Adolescence and puberty

Question 1

Explain the terms puberty and adolescence and give the normal ages at which these events occur in boys and girls.

Answer 1

Adolescence – phase between childhood & adulthood

• Pubertal development may be start of adolescence
• Adulthood: legally, culturally variable
• UN: children < 18 years
• Developmental stages of adolescence:
  
  • Early 11-14.
  • Middle 14-17.
  • Late 18-21.
• Physical development:
  
  • Gender differences – girls grow taller, start puberty and are more mature, earlier than boys do.
  • Pubertal changes – girls start puberty around 8 (with breast budding) whilst boys start around 10.5.
    
    • Peak for girls is 11-13.5, peak for boys is 13-15.
    • Early maturing girls and late maturing boys are at risk of – depression, substance abuse, ASBOs, eating disorders and bullying.

Question 2

Explain the terms menarche and adrenarche.

Answer 2

• Onset of puberty:
  
  • Onset of puberty is due to two theories:
    
    • Maturation of the CNS affecting GnRH neurons (increased release).
    • Altered set-point to gonadal steroid negative feedback.
  • Not sure what triggers this but maybe environmental.
• Menarche – the first occurrence of menstruation.
  
  • Has decreased over the last 150 years but seems to have been leveling off recently.
    
    • Possibly decreased due to nutritional reasons.
  • Bodyweight at menarche has remained relatively constant at ~47kg over those years.
• Adrenarche – early sexual maturation stage (10 or 11) when DHEA DHEAS is made without cortisol.

Question 3

Psychological Changes

Answer 3

• Emotional development:
  
  • Self-concept – Harter’s 8-dimension model of self-concept:
    
    • Scholastic, job, athletic, physical appearance, social acceptance, close friends, romantic appeal and conduct of self – Some Jobs Are Pretty Shit, Can’t Really Complain.
      
      • Self-concepts have clinical implications – 20-30% adolescents have low self-esteem which can lead to depression, anxiety, poor academia, social isolation, etc. However, people with good self-esteem can also be disposed to this!
  • Identity formation – Erikson’s 8-life-span stages:
    
    • Don’t need to know the stages but one stage is in age’s 10-20 which is “Identity vs. confusion”.
  • Identity formation – Marcia:
    
    • Identity diffusion (no crisis, no commitment) à identity foreclosure (no crisis, commitment) à moratorium (crisis, actively searching for identity) à identity achievement (crisis over).
      
      • Only moratorium necessary for identity development.
      • Identity is associated with higher – achievement, moral reasoning, social skills, etc.
  • Ethnic identity – cultural minorities:
    
    • Integration – retain base culture, develop and maintain with mainstream culture as well. ++
    • Assimilation – lose base culture, develop and maintain into mainstream culture. -+
    • Separation – retain base culture, no development into mainstream culture. +-
    • Marginalisation – lose base culture, no development into mainstream culture. –

Question 4

Social changes

Answer 4

• Social development:
  
  • Social domains – adolescents and parents may have different views about who has the final say depending upon the social “domains” – friendships, clothes, etc. – mid-adolescence is most intense negotiations.
  • Family:
    
    • Conflict with parents – most adolescents have good relationships, high confiding in mothers.
    • Family connectedness is associated with – reduced risk behaviors and increased self-esteem.
  • Peer development:
    
    • Primary school (7-11) – goal to be accepted by peers, prefer same gender and gain loyalty.
    • 11-13 – expect genuineness, intimacy, common interests, emergence of cliques.
    • 13-16 – friendship goals, cross-gender relationships and develop larger groups.
    • 16-18 – emotional support expected and increase dyadic romantic ties.
  • Gender differences:
    
    • Boys – less intimate, disclosing and friendships embedded in larger circles.
    • Girls – close and confiding relationships but are more brittle.
  • Influence:
    
    • Peers influence – interpersonal style, fashion/entertainment.
    • Parents influence – academic choice, career choice and future aspirations.
  • School – 5 or more A*- C at GCSE factors:
    
    • Higher social class, girls > boys, ethnicity (Chinese > Indian > white) – combined effect = ~10%.
  • Culture (“teen” subculture; migration/culture)
  • social influences eg unemployment, poverty/affluence, housing, neighbourhood effec

Question 5

Brain development

Answer 5

• Brain changes:
  
  • Grey matter decreases from 6yo –> adolescence.
  • Linear increase in white matter until age 20
    
    • ~12yo Frontal and parietal lobes develop peak.
    • ~16yo Temporal lobes develop peak.
  • From puberty – increase in density of cortical white matter (more connections).
  • Pre-frontal cortex (executive function – i.e. planning) – increase in density of grey matter until puberty, then decrease.
    
    • Dorso-lateral prefrontal cortex – last area to reach adult full density.
  • Synaptogenesis followed by pruning (synapse elimination) occurs.
  • Brain regions associated with more basic functions such as sensory and motor process mature first followed by association areas involved in top-down processing.
• Grey, white, dopaminergic pathway changes increase vulnerability to risk-taking - adolescents get a risk assessment

1/10 children have a diagnosable condition

1/2 of all mental health problems are established by the age of 14

3/4 of all mental health problems have been established by 24

Question 6

Anorexia nervosa: Define the main features of anorexia nervosa and summarise the aetiological and maintaining factors

Answer 6

• Psychological implications of pubertal development – for boys the changes of puberty may be welcome (i.e. increased height and muscle gain) but for girls, the feelings may be more ambivalent (i.e. increased adiposity).
  
  • Cultural variation – white English girls are most negative.
  • The body shape dissatisfaction may bring about the anorexia (or other extreme weight loss diets).
• Anorexia nervosa:
  
  • Cardinal features:
    
    • Restriction of energy intake relative to requirements leading to significantly low body weight in the context of age, sex, developmental trajectory and physical health.
    • B. Intense fear of gaining weight or becoming fat, or persistent behaviour that interferes with weight gain.
    • C. Disturbance in experience of weight/shape, undue influence of wt/shape on self-evaluation, or persistent lack of recognition of seriousness of low body weight
    • D. Amenorrhoea NOT in DSM-5! • Subtype: Restricting vs. Binge-eating/Purge
  • Causes – genetics, perfectionism, temperaments, subcultures, abuse and adversity, high social class (dieting habits, being female)
  • Treatment – family intervention, cognitive behavioural therapy, (small %) weight restoration.
  • Outcome:
    
    • Community sample 50% recover after 5 years.
    • Clinic sample 37% recover, 25% weight gain (no menstruation), 37% still

underweight (with symptoms) after 1 year.

• Bulimia nervosa:
  
  • Like anorexia nervosa but involves a preoccupation with eating and then involves purging.

Prediction of Eating Problems

• Adolescent eating problems (symptoms) associated with:

• Earlier pubertal maturation, & higher body fat
• Concurrent psychological problem e.g. depression
• Poor body image
• Specific cognitive phenotypes

Question 7

Mood disorders: Summarise the range of mood disorders accompanying adolescent development and identify the main aetiological and maintaining factors of these disorders

Answer 7

• Depression may refer to a single symptom, a symptom cluster or a disorder.
• Types:
  
  • Pre-pubertal depression – 2 main types:
• 1-2% Prevalence*
  * (1) common with co-morbid behavioural problems, bad upbringing (bad parents etc.), course of this resembles children with a conduct disorder. No increased risk of recurrence in later life.
  * (2) less common, highly familial, high rates of anxiety and bipolar. Recurrence common.
  
  • Adolescent depressive disorder: 3-8% Prevalence
    
    • Irritability instead of sadness (especially in boys), social withdrawal.
    • Outcome with high recurrence and impairment in later adult relationships.
• Symptoms:
  
  • (1) Persistent sadness or low mood and/or;
  • (2) Loss of interest or pleasure – anhedonia.
  • (3) Fatigue/low-energy – anergia.
    
    • At least 1 of the above, most of the time for at least 2 weeks and some associated symptoms:
      
      • (4) Disturbed sleep, (5) poor concentration, (6) low self-confidence, (7) changes in appetite and weight, (8) suicidal thoughts/acts, (9) agitation, (10) guilt or self-blame – these changes may be positive or negative (i.e. weight gain or loss).
    • Total 10 symptoms then classify level of depression - <4 (not), 4 (mild depression), 5-6 (moderate), 7> (severe).
• Symptom clusters – the 10 symptoms but clustered:
  
  • Affective – sadness, loss of enjoyment, irritability.
  • Cognitive – self-blame, hopelessness, guilt.
  • Biological – disturbed sleep, reduced appetite.
• Developmental consideration – as you develop, these happen which may predispose to depression:
  
  • Endocrine – especially in females and may increase risk of low mood.
  • Relationships with family – get closer with family as you develop à more conflict.
  • Peers – increased involvement with peers as you develop à more rejection and conflict.
  • Responsibilities and hassle.
• Epidemiology – 2-5% of adolescents.
• Causes – genetics, family interactions (i.e. criticism), life events.
• Prognosis – major depression has a high risk of reoccurrence and pre-pubertal onset has a better prognosis.
• Interventions:
  
  • Cognitive behaviour therapy.
  • Interpersonal psychotherapy.
  • Family intervention.
  • Anti-depressants – SSRIs (for mod à severe depression).

Answer 8

Types

• Depressive episode (~ 50% recur)
• Recurrent depression
• Dysthymia • Bipolar depression
• Psychotic depression
• Atypical depression
• Seasonal affective disorder (SAD)
• ?Inflammatory subtype

Question 9

Antisocial behaviour: Identify the main features of antisocial behaviour, conduct disorder and offending

Question 10

Psychological interventions: Identify the psychotherapeutic and pharmacological interventions that may ameliorate the problems linked to psychological disorders during adolescence

Answer 10

Intervention

• Should be targeted at major modifiable risk factors and should begin at an early age
• Managing underlying hyperactivity
• Parenting programs
• Cognitive problem-solving skills training
• Interventions at school
• Multi-systemic therapy