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Developmental Demands of Adolescence

If you work with teenagers or they live in your home, you are well aware of their many great qualities. Teenagers are eager to grow up and have new experiences, and have a sense of invincibility mixed with some innocence and naïveté. Your experience with teenagers has also led you to understand their rapidly fluctuating emotions, brazen attitudes, and, at times, difficulty appreciating the importance of taking care of themselves. This chapter will provide a context for why teenagers behave the way they do and how different approaches may be necessary when interacting with teenagers. This chapter will help you when that next adolescent patient shows up in your clinic and displays a defiance of convention, a preference for social priorities over personal priorities, and a sense of invulnerability and invincibility. We also discuss how these adolescent qualities affect diabetes management.

Developmental Context

More than 100 years ago, the child development pioneer G. Stanley Hall described adolescence as a time of “storm and stress.” According to Hall (1904), adolescence is marked by three major changes: emotional upheaval, increased risk taking, and extreme parent-child conflict. Hall believed that this period of development is biologically driven and largely universal, but especially problematic for adolescents in the U.S. Hall cited urbanization and individualism as additional causes of storm and stress in U.S. adolescents.

Since Hall’s initial description of adolescence, others have examined the concept of storm and stress empirically. An American psychologist, Jeffrey Arnett (1999), examined adolescents and young adults and coined the term emerging adult, which will be discussed later in the context of transition. In contrast to Hall’s idea of an across-the-board tumultuous time specific to adolescence, Arnett found that rates of psychopathology were relatively consistent from childhood into adolescence and that most youth were not experiencing significant psychological distress. Further, there was no major shift in risk taking during adolescence; however, the consequences of the risks taken by adolescents were much greater than the risks taken by children. Finally, Arnett concurred with Hall in confirming an increase in parent-child conflict as children mature into adolescents.

Arnett’s debunking of Hall’s assertion that adolescence is universally a time of storm and stress, paired with the evidence of unique challenges across biologic, physiologic, and cognitive developments for adolescents, leads to the following assumptions:

• Most adolescent patients do not experience profound psychological distress, but instead experience the normal demands of navigating this developmental period.

• Most adolescent patients do not intend to be “difficult.”

• You should approach each encounter with an adolescent patient with a fresh perspective, because development will trigger almost daily changes in attitudes, perceptions, and mood.

Further, to be fully prepared to help the adolescent patient in front of you, consider the areas discussed below.

Defiance of Convention

When working with adolescents, most professionals struggle with the normal developmental demand of defiance of convention. Defiance of convention is characterized by pushing against the status quo and challenging authority as a means of developing a sense of self. Teens are trying on a number of personality “hats” to define who they are and how they are different from parents and teachers. Besides parents and teachers, health care providers also represent convention. So when teens do not follow the directives of health care providers, they are doing what one would expect developmentally. The single best example of this is the “Just Say No” campaign for which former first lady Nancy Reagan was the spokesperson. Data on the effectiveness of the “Just Say No” campaign and other similarly messaged campaigns indicate that authority figures used for campaigns targeting teens are of questionable effectiveness (Fishbein 2002). Few represent convention and authority more than the wife of the president of the United States.

“I Wonder If She Likes Me?”

Teens are generally more focused on their social relationships than on their families. Much of social and moral learning comes from peers rather than parents, which is a shift from childhood, when parents were more influential. Data show that although there is some increase in parent-teen conflict during adolescence, parents can and should remain an important influence in the teen’s life. This influence is different from the influence parents have with younger children. With younger children, it is the spoken message of the parent that affects them. However, with teens, it is the parents’ behavior rather than what they say that carries the most weight. Parents often continue to try to “talk some sense” into their teens, as do professionals. It often seems like the teens only hear “wah, wah, wah,” as depicted when adults talk in Charlie Brown cartoons. Professionals may not realize that their reminders and lectures (though perhaps necessary) do not have the same impact on a teen as they have on a younger child.

In the realm of diabetes care, parents and professionals may conclude that teens do not care about their diabetes. The truth is that teens do care about their diabetes, but there are competing demands that hold a higher level of priority in a teen’s life. Instead of giving instructions and offering advice, the professional might ask if there are other areas that are creating stress and making it hard to manage diabetes, or offer suggestions in those areas in an attempt to alleviate stress and make more time for diabetes management. For example, parents and teens are likely to be embroiled in conflict over curfew, homework, or chores. If a professional were able to offer suggestions about non–diabetes-related conflicts, then the parents and their teens might have more time to focus on diabetes management. The most successful suggestions from professionals should involve a quid pro quo solution where both parents and teens are giving something to get something.

Invulnerability and Invincibility

Developmentally, teens do not have the cognitive capacity to fully understand how their actions today will impact their lives in the future, especially when it comes to thinking about their own mortality. Parents (and health care providers) want teens with diabetes to see how their health behaviors today will impact their lives in the future. It is not uncommon for health care providers and parents to resort to the scared straight approach with teens around their health. For example, health care providers might take teens with diabetes to a dialysis unit to show them what will happen in the event that they evidence kidney disease from poorly controlled diabetes. Developmentally, most teens are unaffected by this and often are more impressed with the technology and science of dialysis. The scared straight approach has been implemented in many areas, including juvenile justice, but has shown little effect on behavior (Ashton 1999, Lilenfeld 2005). If teens could understand how their behaviors today will impact their health in the future, they would not be teens—they would be adults. The ability to change current behavior to avoid negative long-term consequences depends in part on the maturity of brain development, a process that is not completed until adulthood. This brain development is not magically sped up when young people are diagnosed with diabetes such that they suddenly make the link between current behavior and future outcomes.

What does happen to all children as they mature into teens, however, is that they begin to naturally question authority as they develop the cognitive skill of abstract reasoning. Teens begin to see the disconnect between what they are told by adults and authority figures, and what they see adults and authority figures do. For example, a teen with diabetes is being lectured about needing to take better care of his or her health (through more exercise, better eating habits, etc.), but is trying to reconcile that message coming from parents, health care providers, and other adults who do not exercise or eat well.

How Does Adolescence Affect Diabetes Management?

It is well established that the teen years are the most difficult time to control blood glucose levels. Although the reasons for this trend are multifaceted and complex, we do know that adolescence is the time when diabetes self-management is the poorest. We also know that dramatic changes in one’s body have a negative impact on blood glucose levels, and clearly adolescence is a time of major physical maturation. Many professionals continue to view diabetes control as a proxy for adherence in diabetes. However, research has shown that there is not a one-to-one relationship between health behaviors and diabetes control in diabetes (i.e., the hemoglobin A1C value). There are many other factors that can impact blood glucose levels, including development, stress, and the natural course of diabetes. Focusing on diabetes control as the primary outcome for teens with diabetes is a setup for failure for both the teens and the health care providers.

Instead of focusing on diabetes control in teens with diabetes, focus on health behaviors. These behaviors include checking blood glucose values, taking insulin, and counting carbohydrates. These are things that teens have control over and that can produce immediate and visible improvements. Likewise, although there is not a one-to-one relationship between health behaviors and diabetes control, there is evidence that as health behaviors improve, diabetes control will likely also improve. For example, a simple change like helping a teen to take his or her insulin before rather than after he or she eats will undoubtedly have a positive impact on diabetes control because blood glucose levels will not immediately spike during a meal.

Case Example

Casey is a 16-year-old male diagnosed with diabetes when he was 4 years old. Casey lives with his parents, 14-year-old sister, 10-year-old sister, and 5-year-old twin brothers. Both of Casey’s parents work and are college educated. Casey’s diabetes control has been quite good, with A1C values in the mid-7% range until recently. Casey’s diabetes self-management was always at the highest level and he has always been able to manage his diabetes independently when at school or away from home. Within the past 2 years, Casey’s A1C values have averaged around 9%, and he frequently reports forgetting to bolus at lunch. Casey has frequently gone to high school sporting events without his insulin and has eaten while at these events without bolusing. Casey’s parents are very upset with him for not caring about his diabetes, taking huge risks with his health, and not being aware of how his current diabetes self-management will impact his diabetes down the road. Casey’s parents have decided to take back the control for his diabetes and not allow him to spend time with friends or go out on weekends and evenings until his diabetes control has improved. In addition, Casey’s parents have not allowed him to sign up for driver’s education and will not allow him to do so until his diabetes control has improved. Casey has been referred to the clinic psychologist by his parents to address the problem of “his not caring about his diabetes.”

Assessment and Intervention

This is a typical case in that Casey and his parents begin to struggle as he matures from being a child with diabetes into being an adolescent with diabetes. Developmentally, Casey is attending to the priority of most teens, his social relationships. Likewise, Casey’s parents are viewing the changes in Casey’s behavior through the lens of storm and stress and responding reflexively with attempts at taking back the control. In this particular case, the intervention could be something as simple as psychoeducation around normal adolescent development, thus providing insight to Casey’s parents about his change in behavior. Casey could also benefit from a discussion about how to attend simultaneously to his desire to be a “normal teenager” and to the demands of his diabetes. The intervention for Casey involved the aforementioned along with moving him off insulin shots and onto an insulin pump. This allowed Casey greater freedom to come and go as he pleased, while having his insulin with him at all times to accommodate impromptu changes in his activities and eating.