Behavior Problems in Adolescents
(See also Introduction to Problems in Adolescents.)
Adolescence is a time for developing independence. Typically, adolescents exercise their independence by questioning their parents' rules, which at times leads to rule breaking. Parents and health care practitioners must distinguish occasional errors of judgment from a degree of misbehavior that requires professional intervention. The severity and frequency of infractions are guides. For example, recurrent binge drinking and engaging in recurrent truancy or theft are much more significant than isolated episodes of the same activities. Warning signs that suggest disruptive behaviors are impairing functioning include deterioration of performance at school and running away from home. Of particular concern are adolescents who cause serious injury or use a weapon in a fight.
Because adolescents are much more independent and mobile than they were as children, they are often out of the direct physical control of adults. In these circumstances, adolescents' behavior is determined by their own moral and behavioral code. Parents guide rather than directly control their children's actions. Adolescents who feel warmth and support from their parents are less likely to engage in risky behaviors, as are those whose parents convey clear expectations regarding their children's behavior and show consistent limit setting and monitoring.
Authoritative parenting is a parenting style in which children participate in establishing family expectations and rules. This parenting style, as opposed to harsh or permissive parenting, is most likely to promote mature behaviors.
Authoritative parents typically use a system of graduated privileges, in which adolescents initially are given small bits of responsibility and freedom (eg, caring for a pet, doing household chores, purchasing clothing, decorating their room, managing an allowance, going to social events with friends, driving). If adolescents handle this responsibility well over a period of time, more privileges are granted. By contrast, poor judgment or lack of responsibility leads to loss of privileges. Each new privilege requires close monitoring by parents to make sure adolescents comply with the agreed-upon rules.
Some parents and their adolescents clash over almost everything. In these situations, the core issue is really control. Adolescents want to feel in control of their lives, but parents are not ready to give up that control. In these situations, everyone may benefit from the parents picking their battles and focusing their efforts on the adolescent's actions (eg, attending school and complying with household responsibilities) rather than on expressions (eg, dress, hairstyle, and preferred entertainment).
Adolescents whose behavior is dangerous or otherwise unacceptable despite their parents' best efforts may need professional intervention. Substance use disorders are a common trigger of behavioral problems, and substance use disorders require specific treatment. Behavioral problems also may be a symptom of learning disabilities, depression, or other mental health disorders. Such disorders typically require treatment with drugs as well as counseling. If parents are not able to limit their child's dangerous behavior, they may request help from the court system and be assigned to a probation officer who can help enforce reasonable household rules.
Disruptive behavioral disorders are common during adolescence.
Attention-deficit/hyperactivity disorder (ADHD) is the most common mental health disorder of childhood and often persists into adolescence and adulthood. Once thought of as a "nuisance" disorder of childhood, research has shown poor long-term functional outcomes in children diagnosed with ADHD as compared to their peers. Behavioral and drug therapy can improve outcomes. Clinicians should continue to treat and monitor adolescent patients diagnosed with ADHD in childhood. Although substance use disorders are more common among people with ADHD, treating with stimulants does not appear to increase the risk of developing a substance use disorder and may even decrease the risk.
Clinicians are cautioned to make the diagnosis of ADHD carefully before initiating treatment because other conditions, such as depression or learning disabilities, may manifest primarily with symptoms of inattention and can mimic ADHD. In some cases, an adolescent may complain of symptoms of inattention in an attempt to obtain a prescription for stimulants, either to be used as a study aid or recreationally. Because of the high potential for misuse and dependence, stimulants should be prescribed only after a diagnosis of ADHD has been confirmed.
Children occasionally engage in physical confrontation and bullying. During adolescence, the frequency and severity of violent interactions may increase. Although episodes of violence at school are highly publicized, adolescents are much more likely to be involved in violent episodes (or more often the threat of violence) at home and outside of school. Many factors contribute to an increased risk of violence for adolescents, including
There is little evidence to suggest a relationship between violence and genetic defects or chromosomal abnormalities.
Gang membership has been linked with violent behavior. Youth gangs are self-formed associations made up of 3 or more members, typically ranging in age from 13 to 24. Gangs usually adopt a name and identifying symbols, such as a particular style of clothing, the use of certain hand signs, or graffiti. Some gangs require prospective members to perform random acts of violence before membership is granted.
Increasing youth gang violence has been blamed at least in part on gang involvement in drug distribution and drug use, particularly methamphetamines and heroin. Firearms and other weapons are frequent features of gang violence.
Violence prevention begins in early childhood with violence-free discipline. Limiting exposure to violence through media and video games may also help because exposure to these violent images has been shown to desensitize children to violence and cause children to accept violence as part of their life. School-age children should have access to a safe school environment. Older children and adolescents should not have unsupervised access to weapons and should be taught to avoid high-risk situations (such as places or settings where others have weapons or are using alcohol or drugs) and to use strategies to defuse tense situations.
All victims of gang violence should be encouraged to talk to parents, teachers, and even their doctor about problems they are experiencing.