine, 2017).

Sexually Transmitted Infections Some forms of contraception, such as birth control pills or implants, do not protect against sexually transmitted infections, or STIs.  Sexually transmitted infections (STIs)  are contracted primarily through sexual contact, including oral-genital and anal-genital contact. Every year more than 3 million American adolescents (about one-fourth of those who are sexually experienced) acquire an STI (Centers for Disease Control and Prevention, 2018). In a single act of unprotected sex with an infected partner, a teenage girl has a 1 percent risk of getting HIV, a 30 percent risk of acquiring genital herpes, and a 50 percent chance of contracting gonorrhea (Glei, 1999). Yet another very widespread STI is chlamydia. We will consider these and other sexually transmitted infections in more detail later.

Adolescent Pregnancy Adolescent pregnancy is another problematic outcome of sexuality in adolescence and requires major efforts to reduce its occurrence (Brindis, 2017; Chandra-Mouli & others, 2018; Fridy & others, 2018; Marseille & others, 2018; Romero & others, 2017; Tevendale & others, 2017). In cross-cultural comparisons, the United States continues to have one of the highest adolescent pregnancy and childbearing rates in the industrialized world, despite a considerable decline during the 1990s. The U.S. adolescent pregnancy rate is eight times as high as that in the Netherlands. Although U.S. adolescents are no more sexually active than their counterparts in the Netherlands, their adolescent pregnancy rate is dramatically higher. In the United States, 82 percent of pregnancies in adolescents 15 to 19 years of age are unintended (Koh, 2014). A cross-cultural comparison found that among 21 countries, the United States had the highest adolescent pregnancy rate among 15- to 19-year-olds and Switzerland the lowest (Sedgh & others, 2015).

Despite the negative comparisons of the United States with many other developed countries, there have been some encouraging trends in U.S. adolescent pregnancy rates. In 2015, the U.S. birth rate for 15- to 19-year-olds was 22.3 births per 1,000 females, the lowest rate ever recorded, which represents a dramatic decrease from the 61.8 births for the same age range in 1991 and down even 8 percent from 2014 (Martin & others, 2017) (see  Figure 6 ). There also has been a substantial decrease in adolescent pregnancies across ethnic groups in recent years. Reasons for the decline include school/community health classes, increased contraceptive Page 349use, and fear of sexually transmitted infections such as AIDS.

image13 FIGURE 6 BIRTH RATES FOR U.S. 15- TO 19-YEAR-OLD GIRLS FROM 1980 TO 2015.  Source: Martin, J. A. et al. “Births: Final data for 2015.” National Vital Statistics Reports, 66 (1), 2017, 1.

Ethnic variations characterize birth rates for U.S. adolescents. Latina adolescents are more likely than African American and non-Latina White adolescents to have a child (Martin & others, 2017). Latina and African American adolescent girls who have a child are also more likely to have a second child than are non-Latina White adolescent girls (Rosengard, 2009). And daughters of teenage mothers are at increased risk for teenage childbearing, thus perpetuating an intergenerational cycle (Meade, Kershaw, & Ickovics, 2008).

Adolescent pregnancy creates health risks for both the baby and the mother (Leftwich & Alves, 2017). Infants born to adolescent mothers are more likely to have low birth weights—a prominent factor in infant mortality—as well as neurological problems and childhood illness (Leftwich & Alves, 2017). A recent study assessed the reading and math achievement trajectories of children born to adolescent and non-adolescent mothers with different levels of education (Tang & others, 2016). In this study, higher levels of maternal education were linked to higher academic achievement through the eighth grade. Nonetheless, the achievement of children born to adolescent mothers never reached the levels of children born to adult mothers. Adolescent mothers are more likely to be depressed and to drop out of school than their peers are (Siegel & Brandon, 2014). Although many adolescent mothers resume their education later in life, they generally never catch up economically with women who postpone childbearing until their twenties. Also, a study of African American urban youth found that at 32 years of age, women who had become mothers as teenagers were more likely than non-teen mothers to be unemployed, live in poverty, depend on welfare, and not have completed college (Assini-Meytin & Green, 2015). In this study, at 32 years of age, men who had become fathers as teenagers were more likely than non-teen fathers to be unemployed.

A special concern is repeated adolescent pregnancy. In a recent national study, the percentage of teen births that were repeat births decreased from 2004 (21 percent) to 2015 (17 percent) (Dee & others, 2017). In a recent meta-analysis, use of effective contraception, especially LARC, and education-related factors (higher level of education and school continuation) resulted in a lower incidence of repeated teen pregnancy, while depression and a history of abortion were linked to a higher percentage of repeated teen pregnancy (Maravilla & others, 2017).

Researchers have found that adolescent mothers interact less effectively with their infants than do adult mothers (Leftwich & Alves, 2017). One study revealed that adolescent mothers spent more time negatively interacting and less time in play and positive interactions with their infants than did adult mothers (Riva Crugnola & others, 2014). Also, a recent intervention, “My Baby and Me,” that involved frequent, intensive home visitation coaching sessions with adolescent mothers across three years resulted in improved maternal behavior and child outcomes (Guttentag & others, 2014).

Although the consequences of America’s high rate of adolescent pregnancy are cause for great concern, it often is not pregnancy alone that leads to negative consequences for an adolescent mother and her offspring. Adolescent mothers are more likely to come from low-SES backgrounds (Mollborn, 2017). Many adolescent mothers also were not good students before they became pregnant (Malamitsi-Puchner & Boutsikou, 2006). However, not every adolescent female who bears a child lives a life of poverty and low achievement. Thus, although adolescent pregnancy is a high-risk circumstance, and adolescents who do not become pregnant generally fare better than those who do, some adolescent mothers do well in school and have positive outcomes (Schaffer & others, 2012).

Serious, extensive efforts are needed to help pregnant adolescents and young mothers enhance their educational and occupational opportunities (Carroll, 2018; Craft, Brandt, & Prince, 2016; Mueller & others, 2017; Romero & others, 2017). Adolescent mothers also need help obtaining competent child care and planning for the future.

Adolescents can benefit from age-appropriate family-life education (Barfield, Warner, & Kappeler, 2017; Mueller & others, 2017). Family and consumer science educators teach life skills, such as effective decision making, to adolescents. To read about the work of one family and consumer science educator, see  Connecting with Careers . And to learn more about ways to reduce adolescent pregnancy, see  Connecting Development to Life .

image14 What are some consequences of adolescent pregnancy?  ©Geoff Manasse/Getty ImagesPage 350

connecting with careers

Lynn Blankinship, Family and Consumer Science Educator

Lynn Blankinship is a family and consumer science educator with an undergraduate degree in this field from the University of Arizona. She has taught for more than 20 years, the last 14 at Tucson High Magnet School.

Blankinship has been honored as the Tucson Federation of Teachers Educator of the Year and the Arizona Teacher of the Year. Blankinship especially enjoys teaching life skills to adolescents. One of her favorite activities is having students care for an automated baby that imitates the needs of real babies. She says that this program has a profound impact on students because the baby must be cared for around the clock for the duration of the assignment. Blankinship also coordinates real-world work experiences and training for students in several child-care facilities in the Tucson area.

For more information about what family and consumer science educators do, see the Careers in Life-Span Development appendix.

image15Lynn Blankinship (center) teaches life skills to students.  Courtesy of Lynn Blankinship

connecting development to life

Reducing Adolescent Pregnancy

One strategy for reducing adolescent pregnancy, called the Teen Outreach Program (TOP), focuses on engaging adolescents in volunteer community service and stimulates discussions that help adolescents appreciate the lessons they learn through volunteerism.

Girls Inc. has four programs that are intended to increase adolescent girls’ motivation to avoid pregnancy until they are mature enough to make responsible decisions about motherhood (Roth & others, 1998). Growing Together, a series of five two-hour workshops for mothers and adolescents, and Will Power/Won’t Power, a series of six two-hour sessions that focus on assertiveness training, are for 12- to 14-year-old girls. For older adolescent girls, Taking Care of Business provides nine sessions that emphasize career planning as well as information about sexuality, reproduction, and contraception. Health Bridge coordinates health and education services—girls can participate in this program as one of their club activities. Girls who participated in these programs were less likely to get pregnant than girls who did not participate (Girls Inc., 1991).

In 2010, the U.S. government launched the Teen Pregnancy Prevention (TPP) program under the direction of the newly created Office of Adolescent Health (Koh, 2014). Currently, a number of studies are being funded by the program in an effort to find ways to reduce the rate of adolescent pregnancy.

The sources and the accuracy of adolescents’ sexual information are linked to adolescent pregnancy. Adolescents can get information about sex from many sources, including parents, siblings, schools, peers, magazines, television, and the Internet. A special concern is the accuracy of sexual information to which adolescents have access on the Internet.

Currently, a major controversy in sex education is whether schools should have an abstinence-only program or a program that emphasizes contraceptive knowledge (Erkut & others, 2013; MacKenzie, Hedge, & Enslin, 2017). Recent research reviews have concluded that abstinence-only programs do not delay the initiation of sexual intercourse and do not reduce HIV risk behaviors (Denford & others, 2017; Jaramillo & others, 2017; Santelli & others, 2017).

Despite the evidence that favors comprehensive sex education, there recently has been an increase in government funding for abstinence-only programs (Donovan, 2017). Also, in some states (Texas and Mississippi, for example), many students still either get abstinence-only or no sex education at all (Campbell, 2016; Pollock, 2017).

Recently, there also has been an increased emphasis in abstinence-only-until-marriage (AOUM) policies and programs. However, a major problem with such policies and programs is that a very large majority of individuals engage in sexual intercourse at some point in adolescence or emerging adulthood while the age of marriage continues to go up (27 for females, 29 for males in the United States) (Society for Adolescent Medicine, 2017).

Based on the information you read earlier about risk factors in adolescent sexual behavior, which segments of the adolescent population would benefit most from the types of sex education programs described here?

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Review Connect Reflect

LG2 Describe the changes involved in puberty, as well as changes in the brain and sexuality during adolescence.

Review

· What are some key aspects of puberty?

· What changes typically occur in the brain during adolescence?

· What are some important aspects of sexuality in adolescence?

Connect

· How might adolescent brain development be linked to adolescents’ decisions to engage in sexual activity or to abstain from it?

Reflect Your Own Personal Journey of Life

· Did you experience puberty earlier or later than your peers? How did this timing affect your development?

3 Issues in Adolescent Health

LG3 Identify adolescent problems related to health, substance use and abuse, and eating disorders.

Adolescent Health

Substance Use and Abuse

Eating Disorders

Many health experts argue that whether adolescents are healthy depends primarily on their own behavior. To improve adolescent health, adults should aim to (1) increase adolescents’ health-enhancing behaviors, such as eating nutritious foods, exercising, wearing seat belts, and getting adequate sleep; and (2) reduce adolescents’ health-compromising behaviors, such as drug abuse, violence, unprotected sexual intercourse, and dangerous driving.

ADOLESCENT HEALTH

Adolescence is a critical juncture in the adoption of behaviors that are relevant to health (Coore Desai, Reece, & Shakespeare-Pellington, 2017; Devenish, Hooley, & Mellor, 2017; Oldfield & others, 2018; Yap & others, 2017). Many of the behaviors that are linked to poor health habits and early death in adults begin during adolescence (Blake, 2017; Donatelle & Ketcham, 2018). Conversely, the early formation of healthy behavior patterns, such as regular exercise and a preference for foods low in fat and cholesterol, not only has immediate health benefits but helps in adulthood to delay or prevent disability and mortality from heart disease, stroke, diabetes, and cancer (Hales, 2018; Powers & Dodd, 2017).

Nutrition and Exercise Concerns are growing about adolescents’ nutrition and exercise habits (Donatelle, 2019; Powers & Dodd, 2017; Schiff, 2017, 2019; Smith & Collene, 2019). National data indicated that the percentage of overweight U.S. 12- to 19-year-olds increased from 11 percent in the early 1990s to nearly 20.5 percent in 2014 (Centers for Disease Control and Prevention, 2016). In another study, 12.4 percent of U.S. kindergarten children were obese, but by 14 years of age, 20.8 percent were obese (Cunningham, Kramer, & Narayan, 2014).

A special concern in American culture is the amount of fat we consume. Many of today’s adolescents virtually live on fast-food meals, which are high in fat. A comparison of adolescents in 28 countries found that U.S. and British adolescents were more likely to eat fried food and less likely to eat fruits and vegetables than adolescents in most other countries that were studied (World Health Organization, 2000). The National Youth Risk Survey found that U.S. high school students showed a linear decrease in their intake of fruits and vegetables from 1999 through 2015 (Kann & others, 2016a).

Being obese in adolescence predicts obesity in emerging adulthood. For example, a longitudinal study of more than 8,000 adolescents found that obese adolescents were more likely to develop severe obesity in emerging adulthood than were overweight or normal-weight adolescents (The & others, 2010). In another longitudinal study, the percentage of overweight individuals increased from 20 percent at 14 years of age to 33 percent at 24 years of age (Patton & others, 2011).

image16 ©Shutterstock/Thirteen

Researchers have found that individuals become Page 352less active as they reach and progress through adolescence (Alberga & others, 2012). A national study of U.S. adolescents revealed that physical activity increased until 13 years of age in boys and girls but then declined through 18 years of age (Kahn & others, 2008). A recent national study also found that adolescent girls were much less likely to have engaged in 60 minutes or more of vigorous exercise per day in 5 of the last 7 days (61 percent) than were boys (42 percent) (YRBSS, 2016). Ethnic differences in exercise participation rates of U.S. adolescents also occur, and these rates vary by gender. In the national study just mentioned, non-Latino White boys exercised the most, African American and Latino girls the least (YRBSS, 2016).

Positive physical outcomes of exercise in adolescence include a lower rate of obesity, reduced triglyceride levels, lower blood pressure, and a lower incidence of type II diabetes (Barton & others, 2017; Powers & Howley, 2018; Son & others, 2017; Walton-Fisette & Wuest, 2018; Xie & others, 2017). Also, one study found that adolescents who were high in physical fitness had better connectivity between brain regions than adolescents who were low in physical fitness (Herting & others, 2014). Exercise in adolescence also is linked to other positive outcomes. Higher levels of exercise are related to fewer depressive symptoms in adolescents (Gosmann & others, 2015). In a recent study, a high-intensity exercise program reduced depressive symptoms and improved the moods of depressed adolescents (Carter & others, 2016). In another study, young adolescents who exercised regularly had higher academic achievement (Hashim, Freddy, & Rosmatunisah, 2012). And in a recent research review, among a number of cognitive factors, memory was the factor that most often was improved by exercise in adolescence (Li & others, 2017).

image17 What are some characteristics of adolescents’ exercise patterns?  ©Tom Stewart/Corbis/Getty Images

Adolescents’ exercise is increasingly being found to be associated with parenting and peer relationships (Mason & others, 2017; Michaud & others, 2017). One study revealed that family meals during adolescence protected against becoming overweight or obese in adulthood (Berge & others, 2015). Another study revealed that female adolescents’ physical activity was linked to their male and female friends’ physical activity, while male adolescents’ physical activity was associated with their female friends’ physical activity (Sirard & others, 2013).

Researchers have found that screen time is associated with a number of adolescent health problems, including a lower rate of exercise and a higher rate of sedentary behavior (Pearson & others, 2017). In one research review, a higher level of screen-based sedentary behavior was associated with being overweight, having sleep problems, being depressed, and having lower levels of physical activity/fitness and psychological well-being (higher stress levels, for example (Costigan & others, 2013).

What types of interventions and activities have been successful in reducing overweight in adolescents and emerging adults? Research indicates that dietary changes and regular exercise are key components of weight reduction in adolescence and emerging adulthood (Fukerson & others, 2018; Lipsky & others, 2017; Martin & others, 2018; Powers & Howley, 2018). For example, a recent study found that a combination of regular exercise and a diet plan resulted in weight loss and enhanced executive function in adolescents (Xie & others, 2017).

Sleep Like nutrition and exercise, sleep is an important influence on well-being. Might changing sleep patterns in adolescence contribute to adolescents’ health-compromising behaviors? Recently there has been a surge of interest in adolescent sleep patterns (Hoyt & others, 2018; Meltzer, 2017; Palmer & others, 2018; Reddy & others, 2017; Seo & others, 2017; Wheaton & others, 2018). A longitudinal study in which adolescents completed a 24-hour diary every 14 days in ninth, tenth, and twelfth grades found that regardless of how much students studied each day, when the students sacrificed sleep time to study more than usual they had difficulty understanding what was taught in class and were more likely to struggle with class assignments the next day (Gillen-O’Neel, Huynh, & Fuligni, 2013). Also, a recent experimental study indicated that when adolescents’ sleep was restricted to five hours for five nights, then returned to ten hours for two nights, their sustained attention was negatively affected (especially in the early morning) and did not return to baseline levels during recovery (Agostini & others, 2017). Further, researchers have found that adolescents who get less than 7.7 hours of sleep per night on average have more emotional and peer-related problems, higher anxiety, and a higher level of suicidal ideation (Sarchiapone & others, 2014). And a recent national study of more than 10,000 13- to 18-year-olds revealed that later weeknight bedtime, shorter weekend bedtime delay, and both short and long periods of weekend oversleep were linked to increased rates of anxiety, mood, substance abuse, and behavioral disorders (Zhang & others, 2017). Further, in a four-year longitudinal study beginning at 12 years of age, poor sleep patterns (for example, shorter sleep duration and greater daytime sleepiness) at age 12 was associated with an increased likelihood Page 353of drinking alcohol and using marijuana at 16 years of age (Miller, Janssen, & Jackson, 2017). Also, recent Swedish studies revealed that adolescents with a shorter sleep duration were more likely to have more school absences, while shorter sleep duration and greater sleep deficits were linked to having a lower grade point average (Hysing & others, 2015, 2016).

In a recent national survey of youth, only 27 percent of U.S. adolescents got eight or more hours of sleep on an average school night (Kann & others, 2016a). In this study, the percentage of adolescents getting this much sleep on an average school night decreased as they got older (see  Figure 7 ). Also, in other research with more than 270,000 U.S. adolescents from 1991–2012, adolescents were getting less sleep in recent years than in the past (Keyes & others, 2015).

image18 FIGURE 7 DEVELOPMENTAL CHANGES IN U.S. ADOLESCENTS’ SLEEP PATTERNS ON AN AVERAGE SCHOOL NIGHT

The National Sleep Foundation (2006) conducted a U.S. survey of adolescent sleep patterns. Those who got inadequate sleep (eight hours or less) on school nights were more likely to feel tired or sleepy, to be cranky and irritable, to fall asleep in school, to be in a depressed mood, and to drink caffeinated beverages than their counterparts who got optimal sleep (nine or more hours). Also, a longitudinal study of more than 6,000 adolescents found that sleep problems were linked to subsequent suicidal thoughts and attempts in adolescence and early adulthood (Wong & Brower, 2012). Further, one study found that adolescents who got less than 7.7 hours of sleep per night on average had more emotional and peer-related problems, higher anxiety, and a higher level of suicidal ideation than their peers who got 7.7 hours of sleep or more (Sarchiapone & others, 2014).

Why are adolescents getting too little sleep? Among the reasons given are those involving electronic media, caffeine, and changes in the brain coupled with early school start times (Bartel, Scheeren, & Gradisar, 2018; Owens, 2014). In one study, adolescents averaged engaging in four electronic activities (in some cases, this involved simultaneous use of different devices) after 9 p.m. (Calamaro, Mason, & Ratcliffe, 2009). Engaging in these electronic activities in the evening can replace sleep time, and such media use may increase sleep-disrupting arousal (Cain & Gradisar, 2010). Also, a study of fourth- and seventh-graders found that sleeping near small screens (smartphones, for example), sleeping with a TV in the room, and more screen time were associated with shorter sleep duration in both children and adolescents (Falbe & others, 2015).

Caffeine intake by adolescents appears to be related to inadequate sleep (Owens, 2014). Greater caffeine intake as early as 12 years of age is linked to later sleep onset, shorter sleep duration, and increased daytime sleepiness (Carskadon & Tarokh, 2014). Further, researchers have yet to study the connection between adolescent sleep patterns and high levels of caffeine intake from energy drinks.

Mary Carskadon and her colleagues (2004, 2005, 2011a, b; Crowley & Carskadon, 2010; Tarokh & Carskadon, 2010) have conducted a number of research studies on adolescent sleep patterns. They found that when given the opportunity, adolescents will sleep an average of 9 hours and 25 minutes a night. Most get considerably less than nine hours of sleep, however, especially during the week. This shortfall creates a sleep deficit, which adolescents often attempt to make up on the weekend. The researchers also found that older adolescents tend to be sleepier during the day than younger adolescents. They theorized that this sleepiness was not due to academic work or social pressures. Rather, their research suggests that adolescents’ biological clocks undergo a shift as they get older, delaying their period of sleepiness by about one hour. A delay in the nightly release of the sleep-inducing hormone melatonin, which is produced in the brain’s pineal gland, seems to underlie this shift. Melatonin is secreted at about 9:30 p.m. in younger adolescents and approximately an hour later in older adolescents.

Carskadon concludes that early school starting times may cause grogginess, inattention in class, and poor performance on tests. Based on her research, school officials in Edina, Minnesota, decided to start classes at 8:30 a.m. rather than the usual 7:25 a.m. Since then there have been fewer referrals for discipline problems, and the number of students who report being ill or depressed has decreased. The school system reports that test scores have improved for high school students but not for middle school students. This finding supports Carskadon’s suspicion that early start times are likely to be more stressful for older than for younger adolescents.

image19In Mary Carskadon’s sleep laboratory at Brown University, an adolescent girl’s brain activity is being monitored. Carskadon (2005) says that in the morning, sleep-deprived adolescents’ “brains are telling them it’s night time . . . and the rest of the world is saying it’s time to go to school” (p. 19).  ©Jim LoScalzo

One study found that just a 30-minute delay in school start time was linked to improvements in adolescents’ sleep, alertness, mood, and health (Owens, Belon, & Moss, 2010). In another study, early school start times were linked to a higher vehicle crash rate in adolescent Page 354drivers (Vorona & others, 2014). The American Academy of Pediatrics recommends that schools institute start times from 8:30 to 9:30 a.m. to improve adolescents’ academic performance and quality of life (Adolescent Sleep Working Group, AAP, 2014).

Do sleep patterns change in emerging adulthood? Research indicates that they do (Galambos, Howard, & Maggs, 2011). One study revealed that more than 60 percent of college students were categorized as poor-quality sleepers (Lund & others, 2010). In this study, the weekday bedtimes and rise times of first-year college students were approximately 1 hour and 15 minutes later than those of seniors in high school (Lund & others, 2010). However, the first-year college students had later bedtimes and rise times than third- and fourth-year college students, indicating that at about 20 to 22 years of age, a reverse in the timing of bedtimes and rise times occurs. In another study, consistently low sleep duration in college students was associated with less effective attention the next day (Whiting & Murdock, 2016). Also, in a recent study of college students, a higher level of text messaging (greater number of daily texts, awareness of nighttime cell phone notifications, and compulsion to check nighttime notifications) was linked to a lower level of sleep quality (Murdock, Horissian, & Crichlow-Ball, 2017).

Leading Causes of Death in Adolescence The three leading causes of death in adolescence are unintentional injuries, homicide, and suicide (National Center for Health Statistics, 2018). Almost half of all deaths from 15 to 24 years of age are due to unintentional injuries, the majority of them involving motor vehicle accidents. Risky driving habits, such as speeding, tailgating, and driving under the influence of alcohol or other drugs, may be more important contributors to these accidents than lack of driving experience (White & others, 2018; Williams & others, 2018). In about 50 percent of motor vehicle fatalities involving adolescents, the driver has a blood alcohol level of 0.10 percent—twice the level at which a driver is designated as “under the influence” in some states. Of growing concern is the increasingly common practice of mixing alcohol and energy drinks, which is linked to a higher rate of driving while intoxicated (Wilson & others, 2018). A high rate of intoxication is also found in adolescents who die as pedestrians or while using vehicles other than automobiles.

Homicide is the second leading cause of death in adolescence, especially among African American males (National Center for Health Statistics, 2018). Also notable is the adolescent suicide rate, which has tripled since the 1950s. Suicide accounts for 6 percent of deaths in the 10-to-14 age group and 12 percent of deaths in the 15-to-19 age group. We will discuss suicide in more detail later.

SUBSTANCE USE AND ABUSE

Each year since 1975, Lloyd Johnston and his colleagues at the Institute of Social Research at the University of Michigan have monitored the drug use of America’s high school seniors in a wide range of public and private high schools. Since 1991, they also have surveyed drug use by eighth- and tenth-graders. In 2017, the study surveyed approximately 45,000 secondary school students in 380 public and private schools (Johnston & others, 2018).

In the University of Michigan study, drug use among U.S. secondary school students declined in the 1980s but began to increase in the early 1990s before declining again in the early part of the first decade of the 21st century. However, from 2006 through 2017, overall use of illicit drugs began increasing again, due mainly to an increase in marijuana use by adolescents. In 2006, 36.5 percent of twelfth-graders reported annual use of an illicit drug but in 2017 that figure had increased to 39.9 percent. However, if marijuana use is subtracted from the annual use figures, there has been a significant decline in drug use by adolescents. When marijuana use is deleted, in 2006, 19.2 percent of twelfth-graders used an illicit drug annually, but that figure showed a significant decline to 13.3 percent in 2017 (Johnston & others, 2018). Marijuana is the most widely used illicit drug by adolescents.

The United States continues to have one of the highest rates of adolescent drug use of any industrialized nation. Because of the increased legalization of marijuana use for adults in a number of states, youth are likely to have increased access to the drug and it is expected that marijuana use by adolescents will increase in the future.

developmental connection
Substance Abuse

Does substance abuse increase or decrease in emerging adulthood? Connect to “Physical and Cognitive Development in Early Adulthood.”

Alcohol How extensive is alcohol use by U.S. adolescents? Sizable declines in adolescent alcohol use have occurred in recent years (Johnston & others, 2018). The percentage of U.S. eighth-graders who reported having had any alcohol to drink Page 355in the past 30 days fell from a 1996 high of 26 percent to 8.0 percent in 2017. The 30-day prevalence fell among tenth-graders from 39 percent in 2001 to 19.7 percent in 2017 and among high school seniors from 72 percent in 1980 to 33.2 percent in 2017. Binge drinking (defined in the University of Michigan surveys as having five or more drinks in a row in the last two weeks) by high school seniors declined from 41 percent in 1980 to 19.1 percent in 2015. Binge drinking by eighth- and tenth-graders also has dropped significantly in recent years. A consistent gender difference occurs in binge drinking, with males engaging in this behavior more than females do (Johnston & others, 2018).

A special concern is adolescents who drive while they are under the influence of alcohol or other substances (White & others, 2018; Williams & others, 2018; Wilson & others, 2018). In the University of Michigan Monitoring the Future Study, 30 percent of high school seniors said they had been in a vehicle with a drugged or drinking driver in the past two weeks (Johnston & others, 2008). And in a national study, one in four twelfth-graders reported that they had consumed alcohol mixed with energy drinks in the last 12 months, and this combination was linked to their unsafe driving (Martz, Patrick, & Schulenberg, 2015).

image20 What are some trends in alcohol use by U.S. adolescents?  ©Daniel Allan/Getty Images

Smoking Cigarette smoking (in which the active drug is nicotine) has been one of the most serious yet preventable health problems among adolescents and emerging adults (McKelvey & Halpern-Felsher, 2017). Cigarette smoking among U.S. adolescents peaked in 1996 and has declined significantly since then (Johnston & others, 2018). Following peak use in 1996, smoking rates for U.S. eighth-graders have fallen by 50 percent. In 2017, the percentage of twelfth-graders who reported having smoked cigarettes in the last 30 days was 9.7 percent, an 8 percent decrease from 2011, while the rate for tenth-graders was 5.0 percent and the rate for eighth-graders was 1.9 percent. Since the mid-1990s an increasing percentage of adolescents have reported that they perceive cigarette smoking as dangerous, that they disapprove of it, that they are less accepting of being around smokers, and that they prefer to date nonsmokers (Johnston & others, 2018).

E-cigarettes—battery-powered devices with a heating element—produce a vapor that users inhale. In most cases the vapor contains nicotine, but the specific contents of “vape” formulas are not regulated (Barrington-Trimis & others, 2017; Gorukanti & others, 2017). While adolescent cigarette use has decreased significantly in recent years, a substantial number of U.S. adolescents are now vaping nicotine. In the national study just described, in 2017, 11.0 percent of twelfth-graders, 8.2 percent of tenth-graders, and 3.5 percent of eighth-graders vaped nicotine (Johnston & others, 2018). Thus, adolescents currently are vaping nicotine more than they are smoking cigarettes. Also, in a recent meta-analysis of longitudinal studies, it was concluded that when adolescents use e-cigarettes they are at increased risk for subsequently smoking cigarettes (Soneji & others, 2018).

The Roles of Development, Parents, Peers, and Education There are serious consequences when adolescents begin to use drugs early in adolescence or even in childhood (Donatelle & Ketcham, 2018). For example, a study revealed that the onset of alcohol use before age 11 was linked to a higher risk of alcohol dependence in early adulthood (Guttmannova & others, 2012). Another study found that early onset of drinking and a quick progression to drinking to intoxication were linked to drinking problems in high school (Morean & others, 2014). Further, a longitudinal study found that earlier age at first use of alcohol was linked to increased risk of heavy alcohol use in early adulthood (Liang & Chikritzhs, 2015). And another study indicated that early- and rapid-onset trajectories of alcohol, marijuana, and substance use were associated with substance abuse in early adulthood (Nelson, Van Ryzin, & Dishion, 2015).

image21 What are some of the ways that parents influence whether their adolescents take drugs?  ©Picturenet/Blend Images LLC

Parents play an important role in preventing adolescent drug abuse (Cruz & others, 2018; Garcia-Huidobro & others, 2018; Pena & others, 2017). Positive relationships with parents and others can reduce adolescents’ drug use (Chassin & others, 2016; Eun & others, 2018). Researchers have found that parental monitoring is linked with a lower incidence of drug use (Wang & others, 2014). For example, a recent study revealed that parental monitoring was linked to a lower level of polysubstance use by adolescents (Chan & others, 2017). Also, in a recent intervention study, Latino parents who participated in a program that emphasized the importance of parental monitoring had adolescents with a lower level of drug use than a control group of adolescents whose parents did not participate in the program (Estrada & others, 2017). A research review concluded that the more frequently adolescents ate dinner with their families, the less likely they were to have substance abuse problems (Sen, 2010).

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connecting through research

What Can Families Do to Reduce Drinking and Smoking by Young Adolescents?

Experimental studies have been conducted to determine whether family programs can reduce drinking and smoking by young adolescents. In one experimental study, 1,326 families with 12- to 14-year-old adolescents living in various parts of the United States were interviewed (Bauman & others, 2002). After the baseline interviews, participants were randomly assigned either to go through the Family Matters program (experimental group) or not to experience the program (control group) (Bauman & others, 2002).

The families assigned to the Family Matters program received four mailings of booklets. Each mailing was followed by a telephone call from a health educator to “encourage participation by all family members, answer any questions, and record information” (Bauman & others, 2002, pp. 36–37). The first booklet focused on the negative consequences of adolescent substance abuse to the family. The second emphasized “supervision, support, communication skills, attachment, time spent together, educational achievement, conflict reduction, and how well adolescence is understood.” The third booklet asked parents to list things they do that might inadvertently encourage their child’s use of tobacco or alcohol, identify rules that might influence the child’s use, and consider ways to monitor use. Then adult family members and the child met “to agree upon rules and sanctions related to adolescent use.” Booklet four dealt with “what the child can do to resist peer and media pressures for use.”

Two follow-up interviews with the parents and adolescents were conducted three months and one year after the experimental group had completed the program. Adolescents in the Family Matters program reported lower alcohol and cigarette use at three months and at one year after the program had been completed.  Figure 8  shows the results for alcohol.

image22 FIGURE 8 YOUNG ADOLESCENTS’ REPORTS OF ALCOHOL USE IN THE FAMILY MATTERS PROGRAM. Note that at baseline (before the program started) the young adolescents in the Family Matters program (experimental group) and their counterparts who did not go through the program (control group) reported approximately the same lifetime use of alcohol (slightly higher use by the experimental group). However, three months after the program ended, the experimental group reported lower alcohol use, and this reduction was still present one year after the program had ended, although at a reduced level.  Source: Johnston, L. D., et al. Monitoring the Future: National survey results on drug use 2016. Ann Arbor: Institute for Social Research, University of Michigan, 2017.

The topics covered in the second booklet underscore the importance of parental influence earlier in development. For instance, staying actively involved and establishing an authoritative, as opposed to a neglectful, parenting style early in children’s lives will better ensure that children have a clear understanding of the parents’ level of support and expectations when the children reach adolescence.

Along with parents, peers play a very important role in adolescent substance use (Cambron & others, 2018; Choukas-Bradley & Prinstein, 2016; Strong & others, 2017). For example, a large-scale national study of adolescents indicated that friends’ use of alcohol was a stronger influence on adolescent alcohol use than parental use (Deutsch, Wood, & Slutske, 2018).

Academic success is also a strong buffer for the emergence of drug problems in adolescence (Kendler & others, 2018). In one study, early educational achievement considerably reduced the likelihood that adolescents would develop drug problems (Bachman & others, 2008). But what can families do to educate themselves and their children and reduce adolescent drinking and smoking behavior? To find out, see  Connecting Through Research .

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EATING DISORDERS

Let’s now examine two eating problems—anorexia nervosa and bulimia nervosa—that are far more common in adolescent girls than boys.

Anorexia Nervosa Although most U.S. girls have been on a diet at some point, slightly less than 1 percent ever develop anorexia nervosa.  Anorexia nervosa  is an eating disorder that involves the relentless pursuit of thinness through starvation. It is a serious disorder that can lead to death (Pinhas & others, 2017; Westmoreland, Krantz, & Mehler, 2016). Four main characteristics apply to people suffering from anorexia nervosa: (1) weight below 85 percent of what is considered normal for their age and height; (2) an intense fear of gaining weight that does not decrease with weight loss; (3) a distorted image of their body shape (Reville, O’Connor, & Frampton, 2016), and (4) amenorrhea(lack of menstruation) in girls who have reached puberty.

Obsessive thinking about weight and compulsive exercise also are linked to anorexia nervosa (Simpson & others, 2013). Even when they are extremely thin, they see themselves as too fat (Cornelissen & others, 2015). They never think they are thin enough, especially in the abdomen, buttocks, and thighs. They usually weigh themselves frequently, often take their body measurements, and gaze critically at themselves in mirrors.

Anorexia nervosa typically begins in the early to middle adolescent years, often following an episode of dieting and some type of life stress (Fitzpatrick, 2012). It is about 10 times more likely to occur in females than males. When anorexia nervosa does occur in males, the symptoms and other characteristics (such as a distorted body image and family conflict) are usually similar to those reported by females who have the disorder (Ariceli & others, 2005).

Most anorexics are non-Latina White adolescent or young adult females from well-educated middle- and upper-income families and are competitive and high-achieving (Darcy, 2012). They set high standards, become stressed about not being able to reach the standards, and are intensely concerned about how others perceive them (Murray & others, 2017; Stice & others, 2017). Unable to meet these high expectations, they turn to something they can control: their weight. Offspring of mothers with anorexia nervosa are at risk for becoming anorexic themselves (Machado & others, 2014). Problems in family functioning are increasingly being found to be linked to the appearance of anorexia nervosa in adolescent girls (Dimitropoulos & others, 2018; Espie & Eisler, 2015), and research indicates that family therapy is often an effective treatment for adolescent girls with anorexia nervosa (Ganci & others, 2018; Hail & Le Grange, 2018; Hughes & others, 2018).

image23Anorexia nervosa has become an increasing problem for adolescent girls and young adult women. What are some possible causes of anorexia nervosa?  ©Ian Thraves/Alamy

Biology and culture are involved in anorexia nervosa. Genes play an important role in anorexia nervosa (Meyre & others, 2018). Also, the physical effects of dieting may change neural networks and thus sustain the disordered pattern (Scaife & others, 2017). The thin fashion-model image in U.S. culture likely contributes to the incidence of anorexia nervosa (Cazzato & others, 2016). The media portray thin as beautiful in their choice of fashion models, whom many adolescent girls strive to emulate. Social media may also fuel the relentless pursuit of thinness by making it easier for anorexic adolescents to find each other online. A recent study found that having an increase in Facebook friends across two years was linked to enhanced motivation to be thin (Tiggemann & Slater, 2017).

Bulimia Nervosa Whereas anorexics control their weight by restricting food intake, most bulimics cannot.  Bulimia nervosa  is an eating disorder in which the individual consistently follows a binge-and-purge pattern. The bulimic goes on an eating binge and then purges by self-inducing vomiting or using a laxative. Although many people binge and purge occasionally and some experiment with it, a person is considered to have a serious bulimic disorder only if the episodes occur at least twice a week for three months (Castillo & Weiselberg, 2017).

As with anorexics, most bulimics are preoccupied with food, have a strong fear of becoming overweight, are depressed or anxious, and have a distorted body image (Murray & others, 2017; Stice & others, 2017). One study found that bulimics have difficulty controlling their emotions (Lavender & others, 2014). Like adolescents who are anorexic, bulimics are highly perfectionistic (Lampard & others, 2012). Unlike anorexics, individuals who binge and purge typically fall within a normal weight range, which makes bulimia more difficult to detect.

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Approximately 1 to 2 percent of U.S. women are estimated to develop bulimia nervosa, and about 90 percent of bulimics are women. Bulimia nervosa typically begins in late adolescence or early adulthood. Many women who develop bulimia nervosa were somewhat overweight before the onset of the disorder, and the binge eating often began during an episode of dieting. As with anorexia nervosa, about 70 percent of individuals who develop bulimia nervosa eventually recover from the disorder (Agras & others, 2004). Drug therapy and psychotherapy have been effective in treating anorexia nervosa and bulimia nervosa (Agras & others, 2017). Cognitive behavior therapy has especially been helpful in treating bulimia nervosa (Abreu & Cangelli Filho, 2017; Hail & Le Grange, 2018; Peterson & others, 2017).

Review Connect Reflect

LG3 Identify adolescent problems related to health, substance use and abuse, and eating disorders.

Review

· What are key concerns about the health of adolescents?

· What are some characteristics of adolescents’ substance use and abuse?

· What are the characteristics of the major eating disorders?

Connect

· In  Connecting Through Research , you learned that attachment was one of the things that the Family Matters program emphasized as important in reducing drinking and smoking behavior in adolescents. Do the research findings discussed in the chapter entitled “Socioemotional Development in Infancy” support or contradict this emphasis on early attachment’s effect on development and behavior later in life?

Reflect Your Own Personal Journey of Life

· How health-enhancing and health-compromising were your patterns of behavior in adolescence? Explain.

4 Adolescent Cognition

LG4 Explain cognitive changes in adolescence.

Piaget’s Theory

Adolescent Egocentrism

Information Processing

Adolescents’ developing power of thought opens up new cognitive and social horizons. Let’s examine some explanations of how their power of thought develops, beginning with Piaget’s theory (1952).

PIAGET’S THEORY

Jean Piaget proposed that around 7 years of age children enter the concrete operational stage of cognitive development. They can reason logically about concrete events and objects, and they make gains in their ability to classify objects and to reason about the relationships between classes of objects. Around age 11, according to Piaget, the fourth and final stage of cognitive development—the formal operational stage—begins.

developmental connection
Cognitive Theory

Is there a fifth, postformal stage of cognitive development that characterizes young adults? Connect to “Physical and Cognitive Development in Early Adulthood.”

The Formal Operational Stage What are the characteristics of the formal operational stage? Formal operational thought is more abstract than concrete operational thought. Adolescents are no longer limited to actual, concrete experiences as anchors for thought. They can conjure up make-believe situations, abstract propositions, and events that are purely hypothetical, and can try to reason logically about them.

The abstract quality of thinking during the formal operational stage is evident in the adolescent’s verbal problem-solving ability. Whereas the concrete operational thinker needs to see the concrete elements A, B, and C to be able to make the logical Page 359inference that if A = B and B = C, then A = C, the formal operational thinker can solve this problem merely through verbal presentation.

Another indication of the abstract quality of adolescents’ thought is their increased tendency to think about thought itself. One adolescent commented, “I began thinking about why I was thinking what I was. Then I began thinking about why I was thinking about what I was thinking about what I was.” If this sounds abstract, it is, and it characterizes the adolescent’s enhanced focus on thought and its abstract qualities.

Accompanying the abstract nature of formal operational thought is thought full of idealism and possibilities, especially during the beginning of the formal operational stage, when assimilation dominates. Adolescents engage in extended speculation about ideal characteristics—qualities they desire in themselves and in others. Such thoughts often lead adolescents to compare themselves with others in regard to such ideal standards. And their thoughts are often fantasy flights into future possibilities.

image24 Might adolescents’ ability to reason hypothetically and to evaluate what is ideal versus what is real lead them to engage in demonstrations such as this protest related to improving education? What other causes might be attractive to adolescents’ newfound cognitive abilities of hypothetical-deductive reasoning and idealistic thinking?  ©Jim West/Alamy

At the same time that adolescents think more abstractly and idealistically, they also think more logically. Children are likely to solve problems through trial and error; adolescents begin to think more as a scientist thinks, devising plans to solve problems and systematically testing solutions. This type of problem solving requires  hypothetical-deductive reasoning , which involves creating a hypothesis and deducing its implications, steps that provide ways to test the hypothesis. Thus, formal operational thinkers develop hypotheses about ways to solve problems and then systematically deduce the best path to follow to solve the problem.

Evaluating Piaget’s Theory Researchers have challenged some of Piaget’s ideas about the formal operational stage (Reyna & Zayas, 2014). Among their findings is that there is much more individual variation than Piaget envisioned: Only about one in three young adolescents is a formal operational thinker, and many American adults (and adults in other cultures) never become formal operational thinkers.

Furthermore, education in the logic of science and mathematics promotes the development of formal operational thinking. This point recalls a criticism of Piaget’s theory that suggests culture and education exert stronger influences on cognitive development than Piaget maintained (Petersen & others, 2017; Wagner, 2018).

Piaget’s theory of cognitive development has been challenged on other points as well. Children’s cognitive development is not as stage-like as Piaget envisioned (Siegler, 2017; Wu & Scerif, 2018). Because some cognitive abilities have found to emerge earlier than Piaget thought, and others later, children do not appear to move neatly from one stage to another (Bauer, 2018; Liu & Spelke, 2017). Other evidence casting doubt on the stage notion is that children often show more understanding on one task than on another, similar task.

image25Many adolescent girls spend long hours in front of the mirror, depleting cans of hairspray, tubes of lipstick, and jars of cosmetics. How might this behavior be related to changes in adolescent cognitive and physical development?  ©Image Source/Getty Images

Despite these challenges to Piaget’s ideas, we owe him a tremendous debt (Miller, 2016). Piaget was the founder of the present field of cognitive development, and he developed a long list of masterful concepts of enduring power and fascination: assimilation, accommodation, object permanence, egocentrism, conservation, and others. Psychologists also owe him the current vision of children as active, constructive thinkers. And they are indebted to him for creating a theory that has generated a huge volume of research on children’s cognitive development (Miller, 2016).

Piaget also was a genius when it came to observing children. His careful observations demonstrated inventive ways to discover how children act on and adapt to their world. He showed us how children need to make their experiences fit their schemes yet simultaneously adapt their schemes to accommodate their experiences. And Piaget revealed how cognitive change is likely to occur if the context is structured to allow gradual movement to the next higher level.

ADOLESCENT EGOCENTRISM

Adolescent egocentrism  is the heightened self-consciousness of adolescents. David Elkind (1976) points out that adolescent egocentrism has two key components—the imaginary audience and personal fable. The  imaginary audience  is reflected in adolescents’ belief that others are as interested in them as they themselves Page 360are, as well as attention-getting behavior—attempts to be noticed, visible, and “on stage.” For example, an eighth-grade boy might walk into a classroom and think that all eyes are riveted on his spotty complexion. Adolescents sense that they are “on stage” in early adolescence, believing they are the main actors and all others are the audience.

According to Elkind, the  personal fable  is the part of adolescent egocentrism involving a sense of uniqueness and invincibility (or invulnerability). For example, 13-year-old Adrienne says this about herself: “No one understands me, particularly my parents. They have no idea of what I am feeling.” Adolescents’ sense of personal uniqueness makes them believe that no one can understand how they really feel. As part of their effort to retain a sense of personal uniqueness, adolescents might craft a story about the self that is filled with fantasy, immersing themselves in a world that is far removed from reality. Personal fables frequently show up in adolescent diaries.

image26 Might frequent use of social media, such as Facebook, increase adolescents’ egocentrism?  ©Brendan O’Sullivan/Photolibrary/Getty Images

Adolescents often have been portrayed as having a sense of invincibility or invulnerability. For example, during a conversation with a girl who is the same age, 14-year-old Margaret says, “Are you kidding? I won’t get pregnant.” This sense of invincibility may lead adolescents to believe that they themselves are invulnerable to dangers and catastrophes (such as deadly car wrecks) that happen to other people. As a result, some adolescents engage in risky behaviors such as drag racing, drug use, suicide attempts, and having sexual intercourse without using contraceptives or barriers against STIs (Alberts, Elkind, & Ginsberg, 2007).

developmental connection
Cognitive Theory

Piaget described a form of egocentrism that characterizes young children. Connect to “Physical and Cognitive Development in Early Childhood.”

Might social media be an amplification tool for adolescent egocentrism? Earlier generations of adolescents did not have social media to connect with large numbers of people; instead, they connected with fewer people, either in person or via telephone. Might today’s teens be drawn to social media and its virtually unlimited friend base to express their imaginary audience and sense of uniqueness? One analysis concluded that amassing a large number of friends (audience) may help to validate adolescents’ perception that their life is on stage and everyone is watching them (Psychster Inc, 2010). A recent meta-analysis concluded that a greater use of social networking sites was linked to a higher level of narcissism (Gnambs & Appel, 2018).

developmental connection
The Brain

The prefrontal cortex is the location in the brain where much of executive function occurs. Connect to “Physical and Cognitive Development in Early Childhood.”

What about having a sense of invulnerability—is that aspect of adolescent egocentrism as accurate as Elkind argues? An increasing number of research studies suggest that rather than perceiving themselves to be invulnerable, adolescents tend to portray themselves as vulnerable to experiencing a premature death (Reyna & Rivers, 2008). For example, in one study, 12- to 18-year-olds were asked about their chances of dying in the next year and prior to age 20 (Fischhoff & others, 2010). The adolescents greatly overestimated their chance of dying prematurely.

INFORMATION PROCESSING

Deanna Kuhn (2009) identified some important characteristics of adolescents’ information processing and thinking. In her view, in the later years of childhood and continuing in adolescence, individuals approach cognitive levels that may or may not be achieved, in contrast to the largely universal cognitive levels that young children attain. By adolescence, considerable variation in cognitive functioning is present across individuals. This variability supports the argument that adolescents are producers of their own development to a greater extent than are children.

Kuhn (2009) further argues that the most important cognitive change in adolescence is improvement in executive function—an umbrella-like concept that consists of a number of higher-level cognitive processes linked to the development of the prefrontal cortex (Crone, Peters, & Steinbeis, 2018; Gerst & others, 2017). Executive function involves managing one’s thoughts to engage in goal-directed behavior and to exercise self-control (Bardikoff & Sabbagh, 2017; Knapp & Morton, 2017; Wiebe & Karbach, 2018). Our further coverage of executive function in adolescence focuses on cognitive control, decision making, and critical thinking.

Cognitive Control Earlier you read about the increase Page 361in cognitive control that occurs in middle and late childhood. Recall that  cognitive control  involves effective control in a number of areas, including controlling attention, reducing interfering thoughts, and being cognitively flexible (Stewart & others, 2017). Cognitive control continues to increase in adolescence and emerging adulthood (Chevalier, Dauvier, & Blaye, 2018; Romer, Reyna, & Satterthwaite, 2017; Somerville, 2016).

Think about all the times adolescents need to engage in cognitive control, such as the following situations (Galinsky, 2010):

· making a real effort to stick with a task, avoiding interfering thoughts or environmental events, and instead doing what is most effective;

· stopping and thinking before acting to avoid blurting out something that a minute or two later they wished they hadn’t said;

· continuing to work on something that is important but boring when there is something a lot more fun to do, inhibiting their behavior and doing the boring but important task, saying to themselves, “I have to show the self-discipline to finish this.”

image27 What are some different aspects of cognitive control that can benefit adolescents’ development?  ©DreamPictures/Taxi/Getty Images

Control Attention and Reduce Interfering Thoughts Controlling attention is a key aspect of learning and thinking in adolescence and emerging adulthood (Lau & Waters, 2017; Mueller & others, 2017). Distractions that can interfere with attention in adolescence and emerging adulthood come from the external environment (other students talking while the student is trying to listen to a lecture, or the student turning on a laptop or tablet PC during a lecture and looking at a new friend request on Facebook, for example) or intrusive distractions from competing thoughts in the individual’s mind. Self-oriented thoughts, such as worrying, self-doubt, and intense emotionally laden thoughts may especially interfere with focusing attention on thinking tasks (Gillig & Sanders, 2011).

Be Cognitively Flexible Cognitive flexibility involves being aware that options and alternatives are available and adapting to the situation (Buttelmann & Karbach, 2017; Wang, Ye, & Degol, 2017). Before adolescents and emerging adults adapt their behavior in a situation, they must be aware that they need to change their way of thinking and be motivated to do so (Gopnik & others, 2018). Having confidence in their ability to adapt their thinking to a particular situation, an aspect of self-efficacy, also is important in being cognitively flexible (Bandura, 2012).

Decision Making Adolescence is a time of increased decision making—which friends to choose; which person to date; whether to have sex, buy a car, go to college, and so on (Helm & Reyna, 2018; Meschkow & others, 2018; Reyna, 2018; Romer, Reyna, & Satterthwaite, 2017; Steinberg & others, 2018; van den Bos & Hertwig, 2017). How competent are adolescents at making decisions? Older adolescents are described as more competent than younger adolescents, who in turn are more competent than children (Keating, 1990). Compared with children, young adolescents are more likely to generate different options, examine a situation from a variety of perspectives, anticipate the consequences of decisions, and consider the credibility of sources.

Most people make better decisions when they are calm than when they are emotionally aroused. That may especially be true for adolescents, who have a tendency to be emotionally intense (Cohen & Casey, 2017). The same adolescent who makes a wise decision when calm may make an unwise decision when emotionally aroused. In the heat of the moment, emotions may overwhelm decision-making ability (Goddings & Mills, 2017).

image28 How do emotions and social contexts influence adolescents’ decision making?  ©JodiJacobson/E+/Getty Images

The social context plays a key role in adolescent decision making (Breiner & others, 2018; Sherman, Steinberg, & Chein, 2018; Silva & others, 2017). For example, adolescents’ willingness to make risky decisions is more likely to occur in contexts where substances and other temptations are readily available (Helm & Reyna, 2018; Meschkow & others, 2018; Reyna, 2018; Reyna & Rivers, 2008). Recent research reveals that the presence of peers in risk-taking situations increases the likelihood that adolescents will make risky decisions (Silva & others, 2017; Steinberg, 2015a, b). In a recent study, adolescents took greater risks and showed stronger Page 362preference for immediate rewards when they were with three same-aged peers than when they were alone (Silva, Chein, & Steinberg, 2016).

To better understand adolescent decision making, Valerie Reyna and her colleagues (Helm & Reyna, 2018; Meschkow & othes, 2018; Reyna, 2018; Reyna & Farley, 2006; Reyna & others, 2011, 2015, 2017; Romer, Reyna, & Satterthwaite, 2017) have proposed the  fuzzy-trace theory dual-process model , which states that decision making is influenced by two cognitive systems—“verbatim” analytical (literal and precise) and gist-based intuitional (simple bottom-line meaning)—which operate in parallel. Basing judgments and decisions on simple gist is viewed as more beneficial than analytical thinking to adolescents’ decision making. In this view, adolescents don’t benefit from engaging in reflective, detailed, higher-level cognitive analysis about a decision, especially in high-risk, real-world contexts where they would get bogged down in trivial detail. In such contexts, adolescents need to rely on their awareness that some circumstances are simply so dangerous that they must be avoided at all costs.

In risky situations it is important for an adolescent to quickly get the gist, or meaning, of what is happening and glean that the situation is a dangerous context, which can cue personal values that will protect the adolescent from making a risky decision (Helm, McCormick, & Reyna, 2018; Helm & Reyna, 2018; Meschkow & others, 2018; Rahimi-Golkhandan & others, 2017; Reyna, 2018; Reyna & others, 2011, 2015; Romer, Reyna, & Satterthwaite, 2017). An experiment showed that encouraging gist-based thinking about risks (along with factual information) reduced self-reported risk taking up to one year after exposure to the curriculum (Reyna & Mills, 2014). However, some experts on adolescent cognition argue that in many cases adolescents benefit from both analytical and experiential systems (Kuhn, 2009).

Adolescents need more opportunities to practice and discuss realistic decision making. Many real-world decisions on matters such as sex, drugs, and daredevil driving occur in an atmosphere of stress that includes time constraints and emotional involvement. One strategy for improving adolescent decision making is to provide more opportunities for them to engage in role playing and peer group problem solving.

Critical Thinking Adolescence is an important transitional period in the development of critical thinking (Keating, 1990). In one study of fifth-, eighth-, and eleventh-graders, critical thinking increased with age but still occurred in only 43 percent of even the eleventh-graders, and many adolescents showed self-serving biases in their reasoning.

If fundamental skills (such as literacy and math skills) are not developed during childhood, critical-thinking skills are unlikely to mature in adolescence. For the subset of adolescents who lack such fundamental skills, potential gains in adolescent thinking are unlikely. For other adolescents, however, cognitive changes that allow improved critical thinking in adolescence include the following: (1) increased speed, automaticity, and capacity of information processing, which free cognitive resources for other purposes; (2) more breadth of content knowledge in a variety of domains; (3) increased ability to construct new combinations of knowledge; and (4) a greater range and more spontaneous use of strategies or procedures for applying or obtaining knowledge, such as planning, considering alternatives, and cognitive monitoring.

Review Connect Reflect

LG4 Explain cognitive changes in adolescence.

Review

· What is Piaget’s theory of adolescent cognitive development?

· What is adolescent egocentrism?

· What are some important aspects of information processing in adolescence?

Connect

· Egocentrism was also mentioned earlier in the context of early childhood cognitive development. How is adolescent egocentrism similar to or different from egocentrism in early childhood?

Reflect Your Own Personal Journey of Life

· Evaluate the level of your thinking as you made the transition to adolescence and through adolescence. Does Piaget’s stage of formal operational thinking accurately describe the changes that occurred in your thinking? Explain.

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5 Schools

LG5 Summarize some key aspects of how schools influence adolescent development.

The Transition to Middle or Junior High School

Effective Schools for Young Adolescents

High School

Extracurricular Activities

Service Learning

What is the transition from elementary to middle or junior high school like? What are the characteristics of effective schools for adolescents? How can adolescents benefit from service learning?

THE TRANSITION TO MIDDLE OR JUNIOR HIGH SCHOOL

The first year of middle school or junior high school can be difficult for many students (Wigfield, Rosenzweig, & Eccles, 2017; Wigfield, Tonks, & Klauda, 2016). For example, in one study of the transition from sixth grade in an elementary school to seventh grade in a junior high school, adolescents’ perceptions of the quality of their school life plunged in the seventh grade (Hirsch & Rapkin, 1987). Compared with their earlier feelings as sixth-graders, the seventh-graders were less satisfied with school, were less committed to school, and liked their teachers less. The drop in school satisfaction occurred regardless of how academically successful the students were. The transition to middle or junior high school is less stressful when students have positive relationships with friends and go through the transition in team-oriented schools where 20 to 30 students take the same classes together (Hawkins & Berndt, 1985).

The transition to middle or junior high school takes place at a time when many changes—in the individual, in the family, and in school—are occurring simultaneously (Wigfield & others, 2015; Wigfield, Rosenzweig, & Eccles, 2017; Wigfield, Tonks, & Klauda, 2016). These changes include puberty and related concerns about body image; the emergence of at least some aspects of formal operational thought and changes in social cognition; increased responsibility and decreased dependency on parents; change to a larger, more impersonal school structure; change from one teacher to many teachers and from a small, homogeneous set of peers to a larger, more heterogeneous set of peers; and an increased focus on achievement and performance. Moreover, when students make the transition to middle or junior high school, they experience the  top-dog phenomenon , moving from being the oldest, biggest, and most powerful students in the elementary school to being the youngest, smallest, and least powerful students in the middle or junior high school.

image29The transition from elementary to middle or junior high school occurs at the same time as a number of other developmental changes. What are some of these other developmental changes?  ©Creatas/PunchStock

The transition to middle or junior high school also can have positive aspects. Students are more likely to feel grown up, have more subjects from which to select, have more opportunities to spend time with peers and locate compatible friends, and enjoy increased independence from direct parental monitoring. They also may be more challenged intellectually by academic work.

EFFECTIVE SCHOOLS FOR YOUNG ADOLESCENTS

Critics argue that middle and junior high schools should offer activities that reflect a wide range of individual differences in biological and psychological development among young adolescents. In 1989 the Carnegie Corporation issued an extremely negative evaluation of U.S. middle schools. It concluded that most young adolescents attended massive, impersonal schools; were taught from irrelevant curricula; trusted few adults in school; and lacked access to health care and counseling. It recommended that the nation develop smaller “communities” or “houses” to lessen the impersonal nature of large middle schools, have lower student-to-counselor ratios (10 to 1 instead of several hundred to 1), involve parents and community leaders in schools, develop new curricula, have teachers team teach in more flexibly designed curriculum blocks that integrate several disciplines, boost students’ health and fitness with more in-school programs, and help students who need public health care to get it. Twenty years later, experts are still finding that middle schools throughout the nation need a major redesign if they are to be effective in educating adolescents (Roeser, 2016; Wigfield & others, 2015).

To read about one individual whose main career focus is improving middle school students’ learning and education, see  Connecting with Careers.

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connecting with careers

Katherine McMillan Culp, Research Scientist at an Educational Center

Katherine McMillan Culp wanted mainly to live in New York City when she graduated from college and became a receptionist at a center that focused on children and technology. More than 20 years later she is leading research projects at the center (Center for Children and Technology). Not long after her receptionist job, she combined work at the center with graduate school at Columbia University. Culp became especially interested in how content and instruction can best be created to link with the developmental level of children and adolescents.

Today she holds the position of principal research scientist at Education Development Center, directing a number of projects. One of her main current interests is middle school students’ science learning. In this area, she consults with game designers, teachers, and policy makers to improve their understanding of how adolescents think and learn.

Her advice to anyone wanting to do this type of work outside of academia is to get the best education and training possible, then become connected with schools, work with teachers, and obtain experience related to practical problems involved with schools and learning (Culp, 2012).

HIGH SCHOOL

Just as there are concerns about U.S. middle school education, so are there concerns about U.S. high school education (Kitsantas & Cleary, 2016). A recent analysis indicated that only 25 percent of U.S. high school graduates have the academic skills to succeed in college (Bill & Melinda Gates Foundation, 2017). Not only are many high school graduates poorly prepared for college, they also are poorly prepared for the demands of the modern, high-performance workplace (Bill & Melinda Gates Foundation, 2018).

Critics stress that in many high schools expectations for success and standards for learning are too low. Critics also argue that too often high schools foster passivity and that schools should create a variety of pathways for students to achieve an identity. Many students graduate from high school with inadequate reading, writing, and math skills—including many who go on to college and must enroll in remediation classes there. Other students drop out of high school and do not have skills that will allow them to obtain decent jobs, much less to be informed citizens.

The transition to high school can have problems just as the transition to middle school does. For example, high schools are often even larger, more bureaucratic, and more impersonal than middle schools are; there isn’t much opportunity for students and teachers to get to know each other, which can lead to distrust; and teachers rarely make content relevant to students’ interests (Eccles & Roeser, 2016). Such experiences likely undermine the motivation of students.

Robert Crosnoe’s (2011) book, Fitting In, Standing Out, highlighted another major problem with U.S. high schools: how the negative social aspects of adolescents’ lives undermine their academic achievement. In his view, adolescents become immersed in complex peer group cultures that demand conformity. High school is supposed to be about getting an education, but for many youth it is about navigating the social worlds of peer relations that may or may not value education and academic achievement. Adolescents who fail to fit in, especially those who are obese or gay, become stigmatized. Crosnoe recommends increased school counseling services, expanded extracurricular activities, and improved parental monitoring to reduce such problems (Crosnoe & Benner, 2015).

Dropout Rates Yet another concern about U.S. high schools involves students dropping out of school. In the last half of the twentieth century and the first decade of the twenty-first century, U.S. high school dropout rates declined (National Center for Education Statistics, 2017). In the 1940s, more than half of U.S. 16- to 24-year-olds had dropped out of school; by 2015, this figure had decreased to 5.9 percent. The dropout rate of Latino adolescents remains high, although it has been decreasing considerably in the twenty-first century (from 27.8 percent in 2000 to 9.2 percent in 2016). The lowest dropout rate in 2015 was for Asian American adolescents Page 365(2.1 percent), followed by non-Latino White adolescents (4.6 percent), African American adolescents (6.5 percent), and Latino adolescents  (9.2 percent) (National Center for Education Statistics, 2017).

National data on Native American adolescents are inadequate because statistics have been collected sporadically and/or from small samples. However, there are some indications that Native American adolescents may have the highest school dropout rate.

Gender differences have characterized U.S. dropout rates for many decades, but they have been narrowing in recent years. In 2015, the dropout rate for males was 6.3 percent and for females it was 5.4 percent (National Center for Education Statistics, 2017).

The average U.S. high school dropout rates just described mask some very high dropout rates in low-income areas of inner cities. For example, in cities such as Detroit, Cleveland, and Chicago, dropout rates are higher than 50 percent. Also, the percentages cited earlier are for 16- to 24-year-olds. When dropout rates are calculated in terms of students who do not graduate from high school within four years, the percentage of students who drop out is also much higher. Thus, in considering high school dropout rates, it is important to examine age, the number of years it takes to complete high school, and various contexts including ethnicity, gender, and school location.

image30An important educational goal is to increase the high school graduation rate of Native youth. An excellent strategy to accomplish this goal is high quality early childhood educational programs such as this one at St. Bonaventure Indian School on the Navajo Nation in Thoreau, New Mexico.  ©Jim West/Alamy

Students drop out of school for many reasons (Dupere & others, 2015). In one study, almost 50 percent of the dropouts cited school-related reasons for leaving school, such as not liking school or being expelled or suspended (Rumberger, 1983). Twenty percent of the dropouts (but 40 percent of the Latino students) cited economic reasons for leaving school. One-third of the female students dropped out for personal reasons such as pregnancy or marriage.

According to a research review, the most effective programs to discourage dropping out of high school provide early intervention for reading problems, tutoring, counseling, and mentoring (Lehr & others, 2003). Clearly, then, early detection of children’s school-related difficulties and getting children engaged with school in positive ways are important strategies for reducing the dropout rate (Crosnoe, Bonazzo, & Wu, 2015).

One program that has been very effective in reducing school dropout rates is “I Have a Dream” (IHAD), an innovative, comprehensive, long-term dropout prevention program administered by the National “I Have a Dream” Foundation in New York (“I Have a Dream” Foundation, 2017). It has grown to encompass more than 180 projects in 64 cities and 28 states plus Washington, DC, and New Zealand, serving more than 16,000 children (“I Have a Dream” Foundation, 2017). Local IHAD projects around the country “adopt” entire grades (usually the third or fourth) from public elementary schools, or corresponding age cohorts from public housing developments. These children—“Dreamers”—are then provided with a program of academic, social, cultural, and recreational activities throughout their elementary, middle school, and high school years. Evaluations of IHAD programs have found improvements in grades, test scores, and school attendance, as well as a reduction in behavioral problems among Dreamers (Davis, Hyatt, & Arrasmith, 1998).

EXTRACURRICULAR ACTIVITIES

Adolescents in U.S. schools usually can choose from a wide array of extracurricular activities in addition to their academic courses. These adult-sanctioned activities typically occur during the after-school hours and can be sponsored either by the school or by the community. They include such diverse activities as sports, academic clubs, band, drama, and math clubs. Researchers have found that participation in extracurricular activities is linked to higher grades, greater school engagement, less likelihood of dropping out of school, improved probability of going to college, higher self-esteem, and lower rates of depression, delinquency, and substance abuse (Denault & Guay, 2017; Simpkins, Fredricks, & Eccles, 2015; Wigfield & others, 2015). A recent study revealed that immigrant adolescents who participated in extracurricular activities improved their academic achievement and increased Page 366their school engagement (Camacho & Fuligni, 2015). Adolescents gain more benefit from a breadth of extracurricular activities than from focusing on a single extracurricular activity.

image31These adolescents are participating in the “I Have a Dream” (IHAD) Program, a comprehensive, long-term dropout prevention program that has been very successful. What are some other strategies for reducing high school dropout rates?  Courtesy of “I Have a Dream” Foundation of Boulder County (www.ihadboulder.org)

Of course, the quality of the extracurricular activities matters (Simpkins, Fredricks, & Eccles, 2015). High-quality extracurricular activities that are likely to promote positive adolescent development provide competent, supportive adult mentors; opportunities for increasing school connectedness; challenging and meaningful activities; and opportunities for improving skills.

image32 What are some of the positive effects of service learning?  ©Ariel Skelley/Blend Images

SERVICE LEARNING

Service learning  is a form of education that promotes social responsibility and service to the community. In service learning, adolescents engage in activities such as tutoring, helping older adults, working in a hospital, assisting at a child-care center, or cleaning up a vacant lot to make a play area. An important goal of service learning is that adolescents become less self-centered and more strongly motivated to help others (Hart, Goel, & Atkins, 2017; Hart & van Goethem, 2017; Hart & others, 2017; Kackar-Cam & Schmidt, 2014). Service learning is often more effective when two conditions are met (Nucci, 2006): (1) giving students some degree of choice in the service activities in which they participate, and (2) providing students opportunities to reflect about their participation.

Researchers have found that service learning benefits adolescents in a number of ways (Hart & others, 2017). Improvements in adolescent development related to service learning include higher grades in school, increased goal setting, higher self-esteem, and a greater sense of being able to make a difference for others (Hart & van Goethem, 2017). Also, one study revealed that adolescents’ volunteer activities provided opportunities to explore and reason about moral issues (van Goethem & others, 2012).

Review Connect Reflect

LG5 Summarize some key aspects of how schools influence adolescent development.

Review

· What is the transition to middle or junior high school like?

· What are some characteristics of effective schools for young adolescents?

· What are some important things to know about high school dropouts and improving high schools?

· How does participation in extracurricular activities influence adolescent development?

· What is service learning, and how does it affect adolescent development?

Connect

· Compare the optimal school learning environments for adolescents described in this chapter with those described for younger children in previous chapters. Aside from age-appropriate curricula, what else is similar or different?

Reflect Your Own Personal Journey of Life

· What was your middle or junior high school like? How did it measure up to the Carnegie Corporation’s recommendations?

topical connections looking forward

From 18 to 25 years of age, individuals make a transition from adolescence to adulthood. This transitional period, called emerging adulthood, is characterized by identity exploration, instability, and awareness of possibilities. Individuals often reach the peak of their physical skills between 19 and 26 years of age, followed by declining physical development during the early thirties. Cognitive development becomes more pragmatic and realistic, as well as more reflective and relativistic. Work becomes a more central aspect of individuals’ lives.

Page 367

reach your learning goals
Physical and Cognitive Development in Adolescence
1 The Nature of Adolescence

LG1 Discuss the nature of adolescence.

· Many stereotypes of adolescents are too negative. Most adolescents today successfully negotiate the path from childhood to adulthood. However, too many of today’s adolescents are not provided with adequate opportunities and support to become competent adults. It is important to view adolescents as a heterogeneous group because different portraits of adolescents emerge, depending on the particular set of adolescents being described.

· Social policy regarding adolescents too often has focused on health-compromising behaviors and not enough on strength-based approaches. Adolescents need more caring adults in their lives.

2 Physical Changes

LG2 Describe the changes involved in puberty, as well as changes in the brain and sexuality during adolescence.

Puberty

The Brain

Adolescent Sexuality

· Puberty is a period of rapid physical maturation involving hormonal and bodily changes that occur primarily during early adolescence. Determinants of pubertal timing include nutrition, health, and heredity. The pubertal growth spurt begins at an average age of 9 years for girls and 11 for boys, reaching a peak at 11½ for girls and 13½ for boys. Individual variation in pubertal changes is substantial.

· Adolescents show considerable interest in their body image, with girls having more negative body images than boys do. For boys, early maturation brings benefits, at least during early adolescence. Early-maturing girls are vulnerable to a number of risks.

· Changes in the brain during adolescence involve the thickening of the corpus callosum and a gap in maturation between the limbic system and the prefrontal cortex, which functions in reasoning and self-regulation.

· Adolescence is a time of sexual exploration and sexual experimentation. Having sexual intercourse in early adolescence is associated with negative developmental outcomes.

· Contraceptive use by adolescents is increasing. About one in four sexually experienced adolescents acquires a sexually transmitted infection (STI). The adolescent pregnancy rate is higher in the United States than in other industrialized nations, but the U.S. rate of adolescent pregnancy has been decreasing in recent years.

3 Issues in Adolescent Health

LG3 Identify adolescent problems related to health, substance use and abuse, and eating disorders.

Adolescent Health

Substance Use and Abuse

Eating Disorders

· Adolescence is a critical juncture in health because many of the factors related to poor health habits and early death in the adult years begin during adolescence. Poor nutrition, lack of exercise, and inadequate sleep are concerns. The three leading causes of death in adolescence are unintentional injuries, homicide, and suicide.

· Despite recent declines, the United States has one of the highest rates of adolescent illicit drug use of any industrialized nation. Alcohol abuse is a major adolescent problem, although its rate has been dropping in recent years, as has the rate of cigarette smoking. Parents, peers, social support, and educational success play important roles in determining whether adolescents take drugs.

· Eating disorders have increased in adolescence, along with the percentage of adolescents who are overweight. Two eating disorders that may emerge in adolescence are anorexia nervosa and bulimia nervosa. Anorexia nervosa typically starts in the early to middle adolescent years following a dieting episode and involves the relentless pursuit of thinness through starvation. Bulimia nervosa involves a binge-and-purge pattern, and bulimics (unlike anorexics) typically fall within a normal weight range.

Page 368

4 Adolescent Cognition

LG4 Explain cognitive changes in adolescence.

Piaget’s Theory

Adolescent Egocentrism

Information Processing

· During the formal operational stage, Piaget’s fourth stage of cognitive development, thinking becomes more abstract, idealistic, and logical than during the concrete operational stage. However, many adolescents are not formal operational thinkers but are consolidating their concrete operational thought.

· Elkind describes adolescent egocentrism as the heightened self-consciousness of adolescents that consists of two parts: the imaginary audience and the personal fable. Recent research questions whether adolescents perceive themselves to be invulnerable.

· Adolescence is characterized by a number of advances in executive function. Cognitive control involves effective control and flexible thinking in a number of areas, including controlling attention, reducing interfering thoughts, remaining cognitively flexible, making decisions, and thinking critically.

5 Schools

LG5 Summarize some key aspects of how schools influence adolescent development.

The Transition to Middle or Junior High School

Effective Schools for  Young Adolescents

High School

Extracurricular Activities

Service Learning

· The transition to middle or junior high school coincides with many social, familial, and individual changes in the adolescent’s life, and this transition is often stressful. One source of stress is the move from the top-dog position to the lowest position in school.

· Some critics argue that a major redesign of U.S. middle schools is needed. Critics say that U.S. high schools foster passivity and do not develop students’ academic skills adequately. Characteristics of effective schools include lower student-to-counselor ratios, involvement of parents and community leaders in schools, team teaching, and efforts to boost students’ health and fitness.

· A number of strategies have been proposed for improving U.S. high schools, including raising expectations and providing better support. The overall high school dropout rate declined considerably in the last half of the twentieth century, but the dropout rates among Latino and Native American youth remain very high.

· Participation in extracurricular activities is associated with positive academic and psychological outcomes. Adolescents benefit from participating in a variety of extracurricular activities; the quality of the activities also matters.

· Service learning, a form of education that promotes social responsibility and service to the community, has been linked with positive benefits for adolescents such as higher grades, increased goal setting, and improved self-esteem.

key terms

adolescent egocentrism

amygdala

anorexia nervosa

bulimia nervosa

cognitive control

corpus callosum

fuzzy-trace theory dual-process model

hormones

hypothetical-deductive reasoning

imaginary audience

limbic system

menarche

personal fable

puberty

service learning

sexually transmitted infections (STIs)

top-dog phenomenon

key people

David Elkind

Deanna Kuhn

Lloyd Johnston

Jean Piaget

Valerie Reyna

 
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Case Study Psychology Final Paper homework help

Case Study Psychology Final Paper homework help

Addiction: Katie’s Case Study

Hattie Harvey

SNHU

Addiction: Katie’s Case Study

Client’s information

The client, Katie, is a 35 years old female. She is a professional, but her profession is not disclosed. She race is not disclosed either.

Type of addiction

Katie suffers from substance addiction. She abuses Vicodin, an opioid analgesics. Apart from causing the analgesic effect, Vicodin also causes euphoria, which explains why Katie used the drug to make her feel better. Katie’s addiction problem is classified as substance use disorder in the DSM-5. According to NIDA (2017), DSM-IV text revised had two classified named Substance Abuse and Substance Dependence. However, in 2013, the American Psychiatric Association (APA) joined the two disorders into the Substance Use Disorder category. Apparently, Katie was abusing the drugs before the initial treatment that led to her dependence on them. The second time, however, assuming she is telling the truth that she has been off the drugs for a week without any withdrawal symptoms, she is simply abusing Vicodin but has not developed dependence yet. Arguably, though she could be lying that she had stayed a week without using the drug, which means she could be physically dependent.

History of addiction to painkillers

According to Stolberg (2016), the opioid analgesics have been used in the United States in the last century for both medical and recreational purposes. The drug was first used in 1700 where a solution obtained from the poppy plant was used to makes a solution that was used as painkillers in wars. Morphine was later isolated from the raw opium in 1805. Soldiers and casualties greatly used these drug alongside opium in the 1861-1865 American Civil War, 1866 Franco-Austrian and the 1870-1871 Franco-Prussian wars in Europe. This led to massive addiction among the users resulting in the nickname “Soldier’s Disease.” During this time, the use of morphine was unregulated until the passage of Pure Food and Drugs Act bill of 1906 that prohibited the non-medical use and use of morphine without a doctor’s prescription. In 1937, Methadone was created for medical purposes as a painkiller. Shortly after, several other opioid analgesics were made using morphine as the derivative. Despite the law prohibiting and regulation of the morphine and other opioid analgesics, this class of drug was largely abused in the United States leading to massive addictions.

Harvard Medical School (2011) notes that a study conducted by Columbia University indicated that addiction to opioid prescription drugs tripled in 10 years. According to the report, the addiction proportion rose from 0.1 in 1991 and 1992 to 0.3 in the years 2001 and 2002. In 2009 a national survey on the Drug Use and Health in the United States indicated that approximately two million people were either abusing or dependent on the prescription pain relievers, which was twice the rate of cocaine abuse and dependence (Harvard Medical School, 2011). A previous study by CDC in 2007 had indicated that addiction to these drugs killed twice more people than cocaine and five times more people than heroin (Harvard Medical School, 2011).

Consequences of Katie’s addiction

Katie’s addiction has actual adverse effects on her family and herself. It also has potential adverse effects on her profession and community. First, her family is stressed and uncomfortable with her addiction. This is straining their relationship because her husband threatens to divorce her while her father is worried that she might lose her family and finally die out of lack of support, depression, and continued the abuse. Secondly, the financial security of her family is threatened because she buys the Vicodin at a higher price chronically. Thirdly, she is not able to take care of the children as is evidenced in the argument between her and her husband in the presence of her doctor. On the other hand, she is likely to cause tense relations in the workplace, which may lead to termination of her employment. Termination of employment undermines productivity, which indirectly harms the economic welfare of the community because her lack of financial contribution may lead to exploitation of community support resources by the husband.

Results

Katie treatment had mixed results. She responded positively to the initial treatment three years before when she underwent a month’s program in a residential treatment facility. When she first went for treatment, she had abuse and dependence problem, which is classified as Substance Use Disorder in DSM-5. When she came out, she was no longer using the painkillers. She stayed away from them for slightly over two years when she gave birth to a second child and relapsed. She confessed that the pressures had made her start using the drugs again. Notably, though, the initial treatment was terminated inappropriately. Katie did not enroll in a follow-up program, she did not join an AA meeting, and nor did her husband attend a final family meeting. These overlooked measures could have probably helped her restrain from the temptation of using the drugs again. The outcome of the second attempt at treating her is also unsatisfactory. She refused to undergo a rehabilitation program in a residential home, and the family forfeited the outpatient counseling program. Therefore, is not clear whether her husband finally divorced her as he had threatened or whether they had decided to attempt resisting on their own without professional support. In either way, Katie’s might not recover from the addiction without the professional assistance.

References

Harvard Medical School. (2011, January 15). Painkillers fuel growth in drug addiction. Retrieved from Havard Medical School Web site: https://www.health.harvard.edu/newsletter_article/painkillers-fuel-growth-in-drug-addiction

NIDA. (2017, March 2). The Science of Drug Abuse and Addiction: The Basics. Retrieved from National Institute of Health Web site: https://www.drugabuse.gov/publications/media-guide/science-drug-abuse-addiction-basics

Stolberg, V. B. (2016). Painkillers: History, Science, and Issues. Santa Barbara: ABC-CLIO.

Gaming addiction

Hattie Harvey

SNHU

Gaming addiction

Social demographic information

The subject of the case study was a 16 years old male living in the United States. The teenager had Korean descent or roots and came to the United States with his mother and brother upon persuasion by his parents. The case study codes his name as HC to protect his privacy. HC suffers from process addiction. Specifically, he was addicted to digital gaming, which are games played over the internet.

Assessment

Clients use several physiological procedures to administer their addiction such as injection, oral, video gaming, and making phone calls. According to Lee (2011), HC’s physiological procedures for administration of his internet games addiction included video gaming. He developed his addiction and procedures because of his environment. Since moving to the United States four years before, HC had increasingly found himself alone unlike in his initial Korean environment. He withdrew from his friends and maintained an antisocial life where spent 3 to 5 hours daily on weekdays and an average of 13 hours during the weekends. Nonetheless, HC indicates a desire to reduce the hours of gaming that he has been spending. This indicates hope for him.

Addiction history and effects

History

According to Griffiths, Kuss, & King (2012), the first commercial video games emerged in the early 1970s but the first description of video game addiction appeared in the psychiatric and psychological literature about a decade later in the early 1980s. The phenomenon was described in peer-reviewed articles in 1983 by Soper and Miller who were basing their study on several reports from school counselors that claimed the problem was becoming a problem to the school going teenagers. The study of video addiction greatly transformed between the 1980s and 1990s. Griffiths, Kuss, & King (2012) observes that the study of video games in the 1980s was basically focused the pay-to-play video games and most entailed observational, anecdotal, or case studies were done on male teenagers. These early studies posited that cognitive behavioral therapy was effective in treating the new type of addiction. Apart from focusing on the pay-to-play games only, these studies also another common limitation or problem. They did not have a standardized measure for the diagnosis and recognition of video games addiction. They only relied on the confession of the victims who claimed that they were addicted to the video games (Griffiths, Kuss, & King, 2012). In the 1990s studies increased with the researchers’ expanding their focus to involve more than the pay-to-play games. The decade was characterized by additional examination of non-arcade games such as PC gaming, handheld games, and home console games (Griffiths, Kuss, & King, 2012). The phenomenon was officially defined as a disorder in 1995. Researchers in the 1990s used DSM-IV and DSM-III-R to identify and define video gaming. However, according to Griffiths, Kuss, & King (2012), despite the improvement from the previous decade, studies in the 1990s were still problematic because the definition of and tools used to assess video game addiction was very similar to the tool used in gambling examination. In addition, the studies were small scale and self-reported. The 2000s were characterized by better study designs and tools. Kuss (2013) observes that non-self-report tools and techniques were used to study the phenomenon. They included polysomnographic measures, verbal and visual memory tests, and medical examinations that included patient’s history, radiological, physical, pathological, and intraoperative findings, genotyping, electroencephalography, and functional Magnetic Resonance Imaging. These improved studied of the 2000s coincided with increased use of internet games. Kuss (2013) notes that internet games became most popular and prevalent in the 2000s. It is the same era in which gaming communities emerged with the introduction of the expanded game online media termed as MMORPGs (Massively Multiplayer Online Role-Playing Games).

Psychological and physiological effects

According to Attrill (2015), the physiological effects of video game addiction include lack of sleep, compulsive behavior, and eating and weight disorders. These normally develop after the addiction has well established. Lack of sleep sets in due to routine video gaming that fails to recognize time. Compulsive behavior develops due to the constant immediate gratification associated with video gaming. Eating and weight disorders develop primarily due to lack of exercises and increasingly sedentary lifestyle. The psychological effects include anxiety, social dysfunction, aggression, depression, irritability, loss of control, and restlessness (Attrill, 2015). HC had already started exhibiting some of these symptoms before his mother decided to seek help. HC had exhibited depression, antisocial behavior, and negative attitude, especially by displaying disrespect and lack of interest to engage in activities with his father. These symptoms are recognized in the diagnostic criteria of DSM-V. According to Lee (2011), video games addiction victims or clients tend to display four categories of symptoms which include a) excessive use of the games leading to loss of the sense of time, b) social withdrawal accompanied by increased feelings of tension, anger, and depression when unable to access the computer or game, c) tolerance involving many hours playing the game, and d) negative repercussions including arguments, lying, social isolation, fatigue, and poor achievements.

Results

HC eventually responded positively to the treatment. However, the actual factors that contributed to the positive outcome are vague. Throughout his five sessions, HC did not seem to improve. In fact, he expressed boredom and dissatisfaction with the program that required him to make several entries of his emotions and activities every day. However, in his fifth session, he was encouraged to engage in activities that reduced his boredom other than playing the video games. Golfing is the activity that was suggested. After HC started playing golf with his mother, his gaming hours reduced. Perhaps it was the combined effect of cognitive therapy and implementation of a substitute (distractor) activity that made HC reduce his gaming hours. It could also be simply the substitute activity that made him reduce the gaming hours.

References

Attrill, A. (2015). Cyberpsychology. Oxford: Oxford University Press.

Griffiths, M. D., Kuss, D. J., & King, D. L. (2012). Video Game Addiction: Past, Present and Future. Current Psychiatry Reviews, 8(4), 1-11.

Kuss, D. J. (2013). Internet gaming addiction: current perspectives. Psychology Research and Behaviour Management, 6, 125-137.

Lee, E. J. (2011). A case study of Internet Game Addiction. Journal of Addictions Nursing, 22, 208-213.

 
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Counseling Theories CNL-500 Topic 2: Classical Theory Comparison Worksheet

Counseling Theories CNL-500 Topic 2: Classical Theory Comparison Worksheet

cid:D7D4B297-EEAE-4174-AD01-F87097282051@canyon.com

 

CNL-500 Topic 2: Classical Theory Comparison Worksheet

 

Directions: Compare the three theories by answering the questions listed below for each theory as indicated. For the first two questions in the table, each theory should include a 75-100-word explanation. Include a minimum of two scholarly resources for each theory (total of six resources) in addition to the course textbook and include in-text citations when appropriate. Include a full APA formatted reference for the sources used below.

 

Questions Neoanalytic Jungian Individual Psychology
Explain the goals for therapy from each theoretical orientation. (75-100 words each)

 

     
Identify at least two techniques for each theory and the benefit to the client. (75-100 words each) Technique 1:

 

Technique 2:

 

Benefit to the Client:

 

Technique 1:

 

Technique 2:

 

Benefit to the Client:

Technique 1:

 

Technique 2:

 

Benefit to the Client:

List the stages of counseling and how long it would take to complete the process.

 

     
List the counselor’s and client’s roles. Counselor’s Roles:

 

Client’s Roles:

 

Counselor’s Roles:

 

Client’s Roles:

Counselor’s Roles:

 

Client’s Roles:

List the three qualities of a healthy person for each theory. 1.

2.

3.

1.

2.

3.

1.

2.

3.

 

 

References

 

© 2019. Grand Canyon University. All Rights Reserved.

 

© 2019. Grand Canyon University. All Rights Reserved.

 
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Journal Article Critiques homework help

Journal Article Critiques homework help

Running Head: PSYCHOLOGY LABORATORY OF 20TH CENTURY 1

 

PSYCHOLOGY LABORATORY OF 20TH CENTURY

 

3

 

Article:

The Psychology Laboratory at the Turn of the 20th Century

By Ludy T. Benjamin, Jr.

Alice Chan (Student)

AU ID 2750777

PSYCH 290

Journal Article Critique 1

Shelley Sikora (tutor)

November 03, 2011

Body of the Text

1. Research Question or Problem

 

The purpose of the article is to outline the influence that psychology laboratories have had on modern psychology, and how experimental laboratory has changed psychology into a discipline of science.

 

2. Introduction

 

During the 1800s, psychologists made great efforts to change psychology to a discipline of science instead of being a part of philosophy or a mystical subject. They believed that psychology is testable like many other science curriculums. According to the article, by 1880 the experimental laboratory was the “public icon for natural science” (Ludy, 2000, p.318). The first experimental laboratory was founded by Wundt in 1879 and this marks the beginning of modern psychology as science. Many great psychologists, stated in the article, have shown great support and attraction towards the idea of the experimental laboratory. Although the laboratory is no longer viewed as an icon for psychology, it is still an important training place for all undergraduate psychology students.

 

3. Methodology

 

In this article, the author uses history to support his argument that the psychology laboratory was instrumental in transforming psychology from philosophy to science. References of famous psychologists were used and cited to support the author’s historical approach for the article. Table 1 (Ludy, 2000, p319) is a list of laboratories that have been built from 1883 to 1900 in the United States. Figure 1 (Ludy, 2000, p.320) is an example of how the early psychology experimental laboratories looked like.

 

4. Results

 

The experimental laboratory does mark the beginning of psychology and the emergence from philosophy. Ludy uses reference, dated back from 1800, and cited phrases from famous psychologists to explain how the first Wundt Laboratory aided the growth and spread of Psychology worldwide. A list of laboratories from table 1 (Ludy, 2000, p.320) demonstrates how rapidly Psychology spread after the beginning of the Wundt Laboratory in the United States. Cattell’s letter to his parents, cited in the article, gives an example of what was tested in the early laboratory. In addition, the author cites Wolfe’s second annual report to demonstrate how psychologists of the time believed that psychology was a science like any other. Figure 1 (Ludy, 2000, p.320) is a psychology laboratory that shows the similarity with other natural science laboratories. In addition important psychologists, like Harry Kirke Wolfe, Wundt, and Hall are mentioned for their contribution and support of the psychology lab. The “American Journal of Psychology and Science”, mention by Ludy, shows that the public believed that psychology laboratories were no different from other natural science laboratories. At the end of the article Ludy uses references, dated after the 1900, from various sources to show how the use of psychology laboratories changed in the 20th century. According to the cited work, the psychology laboratory is no longer viewed as an icon but a training ground which all undergraduate psychology students must go through.

 

5. Discussion

 

Ludy (2000) concluded that the psychology laboratory “no longer serves as an enduring motif.” (Ludy, 2000, p.321) After the 20th century, psychology has become a discipline of science and the laboratory is no longer an icon; it is just a standard training ground for all psychology students. After Wundt’s first laboratory, “proliferation of American laboratories at the turn of the century changed the nature of graduate education.” (Ludy, 2000, p.321) The laboratory is no longer a place for scholars and psychologists; it has become part of a curriculum that all undergrad psychology students must enrol in to graduate.

 

6. List of Reference

 

The references selected by the author support the article’s purpose and are cited within the body of the text. Because the method used in this article was an historical approach, therefore the references date all the way back from the 1800s to the 1990s. The author used a variety of sources to prove his work and reasoning.

 

7. Personal Reaction

 

I found this to be an interesting article. I have always wondered where psychology emerged from and how it has been scientifically accepted. Contrary to my expectations, the experimental laboratory is the key to all the answers. I was impressed with early psychologists’ determination and diligence in using the scientific method to test their hypotheses, thereby changing public opinion towards an acceptance of psychology as a new science.

After reading the article I have a few questions in mind. The author did not mention the view from the other natural science curriculum, do they support psychology as a counterpart to science or are they against it? Also, are there any psychologists against the experimental laboratory during that time? If so why or why not?

 

 

Reference

 

Ludy T. Benjamin, Jr. (2000). The Psychology Laboratory at the Turn of the 20th Century. Texax A&M Universit, 55(3), 318-321. Doi:10.1037//0003-066X.55.3.318

 
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Homework Question

Homework Question

Question 1

 

REBT is based on the assumption that:

 

[removed] a. Humans have a biological tendency to think irrationally
[removed] b. Humans have a biological tendency to think rationally
[removed] c. Both a and b
[removed] d. None of the above

 

2 points

 

Question 2

 

_____________ is the behavioral intervention used to gradually increase the quality of a behavior.

 

[removed] a. Shaping
[removed] b. Extinction
[removed] c. Stimulus control
[removed] d. Aversive control

 

2 points

 

Question 3

 

DBT utilizes a behavioral technique in which the client learns to tolerate painful emotions without enacting self-destructive behaviors known as:

 

[removed] a. Positive reinforcement
[removed] b. Negative reinforcement
[removed] c. Exposure
[removed] d. Punishment

 

2 points

 

Question 4

 

In reality therapy, behavior is affected by:

 

[removed] a. The impact of external stimuli on behavior
[removed] b. Unconscious conflicts
[removed] c. Current inner motivation
[removed] d. All of the above

 

2 points

 

Question 5

 

In reality therapy, the skilled counselor or therapist treats behavior as:

 

[removed] a. The result of social pressure and limited perceptions of possibilities
[removed] b. Information received from parents and from the surrounding culture
[removed] c. Caused by self-verbalizations that can be helpful or hurtful
[removed] d. Chosen as a result of unmet wants and needs/font>

 

2 points

 

Question 6

 

A method in which the counselor or therapist leads the client through a number of questions to become aware of thoughts and distortions in thinking, and to find and implement more adaptive replacements is called:

 

[removed] a. “Socratic Questioning”
[removed] b. “Platonic Questioning”
[removed] c. A-B-C Model
[removed] d. Reflection

 

2 points

 

Question 7

 

In the A-B-C model proposed by Ellis, the factor that creates the emotional and behavioral consequences is:

 

[removed] a. Activating event
[removed] b. Consequences
[removed] c. Beliefs
[removed] d. None of the above

 

2 points

 

Question 8

 

According to Glasser, human behaviors are composed of:

 

[removed] a. Doing, thinking, feeling, physiology
[removed] b. Doing, resting, sleeping, acting
[removed] c. Responding, initiating, ignoring, acting
[removed] d. None of the above

 

2 points

 

Question 9

 

In practicing reality therapy, counselors and therapists focus on:

 

[removed] a. The interpersonal relationships of the client
[removed] b. Insight into causes of behavior
[removed] c. Family history
[removed] d. Personal history

 

2 points

 

Question 10

 

According to Ellis, the shoulds, oughts, and musts fall under which of the following categories?

 

[removed] a. Self-demandingness
[removed] b. Other-demandingness
[removed] c. World-demandingness
[removed] d. All of the above

 

2 points

 

Question 11

 

In reality therapy, the environment or counseling or psychotherapeutic atmosphere includes which of the following?

 

[removed] a. Attending behaviors
[removed] b. Doing the unexpected
[removed] c. Use of metaphors
[removed] d. All of the above

 

2 points

 

Question 12

 

The DBT model proposes that a successful counseling intervention must meet five critical functions. Which of the following is not one of these functions?

 

[removed] a. Improve and preserve the client’s incentive to change
[removed] b. Boost the client’s capabilities
[removed] c. Ensure the client’s capabilities are specific to his or her environment
[removed] d. Structure the environment so that the treatment can take place

 

2 points

 

Question 13

 

A counselor using CBT might focus on using:

 

[removed] a. Pharmacotherapy
[removed] b. Dream analysis
[removed] c. Transference
[removed] d. Risk-taking exercises

 

2 points

 

Question 14

 

DBT is driven by three theories. Which of the following is not one of those?

 

[removed] a. Behavior therapy
[removed] b. Biosocial theory of BPD
[removed] c. Dialectics
[removed] d. Gestalt theory

 

2 points

 

Question 15

 

Which of the following is true about REBT?

 

[removed] a. REBT was influenced by Rogers’ core conditions of counseling.
[removed] b. REBT was influenced by Freud’s concept of the unconscious.
[removed] c. REBT was influenced by Frankl’s logotherapy.
[removed] d. None of the above

 

2 points

 

Question 16

 

_______________ is the sense of personal competence or feelings of mastery.

 

[removed] a. Self-concept
[removed] b. Self-esteem
[removed] c. Self-efficacy
[removed] d. Self-control

 

2 points

 

Question 17

 

Which of the following is associated with reality therapy?

 

[removed] a. WDEP system
[removed] b. Choice theory
[removed] c. SAMIICCC
[removed] d. All of the above

 

2 points

 

Question 18

 

Cognitive therapy has been criticized for its focus on:

 

[removed] a. Internal events (thinking)
[removed] b. Direct observation
[removed] c. Listening procedures
[removed] d. Intellectual understanding

 

2 points

 

Question 19

 

Which of the following is not consistent with REBT theory?

 

[removed] a. Events or other people make us feel bad or good.
[removed] b. Thinking, feeling, and behaving are interconnected.
[removed] c. Emotional distress results from exaggeration, overgeneralization, and invalidated assumptions.
[removed] d. Irrational beliefs emanate from environmental and genetic factors.

 

2 points

 

Question 20

 

A client is partaking in cognitive distortion when he/she exaggerates a negative event to the point that the event has more impact than it deserves. What is this called?

 

[removed] a. Disqualifying the positive
[removed] b. Catastrophizing
[removed] c. All-or-nothing thinking
[removed] d. None of the above

 

2 points

 

Question 21

 

In choice theory, human motivation springs from which of these five sources?

 

[removed] a. Belonging, survival, knowledge, fun, power
[removed] b. Survival, belonging, power, freedom, fun
[removed] c. Power, achievement, enjoyment, information, security
[removed] d. Survival, achievement, love, success, pride

 

2 points

 

Question 22

 

DBT was initially developed to treat:

 

[removed] a. Narcissistic personality disorder
[removed] b. Histrionic personality disorder
[removed] c. Antisocial personality disorder
[removed] d. Borderline personality disorder

 

2 points

 

Question 23

 

The developer of dialectical behavior therapy is:

 

[removed] a. Dr. Marsha Linehan
[removed] b. Dr. Albert Ellis
[removed] c. Dr. Carl Rogers
[removed] d. Dr. Fritz Perls

 

2 points

 

Question 24

 

DBT targets behaviors in descending order beginning with ________.

 

[removed] a. triggers
[removed] b. biosocial susceptibility
[removed] c. suicidal behavior
[removed] d. enhancing respect for self

 

2 points

 

Question 25

 

According to REBT, certain values promote emotional adjustment and mental health. Which of the following is not one of these values?

 

[removed] a. Non-utopian
[removed] b. Low frustration tolerance
[removed] c. Flexibility
[removed] d. High frustration tolerance

 

 

 
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Ministry Proposal Lay Counseling

Ministry Proposal Lay Counseling

Lay_Counseling_1.pdf  Here you will find the summary of Dr. Siang-Yang Tan’s book, Lay counseling: Equipping Christians for helping ministry (1991). Please read and refer to it when working on your project paper, although do not clone your projects by this. The book is listed in the optional resources.

The last week should be dedicated to finalizing the work on your project; follow the syllabus instructions (see below as well). Note that you are to focus on a Mentoring or Mediation ministry (NOT “Counseling ministry” per se). The project is a ministry project, not a teaching project. So the process must incorporate doing mentoring, or doing mediation as a service, not teaching mentoring or mediation.

There are no other assignments for you to complete this week. If you have any questions regarding this project, please contact me no later than 10 days prior to the due date. That will give us enough time to preview and make necessary edits.

As a reminder, I do not want to see titles that have anything to do with “…..Counseling Program” as I specifically want them to focus only on either of the two topics we’ve studied in this course.

An experiential exercise/project will provide an opportunity to put into practice the principles and concepts studied in the Course. Imagine that your church leaders have asked you to develop a Lay Ministry with the focus on either: 1) Mentoring, or 2) Mediation services, and present your proposal to the pastoral leadership team for review. In order to accomplish this, you have been assigned the following tasks:

a. Outline your ministry proposal in a systematic way through a detailed position paper and formal proposal. The paper must include the following elements under separate appropriately-titled headings (in approximately 8 pages):

1)     name of your ministry [keep this short in one strong complete sentence]

2)     purpose of your ministry [why have this ministry? What was the need that precipitated it?]

3)     the counseling philosophy of your ministry [this must agree with the church philosophy and vision to have buy-in]

4)     the use of supporting scriptures regarding your vision and purpose [list several scriptures that support the need for this ministry but write out only the pertinent phrases of each verse]

5)     the scope of the ministry (including any limitations) – [what is the target population? specific gender or ages? who would you exclude and why? how wide a catchment area?]

6)     the hours and location/s of services [address, phone, website, to where the people will come, or where the main offices are]

7)     how the ministry is accessed – describe the process [how do you get the word out? how do the people reach you? what do they have to do to get services?]

8)     the duration and process of care [what’s the procedure for the service? how long do they partake of services? how do you care for them?]

9)     the potential benefits of the ministry [Use Acts 1:8 as the model: start with a center and go out in widening circles thinking of all who would benefit from this ministry e.g. pastors, congregation, community, etc.]

10)  any costs or fees associated with the ministry [what are both the tangible and intangible costs (borne by whom?), even if the church is already bearing some of those costs; if church policy now is not to have fees, is that wise for your program?]

11)  how staff (mentors or mediators) will be selected, trained, and supervised [start with who will select the staff, how will they be trained, who will supervise them]

12)  how confidentiality and consent issues will be addressed [include any appendices with forms that you may use]

13)  how the ministry will be connected with other community and Christian resources [list how you will network with other similar ministries (which ones?) and how other ministries will support you – how might you collaborate in your “Mentoring/Mediation” services?]

b. List potential references and local contact points that would provide additional resources for the particular ministry focus (in approximately 1-2 pages). [are there other ministries in your community that offer similar services? The ministries should be connected with the type of services you offer]

c. Organize your proposal under the different headings or key elements listed in Sections “ a” and “ b.

d. Type the whole proposal double-spaced and approximately 12-15 pages in total length (including the Title page, Table of Content, and Appendices). Write the paper in APA style format and organize it in an appropriate presentation format[this is not PowerPoint, but properly titled for respective ministry/church], similar to what could be distributed for a leadership review.

*** Submit all files (for all assignments) as MS Word documents only and name them according to the following format: first use the course number; then underscore; then your first name and first letter of your last name; then underscore; and finally, the name of the assignment itself e.g., HSC560_JohnD_proposal. Also, use the same file name in the “subject” line of the email.

Additional Notes and Tips:

  • “Counseling Philosophy” Since you’re not to use the term “counseling” it will be the philosophy of your mentoring or your mediation ministry. So what is “philosophy?” You have to go along with what your church’s or organization’s philosophy is (their vision, their main objective) as you are proposing to be an arm of that church or organization. You can’t appear out of left field with something new that takes the focus away from the aim of your ministry, which should either be mentoring or mediation for this assignment. That section should not be long, just prove that your ministry will be fulfilling the philosophy of the church (are they a relational? community-minded? bible knowledge-based? family oriented? seeker friendly?).
  • Scriptures you use should support this, but not be preachy or long-winded.
  • Scope means who exactly are you serving?
  • Cost: there are also intangible costs that must be considered.
  • Process: how is the (mentoring; mediation) going to happen? Please don’t write out a whole program or a training here, just go through the steps of how do they come for it, then what do they/you do? for how long? how do you know they are finished? This should be a process, not a canned training; so you don’t use someone else’s package. You’ve studied both in this course, so use the phrases and concepts you now know.
  • “Staff” – you will not have counselors, you’ll have mentors or mediators
  • Community connections means from who/where will you get support and who/what will your ministry support?
  • Resources: should be along the lines of what you’re trying to do. If it’s “women mentoring,” then find resources for just that, for women’s services, and/or for mentoring. It shouldn’t be for counseling, family therapy, marriage therapy, finances, poverty support, etc. When pulling resources, keep Acts 1:8 as your pattern. Who’s the closest (Jerusalem)? county (Judea)?, state (Samaria)? uttermost (national and world)?
  • Be sure to give me the reference page if you use ideas from anyone – references is not the same as resources.
  • No, you don’t need to write an abstract. This is a proposal paper.Costs/Benefits: there are intangible costs and benefits to any project, aside from financial. Consider energy, time spent, effort, being away from family, other investments, etc. You want to make sure you consider these as the “board” may ask when you give the proposal.
 
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Evidence And Non-Evidence Based Treatment Options

Evidence And Non-Evidence Based Treatment Options

Limitations to Evidence Based Practice

THOMAS MAIER

The promotion of evidence-based medicine (EBM) or, more generally, of evidence-based practice (EBP) has strongly characterized most medical disciplines over the past 15 to 20 years. Evidence-based medicine has become a highly influential concept in clinical practice, medical education, research, and health policy. Although the evidence-based approach has also been increasingly applied in related fields such as psychology, education, social work, or economics, it was and still is predominantly used in medicine and nursing. Evidence-based practice is a general and nonspecific concept that aims to improve and specify the way decision makers should make decisions. For this purpose it delineates methods of how professionals should retrieve, summarize, and evaluate the available empirical evidence in order to identify the best possible decision to be taken in a specific situation. So EBP is, in a broader perspective, a method to analyze and evaluate large amounts of statistical and empirical information to understand a particular case. It is therefore not limited to specific areas of science and is potentially applicable in any field of science using statistical and empirical data. Many authors often cite Sackett, Rosenberg, Muir Gray, Haynes, and Richardson’s (1996) article entitled “Evidence-based medicine:What it is and what it isn’t” as the founding deed of evidence-based practice. David L. Sackett (born 1934), an American-born Canadian clinical epidemiologist, was professor at the Department of Clinical Epidemiology and Biostatistics of McMaster University Medical School of Hamilton, Ontario, from 1967 to 1994. During that time, he and his team developed and propagated modern concepts of clinical epidemiology. Sackett later moved to England, and from 1994 to 1999, he headed the National Health Services’ newly founded Centre for Evidence-Based Medicine at Oxford University. During that time, he largely promoted EBM in Europe by publishing articles and textbooks as well as by giving numerous lectures and training courses. David Sackett is seen by many as the founding father of EBM as a proper discipline, although he would not at all claim this position for himself. In fact, Sackett promoted and elaborated concepts that have been described and used by others before; the origins of EBM are rooted back in much earlier times. The foundations of clinical epidemiology were already laid in the 19th century mainly by French, German, and English physicians systematically studying the prevalence and course of diseases and the effects of therapies. As important foundations of the EBMmovement, certainly the works and insights of the Scottish epidemiologist Archibald (Archie) L. Cochrane (1909–1988) have to be c04 18 April 2012; 19:44:27 55 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. mentioned. Cochrane, probably the true founding father of modern clinical epidemiology, had long before insisted on sound epidemiological data, especially from RCTs, as the gold standard to improve medical practice (Cochrane, 1972). In fact, the evaluation of epidemiological data has always been one of the main sources of information in modern academic medicine, and many of the most spectacular advances of medicine are direct consequences of the application of basic epidemiological principles such as hygiene, aseptic surgery, vaccination, antibiotics, and the identification of cardiovasular and carcinogenic risk factors. One of the most frequent objections against the propagation of EBM is, “It’s nothing new, doctors have done it all the time.” Rangachari, for example, apostrophized EBM as “old French wine with a new Canadian label” (Rangachari, 1997, p. 280) alluding to the French 19th century epidemiology pioneer Pierre Louis, who was an influencing medical teacher in Europe and North America, and to David L. Sackett, the Canadian epidemiologist. Even though the “conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients” (Sackett et al., 1996, p. 71) seemsto be a perfectly reasonable and unassailable goal, EBM has been harshly criticized from the very beginning of its promotion (Berk &Miles Leigh, 1999; B. Cooper, 2003; Miles, Bentley, Polychronis, Grey, and Price, 1999; Norman, 1999; Williams & Garner, 2002). In 1995, for example, the editors of The Lancet chose to publish a rebuking editorial against EBM entitled “Evidence-based medicine, in its place” (The Lancet, 1995): The voice of evidence-based medicine has grown over the past 25 years or so from a subversive whisper to a strident insistence that it is improper to practise medicine of any other kind. Revolutionaries notoriously exaggerate their claims; nonetheless, demands to have evidence-based medicine hallowed as the new orthodoxy have sometimes lacked finesse and balance, and risked antagonising doctors who would otherwise have taken many of its principles to heart. The Lancet applauds practice based on the best available evidence–bringing critically appraised news of such advances to the attention of clinicians is part of what peer-reviewed medical journals do–but we deplore attempts to foist evidencebased medicine on the profession as a discipline in itself. (p. 785) This editorial elicited a fervid debate carried on for months in the letter columns of The Lancet. Indeed, there was a certain doggedness on both sides at that time, astonishing neutral observers and rendering the numerous critics even more suspicious. The advocates of EBM on their part acted with great self-confidence and claimed no less than to establish a new discipline and to put clinical medicine on new fundaments; journals, societies, conferences, and EBM training courses sprang up like mushrooms; soon academic lectures and chairs emerged; however, this clamorous and pert appearance of EBM repelled many. A somehow dogmatic, almost sectarian, tendency of the movement was noticed with discontent, and even the deceased patron saint of EBM, Archie Cochrane, had to be invoked in order to push the zealots back: How would Archie Cochrane view the emerging scene? His contributions are impressive, particularly to the development of epidemiology as a medical science, but would he be happy about all the activities linked with his name? He was a freethinking, iconoclastic individual with a healthy cynicism, who would not accept dogma. He brought an open sceptical approach to medical problems and we think that he would be saddened to find that his name now embodies a new rigid medical orthodoxy while the real impact of his many achievments might be overlooked. (Williams & Garner 2002, p. 10) THE DEMOCRATIZATION OF KNOWLEDGE How could such an emotional controversy arise about the introduction of a scientific 56 Overview and Foundational Issues c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. method (Ghali, Saitz, Sargious, & Hershman, 1999)? Obviously, the propagation and refusal of EBM have to be seen not only from a rational scientific standpoint but also from a sociological perspective (Miettinen, 1999; Norman, 1999): The rise of the EBM movement fundamentally reflects current developments in contemporary health care concerning the allocation of information, knowledge, authority, power, and finance (Berk & Miles Leigh, 1999), a process becoming more and more critical during the late 1980s and the 1990s. Medicine has, for quite some time, been losing its prestige as an intangible, moral institution. Its cost-value ratio is questioned more and more and doctors are no longer infallible authorities. We do not trust doctors anymore to know the solution for any problem; they are supposed to prove and to justify what they do and why they do it. These developments in medicine parallel similar tendencies in other social domains and indicate general changes in Western societies’ self-conception. Today we are living in a knowledge society, where knowledge and information is democratized, available and accessible to all. There is no retreat anymore for secret expert knowledge and for hidden esoteric wisdom. The hallmarks of our time are free encyclopedic databases, open access, the World Wide Web, and Google©. In the age of information, there are no limitations for filing, storage, browsing, and scanning of huge amounts of data; however, this requires more and more expert knowledge to handle it. So, paradoxically, EBM represents a new specialized expertise that aims to democratize or even to abolish detached expert knowledge. The democratization of knowledge increasingly questions the authority and selfsufficiency of medical experts and has deeply unsettled many doctors and medical scientists. Of course, this struggle is not simply about authority and truth; it is also about influence, power, and money. For all the unsettled doctors, EBM must have appeared like a guide for the perplexed leading them out of insecurity and doubt. Owing to its paradoxical nature, EBM offers them a new spiritual home of secluded expertise allowing doctors to regain control over the debate and to reclaim authority of interpretation from bold laymen. For this purpose, EBM features and emphasizes the most valuable label of our time that is so believable in science: science- or evidencebased. In many areas of contention, terms like evidence-based or scientifically proven are used for the purpose of putting opponents on the defensive. Nobody is entitled to question a fact, which is declared evidence-based or scientifically proven. By definition, these labels are supposed to convey unquestioned and axiomatic truth. It requires rather complex and elaborate epistemological reasoning to demonstrate how even true evidence-based findings can at the same time be wrong, misleading, and/or useless. All these accounts and arguments apply in particular to the disciplines of psychiatry and clinical psychology, which have always had a marginal position among the apparently respectable disciplines of academic medicine. Psychiatrists and psychologists always felt particularly pressured to justify their actions and are constantly suspected to practice quackery rather than rational science. It is therefore not surprising that among other marginalized professionals, such as the general practitioners, psychiatrists and psychotherapists made particularly great efforts over the last years to establish their disciplines as serious matters of scholarly medicine by diligently adopting the methods of EBM (Geddes & Harrison, 1997; Gray & Pinson, 2003; OakleyBrowne, 2001; Sharpe, Gill, Strain, & Mayou, 1996). Yet, there are also specific problems limiting the applicability of EBP in these disciplines.

EMPIRICISM AND REDUCTIONISM In order to understand the role and function of EBP within the scientific context, it may be Limitations to Evidence-Based Practice 57 c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. helpful to give a brief overview of the theoretical backgrounds of science in general. What is science and how does it proceed? Science can be seen as a potentially endless human endeavour that aims to understand and determine reality. Not only are physical objects matters of science, but also immaterial phenomena like language, history, society, politics, economics, human behavior, thoughts, or emotions. Starting with the Greek scientists in the ancient world, but progressing more rapidly with the philosophers of the Enlightenment, modern science adopted defined rules of action and standards of reasoning that delineate science from nonscientific knowledge such as pragmatics, art, or religion. Unfortunately, notions like science, scientific, or evidence are often wrongly used in basically nonscientific contexts causing unnecessary confusion. The heart and the starting point of any positive science is empiricism, meaning the systematic observation of phenomena. Scientists of any kind must start their reasoning with observations, possibly refined through supportive devices or experimental arrangements. Although positive science fundamentally believes in the possibility of objective perception, it also knows the inherent weaknesses of reliability and potential sources of errors. Rather than have confidence in single observations, science trusts repeated and numerous observations and statistical data. This approach rules out idiosyncratic particularities of single cases to gain the benefit of identifying the common characteristics of general phenomena (i.e., reductionism). This approach of comprehending phenomena by analytically observing and describing them has in fact produced enormous advancements in many fields of science, especially in technical disciplines; however, contrasting and confusing gaps of knowledge prevail in other areas such as causes of human behavior, mind–body problems, or genome–environment interaction. Some areas of science are apparently happier and more successful using the classical approach of positive science, while other disciplines feel less comfortable with the reductionist way of analyzing problems. The less successful areas of science are those studying complex phenomena where idiosyncratic features of single cases can make a difference, in spite of perfect empirical evidence. This applies clearly to medicine, but even more to psychology, sociology, or economics. Medicine, at least in its academic version, usually places itself among respectable sciences, meeting with and observing rules of scientific reasoning; however, this claim may be wishful thinking and medicine is in fact a classical example of a basically atheoretical, mainly pragmatic undertaking pretending to be based on sound science. Inevitably, it leads to contradictions when trying to bring together common medical practice and pure science. COMPLEXITY Maybe the deeper reasons for these contradictions are not understood well enough. Maybe they still give reason for unrealistic ideas to some scientists. A major source of misconception appears to be the confused ontological perception of some objects of scientific investigation. What is a disease, a disorder, a diagnosis? What is human behavior? What are emotions? Answering these questions in a manner to provide a basis for scientific reasoning in a Popperian sense (see later) is far from trivial. Complex objects of science, like human behavior, medical diseases, or emotions, are in fact not concrete, tangible things easily accessible to experimental investigation. They are emergent phenomena, hence they are not stable material objects, but exist only as transitory, nonlocal appearances fluctuating in time. They continuously emerge out of indeterminable complexity through repeated self-referencing operations in complex systems (i.e., autopoietic systems). Indeterminable complexity or deterministic chaos means that a huge number of mutually interacting parameters autopoietically 58 Overview and Foundational Issues c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. form a system, rendering any precise calculation of the system’s future conditions impossible. Each single element of the system perfectly follows the physical rules of causality; however, the system as a whole is nevertheless unpredictable. Its fluctuations and oscillations can be described only probabilistically. In order to obtain reasonable and useful information about a system, many scientific disciplines have elaborated probabilistic methods of approaching their objects of interest. Thermodynamics, meteorology, electroencephalography, epidemiology, and macroeconomics are only a few such examples. Most structures in biological, social, and psychological reality can be conceived as emergent phenomena in this sense. Just as the temperature of an object is not a quality of the single molecules forming the object—a single molecule has no temperature— but a statistic description of a huge number of molecules, human behavior cannot be determined through the description of composing elements producing the phenomenon—for example, neurons—even if these elements are necessary and indispensable preconditions for the emergence of the phenomenon. The characteristics of the whole cannot be determined by the description of its parts. When the precise conditions of complex systems turn out to be incalculable, the traditional reaction of positive science is to intensify analytical efforts and to compile more information about the components forming the system. This approach allows scientists to constantly increase their knowledge about the system in question without ever reaching a final understanding and a complete determination ofthe function ofthe system. This is exactly what happens currently in neurosciences. Reductionist approaches have their inherent limitations when it comes to the understanding of complex systems. A similar problem linked to complexity that is particularly important is the assumed comparability of similar cases. In order to understand an individual situation, science routinely compares defined situations to similar situations or, even better, to a large number of similar situations. Through the pooling of large numbers of comparable cases, interfering individual differences are statistically eliminated, and only the common ground appears. The conceptual assumption behind this procedure is that similar—but still not identical— cases will evolve similarly under identical conditions. One of the most important insights from the study of complex phenomena is that in complex systems very small differences in initial conditions may lead to completely different outcomes after a short time—the socalled butterfly effect. This insight is well known to natural scientists; however, clinical epidemiologists do not seem to be completely aware of the consequences of the butterfly effect to their area of research. FROM KARL POPPER TO THOMAS S. KUHN Based on epistemological considerations, the Anglo-Austrian philosopher Karl Popper (1902–1994) demonstrated in the 1930s the limitations of logical empiricism. He reasoned that general theories drawn from empirical observations can never be proven to be true. So, all theories must remain tentative knowledge, waiting to be falsified by contrary observations. In fact, Popper conceived the project of science as a succession of theories to be falsified sooner or later and to be replaced by new theories. This continuous succession of new scientific theories is the result of natural selection of ideas through the advancement of science. According to Popper, any scientific theory must be formulated in a way to render it potentially falsifiable through empirical testing. Otherwise, the theory is not scientific: It may be metaphysical, religious, or spiritual instead. This requires that a theory must be formulated in terms of clearly defined notions and measurable elements. Popper’s assertions were later qualified as being less absolute by the American philosopher of science Thomas S. Kuhn (1922–1996). Limitations to Evidence-Based Practice 59 c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Kuhn, originally a physicist, pointed out that in real science any propagated theory could be falsified immediately by contrary observations because contradicting observations are always present; however, science usually ignores or even suppresses observations dissenting with the prevailing theory in order to maintain the accepted theory. Kuhn calls the dissenting observations anomalies, which are—according to him—always obvious and visible to all, but nevertheless blinded out of perception in order to maintain the ruling paradigm. In Kuhn’s view, science will never come to an end and there will never be a final understanding of nature. No theory will ever be able to integrate and explain consistently all the observations drawn from nature. At this point, even the fundamental limitations to logical scientific reasoning demonstrated by Go¨del’s incompleteness theorems become recognizable (cf. also Sleigh, 1995). Based on his considerations, Kuhn clear-sightedly identified science to be a social system, rather than a strictly logical and rational undertaking. Science, as a social phenomenon, functions according to principles of Gestalt psychology. It sees the things it wants to see and overlooks the things that do not fit. In his chief work The Structure of Scientific Revolutions, Kuhn (1962) gives several examples from the history of science supporting this interpretation. It is in fact amazing to see how difficult it was for most important scientific breakthroughs to become acknowledged by the contemporary academic establishment. Kuhn uses the notion normal science to characterize the established academic science and emphasizes the self-referencing nature of its operating mode. Academic teachers teach students what the teachers believe is true. Students have to learn what they are taught by their teachers if they want to pass their exams and get their degrees. Research is mainly repeating and retesting what is already known and accepted. Journals, edited and peerreviewed by academic teachers, publish what conforms with academic teachers’ ideas. Societies and associations—headed by the same academic teachers—ensure the purity of doctrine by sponsoring those who confirm the prevailing paradigms. Dissenting opinions are unwelcome. Based on Kuhn’s view of normal science, EBP and EBM can be identified as classical manifestations of normal science. The EBP helps to ensure the implementation of mainstream knowledge by declaring to be most valid what is best evaluated. Usually the currently established practices are endorsed by the best and most complete empirical evidence; dissenting ideas will hardly be supported by good evidence, even if these ideas are right. Since EBP instructs its adherers to evaluate the available evidence on the basis of numerical rules of epidemiology, arguments like plausibility, logic consistency, or novelty are of little relevance. AN EXAMPLE FROM RECENT HISTORY OF CLINICAL MEDICINE When in 1982 the Australian physicians Barry Marshall and Robin Warren discovered Helicobacter pylori in the stomachs of patients with peptic ulcers, their findings were completely ignored and neglected by the medical establishment of that time. The idea that peptic ulcers are provoked by an infectious agent conflicted with the prevailing paradigm of academic gastroenterology, which conceptualized peptic ulcers as a consequence of stress and lifestyle. Although there had been numerous previous reports of helicobacteria in gastric mucosa, all these findings were completely ignored because they conflicted with the prevailing paradigm. As a consequence Marshall and Warren’s discovery was ignored for years because it fundamentally challenged current scientific opinion. They were outcast by the scientific community, and only 10 years later their ideas slowly started to convince more and more clinicians. Now, 25 years later, it is common basic clinical knowledge that 60 Overview and Foundational Issues c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Helicobacter pylori is one of the major causes of peptic ulcers, and eradication therapy is the accepted and rational therapy for gastric ulcers. Finally, in 2005 Barry Marshall and Robin Warren gained the Nobel Price for their discovery (Parsonnet, 2005). BENEFITS AND RISKS OF EVIDENCE-BASED PRACTICE The true benefits of EBP for patients and society in terms of outcomes and costs have not been proven yet—at least not through sound empirical evidence (B. Cooper, 2003; Geddes & Harrison, 1997). Nevertheless, there is no doubt that the method has a beneficial and useful potential. Many achievements of EBP are undisputable and undisputed, hence they are evident. Owing to the spread of methodical skills in retrieving and evaluating the available epidemiological evidence, it has become much harder to apply any kind of obscure or idiosyncratic practices. The experts’ community, as well as the customers and the general public, are much more critical toward pretended effects of treatments and ask for sound empirical evidence of effectiveness and safety. It is increasingly important not only to know the best available treatment, but also to prove it. The EBP is therefore a helpful instrument for doctors and therapists to justify and legitimate their practices to insurance, judiciary, politics, and society. Furthermore, individual patients might be less at risk to wrong or harmful treatment due to scientific misapprehension. Of course, common malpractice owing to inanity, negligence, or viciousness will never be eliminated, not even by the total implementation of EBP; however, treatment errors committed by diligent and virtuous doctors are minimized through careful adherence to rational guidelines. In general, clinical decision-making paths have become more comprehensible and rational, probably also due to the spread of EBP. As medicine is in fact not a thoroughly scientific matter (Ghali et al. 1999), continuous efforts are needed to enhance and renew rationality. The EBP contributes to this task and helps clinicians to maintain rationality in a job where inscrutable complexity is daily business. In current medical education, the algorithms of EBP are now instilled into students as a matter of course. Seen from that perspective, EBP is also an instrument of discipline and education, for it compels medical students and doctors to reflect continuously all their opinions and decisions scientifically (Norman, 1999). Today EBP has a great impact on the education and training of future doctors, and it thereby enhances the uniformity and transparency of medical doctrine. This international alignment of medical education with the principles of EBP will, in the long run, allow for better comparability of medical practice all over the world. This is an important precondition for the planning and coordination of research activities. Thus, the circle of normal science is perfectly closed through the widespread implementation of EBP. GENERAL LIMITATIONS TO EVIDENCE-BASED PRACTICE It has been remarked, not without reason, that the EBP movement itself has adopted features of dogmatic authority (B. Cooper, 2003; Geddes et al., 1996; Miles et al., 1999). This appears particularly ironic, because EBP explicitly aims to fight any kind of orthodox doctrine. The ferocity of some EBP adherents may not necessarily hint at conceptual weaknesses of the method; rather, it is more likely a sign of an iconoclastic or even patricidal tendency inherent to EBP. Young, diligent scholars, even students, possibly without any practical experience, are now entitled to criticize and rectify clinical authorities (Norman, 1999). This kind of insurgence must evoke resistance from authorities. If the acceptance of EBP among clinicians should be enhanced, Limitations to Evidence-Based Practice 61 c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. it is advisable that the method is not only propagated by diligent theoreticians, but mainly by experienced practitioners. One of the first and most important arguments against EBP is reductionism (see earlier, Welsby, 1999). Complex and maybe fundamentally diverse clinical situations of individual patients have to be condensed and aggregated to generalized questions in order to retrieve empirical statistical evidence. Important specific information about the individual cases is inevitably lost owing to this generalization. The usefulness of the retrieved evidence is therefore inevitably diluted to a very general and dim level. Of course, there are some frequently used standard interventions, which are really based upon good empirical evidence (Geddes et al., 1996). EXAMPLES FROM CLINICAL MEDICINE Scabies, a parasitic infection of the skin, is an important public health problem, mainly in resource-poor countries. For the treatment of the disease, two treatment options are recommended: topical permethrin and oral ivermectin. Both treatments are known to be effective and are usually well tolerated. The Cochrane Review concluded from the available empirical evidence that topical permethrin appears to be the most effective treatment of scabies (Strong & Johnstone, 2007). This recommendation can be found in up-to-date medical textbooks and is familiar to any well-trained doctor. Acute otitis media in children is one of the most common diseases, one ofthe main causes for parents to consult a pediatrician, and a frequent motive for the prescription of antibiotics, even though spontaneous recovery is the usual outcome. Systematic reviews have shown that the role of antibiotic drugs for the course of the disease is marginal, and there is no consensus among experts about the identification of subgroups who would potentially profit from antibiotics. In clinical practice, in spite of lacking evidence of its benefit, the frequent prescription of antibiotic drugs is mainly the consequence of parents’ pressure and doctors’ insecurity. A recent meta-analysis (Rovers et al., 2006) found that children youngerthan 2 years of age with bilateral acute otitis media and those with otorrhea benefited to some extent from antibiotic treatment; however, even for these two particular conditions, differences were moderate: After 3–7 days, 30% of the children treated with antibiotics still had pain, fever, or both, while in the control group the corresponding proportion was 55%. So, the available evidence to guide a clinician when treating a child with acute otitis media is not really significant and the decision will mostly depend on soft factors like parents’ preferences or practical and economical considerations. Evidently, clinicians choosing these interventions do not really need to apply the algorithms of EBP to make their decisions. They simply administer what they had learned in their regular clinical training. The opponents of EBP rightly argue that the real problems in clinical practice arise from complex, multimorbid patients presenting with several illnesses and other factors that have to be taken into account by the treating clinician. In order to manage such cases successfully there is usually no specific statistical evidence available to rely on. Instead, clinicians have to put together evidence covering some aspects of the actual case and hope that the resulting treatment will still work even if it is not really designed and tested for that particular situation. Good statistical evidence meeting the highest standards of EBP is almost exclusively derived from ideal monomorbid patients, who are rarely seen in real, everyday practice (Williams & Garner, 2002). It is not clear at all—and far from evidence-based—whether evidence from ideal cases can be transferred to 62 Overview and Foundational Issues c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. more complex cases without substantial loss of validity. Another argument criticizing EBP points at an epistemological problem. Because the EBP operates retrospectively by evaluating what was done in the past, it cannot directly contribute to developing new strategies and to finding new therapies. The EBP helps to consolidate well-known therapies, but cannot guide researchers toward scientific innovations. No scientific breakthrough will ever be made owing to EBP. On the contrary, if all clinicians strictly followed recommendations drawn from available retrospective evidence and never dared to try something different, science would stagnate in fruitless selfreference. There is a basically conservative and backward tendency inherent to the method. Although it cannot exactly be called antiscientific on that account (B. Cooper, 2003; Miles et al., 1999), EBP is a classical phenomenon of normal science (Kuhn, 1962). It will not itself be the source of fundamental new insights. Finally, there is an external problem with EBP, which is probably most disturbing of all: Production and compilation of evidence available to clinicians is highly critical and exposed to different nonscientific influences (Miettinen, 1999). Selection of areas of research is based more and more on economic interests. Large, sound, and therefore scientifically significant epidemiologic studies are extremely complex and expensive. They can be accomplished only with the support of financially potent sponsors. Compared with public bodies or institutions, private companies are usually faster and more flexible in investing important amounts of money into medical research. So, for many ambitious scientists keen on collecting publishable findings, it is highly appealing to collaborate with commercial sponsors. This has a significant influence on the selection of diseases and treatments being evaluated. The resulting body of evidence is necessarily highly unbalanced because mainly diseases and interventions promising important profits are well evaluated. For this reason, more money is probably put into trials on erectile dysfunction, baldness, or dysmenorrhea than on malaria or on typhoid fever. So, even guidelines based on empirical evidence—considered to be the ultimate gold standard of clinical medicine—turn out to be arbitrary and susceptible to economical, political, and dogmatic arguments (Berk & Miles Leigh, 1999). So, EBP’s goals to replace opinion and tendency by knowledge are in danger of being missed, if the relativity of available evidence is unrecognized. The uncritical promotion of EBP opens a clandestine gateway to those who have interests in controlling the contents of medical debates and have the financial means to do so. Biasing clinical decisions in times of EBP is probably no longer possible by false or absent evidence; however, the selection of what is researched in an EBP-compatible manner and what is published may result in biased clinical decisions (Miettinen, 1999). One of the most effective treatment options in many clinical situations—watchful waiting—is notoriously under-researched because there is no commercial or academic interest linked to that treatment option. Unfortunately, there will never be enough time, money, and workforce to produce perfect statistical evidence for all useful clinical procedures. So, even in the very distant future, clinicians will still apply many of their probably effective interventions without having evidence about their efficacy and effectiveness; thus, EBP is a technique of significant but limited utility (Green & Britten, 1998; The Lancet, 1995; Sackett et al., 1996). EXAMPLE FROM CLINICAL MEDICINE Lumbar back pain is one of the most frequent health problems in Western countries. About 5% of all low back problems are caused by prolapsed lumbar discs. The treatment is Limitations to Evidence-Based Practice 63 c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. mainly nonsurgical and 90% of acute attacks of nerve root pain (sciatica) settle without surgical intervention; however, different forms of surgical treatments have been developed and disseminated. Usually these methods are considered for more rapid relief in patients whose recovery is unacceptably slow. The Cochrane reviewers criticize that “despite the critical importance of knowing whether surgery is beneficial for disc prolapse, only four trials have directly compared discectomy with conservative management and these give suggestive rather than conclusive results” (Gibson & Waddell, 2007, p. 1). They concluded: Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. (p. 2) Surgical treatments of low back pain hold an enormous commercial potential due to the worldwide frequency of the problem. It appears obvious that there are only a few trials comparing conservative treatment with surgery. SPECIFIC LIMITATIONS TO EBP IN PSYCHIATRY, PSYCHOTHERAPY, AND CLINICAL PSYCHOLOGY In psychiatry and psychotherapy, there is an ambivalent attitude toward EBP. Attempting to increase their scientific respectability, some psychiatrists and clinical psychologists zealously adopted EBP algorithms (Geddes & Harrison, 1997; Gray & Pinson, 2003; OakleyBrowne, 2001; Sharpe et al., 1996) and started evidence-based psychiatry. Others remain hesitant or doubtful about the usefulness of EBP in their field, and several authors have addressed different critical aspects of evidence-based psychiatry (Berk & Miles Leigh, 1999; Bilsker, 1996; Brendel, 2003; Geddes & Harrison, 1997; Goldner & Bilsker, 1995; Harari, 2001; Hotopf, Churchill, & Lewis, 1999; Lawrie, Scott, & Sharpe, 2000; Seeman, 2001; Welsby, 1999; Williams & Garner, 2002) with all of them fundamentally concerning practical and scientific particularities of psychiatry and clinical psychology. Next, we shall try to clarify these arguments. The evidence-based approach to individual cases is critically dependent on the validity of diagnoses. This is an axiomatic assumption of EBP, which is rarely analysed or scrutinized in detail. If in a concrete case no diagnosis could be attributed, the case would not be amenable to EBP, and no evidence could support decisions in such a case. If the diagnosis is wrong, or—even more intricate—if cases labeled with a specific diagnosis are still not homogenous enough to be comparable in relevant aspects, EBP will provide useless results. EXAMPLE FROM PSYCHIATRY According to DSM-IV, eating disorders are classified in different categories: anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise specified (EDNOS). These categories are clinically quite distinct and diagnostic criteria are clear and easily applicable. In spite of the phenomenological diversity of the disease patterns, there is a close relationship between the different forms of eating disorders. In clinical practice, switches between different diagnoses and temporary remissions and relapses are frequent. In the course of time, patients may change their disease pattern several times: At times they may not meet the criteria for a diagnosis anymore, although they are not completely symptom free, and later they may relapse to a full-blown eating disorder again or may be classified as having EDNOS. 64 Overview and Foundational Issues c04 18 April 2012; 19:44:28 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. Corresponding to these clinical impressions, longitudinal studies demonstrate that the stability of eating disorder diagnoses over time is low ( Fichter & Quadflieg, 2007; Grilo et al., 2007; Milos, Spindler, Schnyder, & Fairburn, 2005). Based on systematic evaluation of the available evidence, however, treatment guidelines give specific recommendations for the different conditions (National Institute for Clinical Excellence [NICE], 2004). For patients with AN, psychological treatment on an outpatient basis is recommended. The treatment should be offered by “a service that is competent in giving that treatment and in assessing the physical risk of people with eating disorders” (p. 60). For patients with BN, the NICE guideline proposes as a possible first step to follow an evidence-based self-help program. As an alternative, a trial with an antidepressant drug is recommended, followed by cognitive behavior therapy for bulimia nervosa. In the absence of evidence to guide the treatment of EDNOS, the NICE guideline recommends pragmatically that “the clinician considers following the guidance on the treatment of the eating problem that most closely resembles the individual patient’s eating disorder” (p. 60). So even though specific diagnoses of eating disorders are not stable and a patient with AN might be diagnosed with BN a few months later, treatment recommendations vary considerably for the two conditions. It becomes obvious that different treatment recommendations for seemingly different conditions reflect rather accidental differences in the availability of empirical evidence than real differences in the response of certain conditions to specific treatments. Hence, the guidance offered by the guideline is basically a rather unstable crutch, and of course, cognitive behavior therapy or an evidence-based self-help program might be just as beneficial in AN or in EDNOS than it is in BN, even though nobody has yet compiled the statistical evidence to prove this. What does the validity of a diagnosis mean? The question concerns epistemological issues and requires a closer look to the nature of medical diagnoses with special regard to psychiatric diagnoses. R. Cooper (2004) questioned if mental disorders as defined in diagnostic manuals are natural kinds. In her thoughtful paper, the author concluded that diagnostic entities are in fact theoretical conceptions, describing complex cognitive, behavioral, and emotional processes (R. Cooper, 2004; Harari, 2001). Diagnostic categories are based upon observations, still they are strongly influenced by theoretical, social, and even economical factors. The ontological structure of psychiatric diagnoses is therefore not one of natural kinds. They are not something absolutely existing that can be observed independently. Rather they are comprehensive theoretical definitions serving as tools for communication and scientific observation. Kendell and Jablensky (2003) have also recently addressed the issue of diagnostic entities and concluded that the validity of psychiatric diagnoses is limited. They analysed whether diagnostic entities are sufficiently separable from each other and from normality by zones of rarity. They concluded that this was not the case; rather, they concluded that psychiatric diagnoses often overlap (R. Cooper, 2004; Welsby, 1999), shift over time within the same patient, and several similar diagnoses can be present in the same patient at the same time (comorbidity). Not surprisingly, diagnosis alone is a poor predictor of outcome (Williams & Garner, 2002). Acknowledging this haziness of diagnoses, one realizes these problems when trying to match individual cases to empirical evidence. When even the presence of a correctly assessed diagnosis does not assure comparability to other cases with the same diagnosis, empirical evidence about mental disorders is highly questionable (Harari, 2001). Of course, limited validity does not imply complete absence of validity, and empirical evidence on mental disorders is still useful to some extent; however, insight Limitations to Evidence-Based Practice 65 c04 18 April 2012; 19:44:29 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. into the limitations is important and that insight points out that psychiatric diagnoses represent phenomenological descriptions rather than natural kinds. Several authors have treated the same issue when writing about the complexity of cases, the problem of subsyndromal cases, and of single cases versus statistical evidence (Harari, 2001; Welsby, 1999; Williams & Garner, 2002). NONLINEAR DYNAMICS IN THE COURSE OF DISEASES It might be fruitful to look at evidence-based psychiatry from another perspective and to address the issues of complexity and nonlinear dynamics. With regard to their physical and mental functioning, humans can be conceptualized as systems of high complexity (Luhmann, 1995). This means that they cannot be determined precisely, but only in a probabilistic manner; however, probabilistic determination is sufficient for most purposes in observable reality. Human life consists fundamentally in dealing with probabilities. Social systems and human communication are naturally designed to manage complexity more or less successfully. Medicine itself is a social system (Luhmann, 1995) trying to handle the effects of complexity (Harari, 2001), for example, by providing probabilistic algorithms for treatments of diseases. In most situations, medicine can ignore the particular effects emerging from the complex nonlinear structure of its objects, although such effects are always present. Only sometimes do these effects become obvious and irritating, as for example in fluctuations of symptoms in chronic diseases, variations in response to treatment, unexpected courses in chronic diseases, and so on. Such phenomena can be seen as manifestations of the butterfly effect (see earlier). This insight questions deeply the core principle of EBP that assumes that it is rational to treat similar cases in the same manner because similarity in the initial conditions will predict similar outcomes under the identical treatment. The uncertainty of this assumption is particularly critical in psychiatry and psychotherapy. In these fields similar appearance is just a palliation for untraceable difference, and this exact difference may crucially influence the outcome. Addressing such problems is daily business for psychiatrists and psychotherapists, so their disciplines have developed special approaches. Diagnostic and therapeutic procedures in these disciplines are much less focused on critical momentary decisions, but more on gradual, iterative procedures. Psychiatric treatments and even more psychotherapy are self-referencing processes, where assessments and decisions are constantly reevaluated. Instead, EBP focuses primarily on decision making as the crucial moment of good medical practice. One gets the impression that EBM clinicians are constantly making critical decisions, and after having made the right decision, the case is solved. Maybe it is because of this misfit between the proposals of the method and real daily practice that many psychiatrists are not too attracted by EBP. EXAMPLE FROM PSYCHIATRY The diagnosis of posttraumatic stress disorder (PTSD) was first introduced in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980. Before that time, traumatized individuals were either diagnosed with different nonspecific diagnoses (e.g., anxiety disorders, depression, neurasthenia) or not declared ill at all. Astonishingly, the newly discovered entity appeared to be a clinically distinct disorder and the corresponding symptoms (re-experiencing, avoidance, hyperarousal) were quite characteristic and easily identifiable. Within a short time after its invention (Summerfield, 2001), PTSD became a very popular disorder; 66 Overview and Foundational Issues c04 18 April 2012; 19:44:29 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. clinicians and even patients loved the new diagnosis (Andreasen, 1995). The key point for the success of the new diagnosis was that it is explicitly based on the assumption of an external etiology; that is, the traumatic experience. This conception makes PTSD so appealing for the attribution of cause, responsibility, and guilt is neatly separated from the affected individual. PTSD allows for the exculpation of the victim, a feature that was particularly important when caring for Holocaust survivors and Vietnam War veterans. But what was almost proscribed for some time after the introduction of PTSD is now evidence-based: Preexisting individual factors play an important role in the shaping of posttraumatic response. Whether or not an individual develops PTSD after a traumatic experience is not only determined by the nature and the intensity of the traumatic impact, but also by various pretraumatic characteristics of the affected individual. Furthermore, PTSD is not the only posttraumatic mental disorder. A whole spectrum of mental disorders is closely linked to traumatic experiences, although they lack the monocausal appearance of PTSD. Anyway, the most frequent outcome after traumatic experiences is recovery. In the second rank of frequency comes major depression. Borderline personality disorder is fully recognized now as a disorder provoked by traumatic experiences in early childhood. Dissociative disorders, chronic somatoform pain, anxiety disorders, substance abuse, and eating disorders are equally related to traumatic experiences. Not surprisingly, PTSD is often occurring as a comorbid condition with one or more additional disorder or vice versa. In clinical practice, traumatized patients usually present more complex than expected. This may explain to some extent why PTSD was virtually overlooked by clinicians for many decades before its introduction, a fact that is sometimes hard to understand by younger therapists who are so familiar with the PTSD diagnosis. At any rate, the high-functioning, intelligent, monomorbid PTSD patient is indeed best evaluated in clinical trials, but rarely seen in everyday practice. PTSD was right in the focus of research since its introduction. Also from a scientific point of view, the disorder is appealing because it is provoked by an external event. PTSD allows ideally for the investigation of the human-environmentinteraction, whichis a crucial issue for psychiatry and psychology in general. The number of trials on diagnosis and treatment of PTSD is huge, and the disorder is now probably the best evaluated mental disorder. What is the benefit of the accumulated large body of evidence on PTSD for clinicians? There are several soundly elaborated guidelines on the treatment of PTSD (American Psychiatric Association, 2004; Australian Centre for PosttraumaticMental Health, 2007; NICE, 2005), meta-analyses, and Cochrane Reviews providing guidance for the assessment and treatment of the disorder. When we look at the existing conclusions and recommendations, we learn that: Debriefing is not recommended as routine practice for individuals who have experienced a traumatic event. When symptoms are mild and have been present for less than 4 weeks after the trauma, watchful waiting should be considered. Trauma-focused cognitive behavior therapy on an individual outpatient basis should be offered to people with severe posttraumatic symptoms. Eye movement desensitization and reprocessing is an alternative treatment option. Drug treatment should not be used as a routine first-line treatment in preference to a trauma-focused psychological therapy. Drug treatment (Specific Serotonin Reuptake Inhibitors) should be considered Limitations to Evidence-Based Practice 67 c04 18 April 2012; 19:44:29 Hersen, Michel, and Peter Sturmey. Handbook of Evidence-Based Practice in Clinical Psychology : Adult Disorders, John Wiley & Sons, Incorporated, 2011. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/ashford-ebooks/detail.action?docID=817356. Created from ashford-ebooks on 2017-11-07 11:26:43. Copyright © 2011. John Wiley & Sons, Incorporated. All rights reserved. for the treatment of PTSD in adults who express a preference not to engage in trauma-focused psychological treatment. In the context of comorbid PTSD and depression, PTSD should be treated first. In the context of comorbid PTSD and substance abuse, both conditions should be treated simultaneously. These recommendations are obviously clear, useful, and practical. They give real guidance to therapists and do not leave much room for doubts or insecurity. On the other hand, they are basically very simple, almost trivial. For trauma therapists, these recommendations are commonplace and serve mainly to endorse what they are practicing anyway. The main points of the guidelines for the treatment of PTSD could be taught in a 1-hour workshop. The key messages of the guidelines represent basic clinical knowledge on a specific disorder as it has been instructed in times before EBP. Through their standardizing impact on the therapeutic community, guidelines may in fact align and improve the general service quality offered to traumatized individuals, although this effect has not yet been demonstrated by empirical evidence. The treatment of an individual patient remains a unique endeavor where interpersonal relationship, flexibility, openness, and cleverness are crucial factors. This challenge is not lessened by evidence or guidelines.

 
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