Adolescent alliance building: a contemporary approach to an ancient concept.
Subject: Decision-making (Psychological aspects)
Human growth (Psychological aspects)
Human growth (Analysis)
Teenage girls (Psychological aspects)
Teenage girls (Growth)
Teenage girls (Analysis)
Author: Eliot, Alexandra O.
Pub Date: 09/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2009 Source Volume: 12 Source Issue: 3
Topic: Computer Subject: Company growth
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 208639909
Full Text: ABSTRACT

This paper discusses an approach to interacting with adolescents in a way that invites their active participation in the activities and rules that affect their lives as they journey into young adulthood. It presents a concept of building alliances with teens instead of imposing regulations upon them that are unilaterally defined by adults in authority, so that they become an integral part of the results and consequences of their behavior. It emphasizes the deployment of the old concept of habituation, used by Aristotle, who believed that the forming of "habits" was an important part of adolescent development.

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This article discusses an approach to interacting with adolescents in a way that invites their active participation in the activities and rules that affect their lives as they journey into young adulthood It presents a concept of building alliances with teens instead of imposing regulations upon them that are unilaterally defined by adults in authority, so that they become an integral part of the results and consequences of their behavior. It emphasizes the deployment of the old concept of habituation, used by Aristotle, who believed that the forming of "habits" was an important part of adolescent development.

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The complex and often misunderstood part of the life cycle, known as adolescence, is the pivotal flashpoint that marks the end of the comparatively quiescent stages of childhood and latency and the beginnings of emerging adulthood. The term adolescent is derived from the Latin verb adolescere, which means "to grow to maturity." This implies both a process and a purpose; that is, adolescence is a transitional and dynamically changing process with the goal of creating an adult. First conceptualized by Aristotle in 350 BC, a young person between 12 and 21 years of age has been the object of neglect, disdain, fear, and perennial fascination. This Greek philosopher left the first detailed records describing adolescence as the stage of habituation in the development of moral character. It was his premise that human beings become what they repeatedly do. The habits deployed by people throughout adulthood--both positive and negative--have their roots in early life but achieve their major and permanent consolidation in adolescence.

The efficacy of habit formation lies in its power to enhance efficiency and conserve energy. The energy thus freed up as a habit is reinforced and will leave more energy for the higher-level, abstract, and future-oriented thinking that comprises the primary tasks of adolescence and is eventually the determinant of successful functioning in adulthood. For example, if one were required to apply the toddler's intense degree of concentration into brushing one's teeth in the morning, exhaustion would set in before noon and ensuing cognitive functioning would not be possible.

By the same token, as customary habits become embedded into the fabric of the human personality, a sense of unique personal identity and character gradually evolves. Just as the process of habituation coalesces in adolescence, the physical and reproductive mechanisms come to maturity, and the identity formation that will define the individual comes to fruition at this time. As observed by B.F. Skinner, "The older I become, the more I become who I am," an idea that was put more simply by Peanuts's Charlie Brown when he mused that "adolescence is all about trying to find out what's going on in the world and make sense of it" (Michaelis, 2007).

Emotional, cultural, and intellectual habits or customary behaviors, as well as self-identity, are established concepts and draw from the material of many definitions and theoretical models. As applied to the developmental stages of adolescence and young adulthood, some definitions and a brief summary of historical context is useful. This will provide some background to illustrate the basic premise of this article, which aims to renew encouragement for an approach of mutual alliance building. Since ancient times, in fact, little of note has been written about adolescence, perhaps because it was not defined as a precise developmental stage. In preindustrial America, the term "infancy" referred to all the years of being under maternal control and infant schools lasted from 18 months to 16 years. "Childhood" was loosely defined as any age until 21 years. Cotton Mather distinguished among three groups: children, young men, and old men, rather analogous to the answers to the riddle of the Sphinx. Adolescence was described by Kett (1977) as an artifact of the 20th century, a concept of behavior imposed upon youths rather than an empirical assessment of the way they actually behaved or the things to which they actually aspired.

In medieval times, childhood "ended" between the ages of 5 and 7 and, except for offspring of the wealthy few, children were summarily thrown into the streets because there was neither food nor space for them at home. The Industrial Revolution witnessed the replacement of apprentices--who had previously moved from rural areas to the cities--by these now homeless urban child laborers. Among them was Charles Dickens, who, forced to leave school at age 12, was apprenticed to an undertaker and a bootblack when his father was sent to debtor's prison in 1824 (Funk & Wagnalls, 1972). Many of the famous passages in his novels were barely disguised autobiograhical descriptions of the horrible conditions of 19th century London life.

In Victorian times, the period for girls between menarche and marriage was highly guarded and the appellation for their virginal hymens was referred to as the "meaningful membrane" (Brumberg, 1997). Privileged female adolescents were regarded as "emotionally precious and economically useless." Rousseau, in the 1830s, was skeptical about manifestations of teenage intellectual maturity because of a depletion of bodily energy. Harvard Medical School's D. Edward Clarke (1873) promulgated the notion of ovarian determinism, wherein adolescent girls seeking higher education risked damage by any challenge drawing energy from the ovaries to the brain (Brumberg, 1997).

It was G. Stanley Hall, founder of the first branch of educational psychology native to the United States, who gave extensive thought to the contradictions inherent in adolescence (Funk & Wagnalls, 1972). In Hall's tome, Adolescence (1904), influenced by William James's religious psychology as well as Goethe and Schiller's storm und drang theory, he pondered if young people should be parented in a liberal or repressive environment; that is, whether they should be allowed freedom or be subjected to regimentation, thus arguably introducing the nascent debate around a variation on this theme: adolescent alliance building or strictly controlled management techniques (Offer, 1982). These views may have been a reflection of his own troubled upbringing. Hall was an unusual man who grew up on a dreary farm in Ashfield, Massachusetts. He allegedly disliked his father for having paid a substitute to fight for him in the Civil War and, perhaps less consciously, for attempting to imbue him with the belief that his adolescent genitals were "the dirty place."

Although it was Hall who invited Sigmund Freud to lecture at Clark University in 1909, Freud himself wrote relatively little on the subject of adolescence. In 1894, he noted that he thought exposure to previously hidden sexual material resulted in "virginal anxiety" (anxiety neurosis) or adolescent hysteria. Anna Freud had a similarly pessimistic view of adolescence in which she posited that the increased strength of instinctual forces combined with a weakened ego resulted in unbridled chaos, akin to the beginning phases of an acute psychotic reaction. She lent ominous emphasis to this point by noting that "the naughtiness of the latency period turns into the criminal behavior of adolescence," suggesting a strong need for control (A. Freud, 1946, pp. 158-59). She also referred to Wayward Youth, in which Aichhorn wrote of the perils of failing to impose external checks that later could be transformed into the internal standards of the adolescent.

In the 1940s, Erikson described the severe state of Pubertat as a paradoxical mixture of cynical rebellion and submissive obedience, a resulting despondency that threatened to break an adolescent's spirit (Erikson, 1950). He expanded on this concept, applying it to Hitler's childhood and a German quality of harshness that was not finely integrated or tempered with dignity and tenderness; instead, ultimately leading to catastrophic hostility and the breakdown of social institutions. Hitler's obsession with control over youth dominated his goals and actions and represents an ultimate departure from any form of alliance building.

In short, numerous venerable mental health clinicians of the 20th century expounded upon the so-called normal period of abnormality inherent in adolescence and crucial to the task of separation from the family of origin: Hall, Kett, A. Freud, Erikson, Deutsch, Blos, Mahler, and Masterson, to name but a few. This firm belief in the universality of adolescent impulsivity and turmoil might suggest a presupposition for tolerance of the behavior it generated in the interests of normal development (Blos, 1962). Instead, professionals trained in the Western tradition focused on the need for strict adult control in order to counteract the perceived storm and turmoil theory that received almost unanimous support until the mid-1970s. Similar to Kett's belief that the developmental stage of adolescence was a 20th century imposed frame of reference, so too the conventional wisdom of parenting tended toward imposed constraint rather than dynamic collaboration.

This approach was not without precedent in other parts of the world, both in democracies and in dictatorships. Mussolini offered his solution to alienated youth control by sponsoring his commitment to militant groups as a substitute for the parental "mildew of the old ideas." By the 1930s, Hitler had already marshaled 3.5 million into the Hitler Youth, a movement that far overran any collaborative familial influence over teens (Savage, 2007). In Russia, Markowitz (1999) observed that young people perceived themselves to be acted upon, not active agents of change. Passive obedience was taken for granted and enforced by threatened exclusion from prestigious groups, a rigidly standardized curriculum and virtual lack of acknowledgement of adolescence as a distinct period of human development. The absence of being active on one's own behalf was personified by teenagers being referred to as "children" throughout high school. Their predominant aspiration was to "live well, to live at ease," free from upheaval and the daunting responsibility of autonomous decision-making or any discussion of it.

The parent-adolescent relationship in China was subsumed by the ubiquitous and tumultuous change that its contemporary society began to undergo after the end of the Cultural Revolution in the early 1970s. The earlier persecution of intellectuals resulted in a national hunger by older generations for personal and national advancement in all areas, and young people were automatically inculcated with obedience to the necessities of attaining the highest possible goals. Although infants were greatly indulged following the "one child" policy implemented in 1979, by the time they reached adolescence the expectation for academic excellence exceeded all other parental concerns. On a micro level, the unremitting scrutiny of relatives and neighbors in the hutongs ensured social conformity and went unquestioned.

In India, struggling to disengage itself from the inextricable rigidity of the caste system as it entered the economy of the 20th century, parental constraint was implicit, although perhaps more nuanced, in the intense interaction between adolescents and their parents and extended family as so poignantly portrayed by Lahiri (2003). Dissent was subsumed by a plethora of traditional customs, rituals, and the age-old imperative of adhering to generational patterns of respect and dependency that inevitably bowed to the wisdom of superstition and higher powers rather than to any original ideas offered by the young. When numbers of them, whose parents had immigrated to the United States in pursuit of higher education, encountered the greater freedom enjoyed by American youth, they were torn with ambivalence between familial attachment and growing resentment of the invincibly strict Indian rules that dominated domestic life.

Perhaps the most extreme example of compulsory compliance to a non-diversified value system affecting adolescents was recently depicted in a novel by Kirino (2008) in which her Japanese character "Worm" bludgeons his mother to death because she forced him to attend a high school for which he was intellectually ill-equipped. Her tale was based on the true story of a 14-year-old serial killer from Kobe with a history of having tortured both animals and children, who wrote a letter to the police protesting against Japan's system of compulsory education. Until the 1970s, obedience and self-discipline among Japanese students was legendary, at which time reports of violence toward teachers and family members began to surface (John, 2003). An alarming incidence of adolescent suicide and possible criminal insanity surfaced in a country whose paramount traditional ethic was respect for one's elders and their belief systems.

Finally, another example of comparative mores with regard to the empowerment of young people in the decisions and rules that affect their lives is seen among evangelical groups such as the Amish Mennonites, who took root primarily in Pennsylvania, and the Mormons of Idaho. In a detailed analysis of the teenage years of the former, Stevick (2007) notes that the entire community maintains the conformity of its members through constant positive reinforcement and modeling of acceptable behavior, resulting in close internal ties of loyalty and discomfort with the people and ways of the outside world. Strict rules that govern all aspects of daily life create relative alienation from nonbelievers and abnegate the spoken desire for noncompliance or even a difference of opinion. Alliance building resulting in compromise or alternative action is not seen as a rational or possible solution to a problem. Similarly, the Book of Mormon is seen as the word of God, and its literal interpretation governs every aspect of daily life, especially in the misogynous atmosphere regulating adolescent behavior.

Against this backdrop of relative youthful compliance in the mid-20th century, and despite considerable global concurrence, it was inevitable that there would be a reaction to this concept of imposed ideas about adolescent rearing, particularly in the United States. The concept of the inevitability of teenage rebellious and dysfunctional behavior was challenged by Daniel Offer and Melvin Sabshin, who initially published their findings in 1975. This appeared to offer some resolution to a contradiction in terms between observation and actual knowledge of this age group as well as a resurgence of enthusiasm for the "personhood" of the child with its implied individual powers and desire for power reciprocity (John, 2003). Developmental psychology looked with interest extending beyond infancy to the unique stage between puberty and adult maturity and renewed Winnicott's belief in the origin of "good enough" mothering, which focused on mutual interaction and maternal sensitivity that determines the manner in which a young person relates to the world around him and eventually perceives his place in it (Kestenbaum, 1998). By the same token, closer scrutiny was given to the consequences of harsh discipline that Kindlon and Thompson (1995) described as causing children and adolescents to develop powerful defenses, potentially harmful to themselves and others, against such treatment.

Offer and Sabshin rejected the ubiquity of the sturm und drang concept, based upon 20,000 questionnaires sent to high school students between 1962 and 1981. Of the initial population, four thousand students whose responses indicated that they had severe symptoms or who were hospitalized or receiving special services were excluded from the study. The sample, therefore, aimed to examine 16,000 "normal" teens, eighty of whom also were interviewed in depth over 10 years. They concluded from the 75 percent of students who showed little evidence of unpredictable behavior, extreme mood swings, or generally inadequate management of their everyday lives, that personality disorganization and tumult during adolescence was no more inevitable than was psychopathology an inevitable part of any other stage in the life cycle. These students did experience situational anxiety, mild depression, and some loneliness. When severe symptoms were present, Offer and Sabshin (1984) warned that these should be diagnosed as such; these symptoms should not regarded as "normal," but should be further evaluated and treated as needed.

Despite this and subsequent efforts to reaffirm and support the normative aspects of adolescence and to make attitudinal adjustments with the majority who fall into this category, recent decades have again witnessed a sustained effort to control the behavior of this age group by increasingly authoritative and punitive means. There are serious reasons for this that cannot be ignored. The three leading causes of death among youths are accidents, many involving violence, homicide (22% of all youths between 14 and 25 in 1991), and suicide (Pollack, 1998). Beginning in the mid-1980s, the rate of violence committed by young people under age 20 began to rise dramatically, peaking in the 90s before starting to decline by the end of that decade (Blumstein, 2002). A recent and tragic example of rampant violence occurred in Omaha, Nebraska, killing eight innocent shoppers. "Drugs and guns intersected in America's inner cities, leading to a rapid increase in violence among minority youth" (Blumstein, 2002, p. 41). Previously, youth violence had been confined to the "war zone" neighborhoods in the United States, such as the inner cities of New York, Detroit, and Chicago. The nation was therefore stunned when the incidence of lethal gun shootings began to occur in middle class, predominantly white suburbs and small towns (Garbarino, 1999).

Violence, apparently without reason, became a tragic fact of life fueled by a sense of bravado and invulnerability unique to this age group (Malekoff, 1997). But the stories from Columbine and Santee, California, and other affluent communities carried with them a common theme. These perpetrators (primarily, but not exclusively boys) reported that they felt socially isolated, victimized and rejected by their peers, with no one in the adolescent or adult world to turn to for emotional help (Kindlon & Thompson, 1995). Their desire for revenge in order to assuage their anger as well as a ready availability of weapons, in common with the developmental vulnerabilities of impulsiveness and poor judgment, resulted in tragic consequences. This writer, among a large group of mental health workers in Chicago, listened as serial killer Jeffrey Dahmer's attorney said that this young man told him that his biggest problem was that he never had anyone to talk to or to listen to him (International Society for Adolescent Psychiatry, 1992).

Societal issues and severe problems of economic disparity, racism, family breakdown, substance abuse, delinquency, and misguided acceptance of violence as a solution to conflict instead of as a problem, have inspired fear and even a desire for retaliation and vengeance among authority figures. Juvenile incarceration is at an all-time high, while funding for rehabilitation has plummeted. Computer technology, the Internet, and mass media have subjected and enticed teens with a constant stream of real and fantasized violent images (Malekoff, 1997). Malekoff suggests that a public health approach needs to be adopted that highlights primary, secondary, and tertiary prevention of violence and involves the inclusion of parents, teens, community, and media in group settings. Unfortunately, the current climate of negativity forecloses the possibilities for understanding the needs and motivations of teenagers, and thus to facilitate and negotiate the alliance formation with them, which can achieve mutually beneficial goals for protection, mastery, and optimal development. In a recent New Fork Times interview, the author Ian McEwan ruefully mused, "I was managed as a child. I don't think anyone ever said to me, 'Are you happy?'" (Solomon, 2007).

A caveat is in order here to stress the point that just as Offer and Shabshin (1984) eliminated those teens with serious mental instability from their study of average adolescent characteristics and behavior, the approach discussed here is not meant to include adolescents with specialized needs or severe sociopathic or psychological problems but rather, those typical youths who would flourish in an atmosphere of greater bilateral participation in the rules designed to guide them, deploying the concept of alliance building.

Alliance is defined in several related ways:

* A close association of groups formed to advance common interests or causes

* A formal agreement establishing such an association

* A connection based on kinship, marriage, or common interest

* A bond or tie

* An affinity based upon the act of being allied

(American Heritage Dictionary, 1992)

Just as the aforementioned definition of adolescence suggests process and purpose, so do these definitions of the term alliance. In the case of the adolescent stage, the process represents the journey toward maturity; the purpose is to achieve successful adulthood. Successful alliances formed to advance common interests (purpose) go through the processes of agreement, connection, and affinity.

There are developmental tasks involved in this journey toward maturity that are necessary toward its successful achievement. The adolescent needs to do the following:

* Achieve a balance and framework within one's capacities between inner needs and desires and the demands of reality (Miller, 1982)

* Find ways to become active on one's own behalf

* Make and sustain meaningful and positive peer and adult relationships

* Contemplate one's emotional, intellectual, and vocational future

* Consolidate self and gender identity

* Establish a personal value system, a sense of what is to be valued and defended

* Transition from the microworld of the family toward entry into the larger world (Havens, 1989)

This is a tall order for every adolescent, and these tasks, while universal, vary according to individual familial and environmental influences. They are also determined by dramatic changes in the brain that occur with the onset of puberty and are rivaled only by those that occur in utero and in the first 18 months of life. Recent advances in high resolution images of living brain tissue have shown that there is an actual thickening in the white matter of the prefrontal cortex that involves a kind of "remodeling" of this part of the brain, although not a change in volume. The neurotransmitters (white matter) become insulated, and this is accompanied by a pruning of unnecessary neurons, resulting in frontal lobe changes in structure and function (Silveri, 2007).

There are also changes in another area of the brain, the amygdala, the part of the limbic system that seems to affect impulsive behavior and "gut" reactions (Silveri, 2007). These alterations combine to interact and slowly mature during adolescence until the executive functions of the frontal lobe can control impulsivity stimulated by the amygdala. These high-level functions include future planning, problem-solving, impulse control, mood stability, appropriate judgment, and delayed gratification, and they play a crucial part in the accomplishment of the developmental tasks necessary for adult maturation (Frontline, 2002). But until the cerebral apparatus of the brain is fully operational, these cognitive functions governed by the frontal cortex need additional support from more experienced sources. Adults are essential in this capacity and function as CEOs of the teenage brain. The aim is to develop executive decision-making, which will fully engage the interest and participation of the adolescent. In this way, the habit of alliance building can foster mastery of adolescent developmental tasks. But this process takes time and repetition, and adult expectations are misguided and doomed to failure if they exceed the physical capability of the immature brain.

Thus, it seems logical to call on Aristotle's notion of habituation as a logical process by which to accomplish the tasks of adolescence and to use the vehicle of alliance building as an efficient and effective means toward this end. If alliance or coalition building is a sensible way to negotiate with adolescents, the process needs to be repeated in order to establish its beneficial aspects. For example, adolescents are always eager to expand upon what interests them and what their immediate goals are (common interests and causes). This provides a foundation for creating a "family contract" (Jorgensen, 2005), a formal agreement that enumerates important rules and behaviors for the teenager and the parents; this is a bilateral rather than a unilaterally inspired covenant that proposes instead of imposes. Similarly, the affinity created in such alliances can advance mutual interests. A distinct advantage here is that mutual involvement in the creation of an agreement results in both adult and adolescent having a stake in its results and consequences. Although conventional wisdom usually places the burden of blame on the young person for exasperating his elders, adults are often responsible for adolescent button pushing. Sells (1998) gives some pertinent examples of this tango, including preaching, collecting criticisms, labeling, and just too much talking.

Fortuitously, there is once again interest in the earlier seminal work of the aforementioned clinicians and studies by others that arguably give new life to the importance of adolescent alliance building. Classic works by Blos (1962) and Masterson (1968) postulate that the formative stage of adolescence may allow them a second chance to resolve earlier conflicts prior to consolidating an adult identity, and that problems surfacing in adolescence are unlikely to be spontaneously outgrown and deserve close and sensitive attention at this time.

Diamond et al. (2005) studied 65 substance abusers and found that cannabis use was moderated by the strength of alliance with parents, and that a paucity of such positive relationships actually predicted premature termination of treatment. Three themes have been deemed crucial by adolescents themselves to the formation of successful alliance creation as examined by Everall and Paulson (2002). These involve a safe environment, the uniqueness of the therapeutic relationship itself, and the characteristics of the therapist. These qualities bear a distinct similarity to the criteria by which teens judge the appeal and choices of their peer relationships.

In his discussion of resilience, an unfamiliar concept before the 1970s, Brooks (1994) notes that young people cannot be bystanders to their own lives and must be active participants in decisions that affect them. Asking a recalcitrant adolescent how he wants to be reminded instead of summarily nagging him is a good example of alliance building. A recent and popular approach is that of Freire's "Therapy for Liberation," which seeks to empower people of all ages by seeing the problem from the client's point of view, analyzing it, and formulating an action plan (Castano et al., 1993).

Malekoff (1997) emphasizes alliance formation in order to contribute to a sense of grounding, especially needed in times of crisis. Inclusive networking can enhance resolution and prevent the isolation that often besets parents who are expected to do it all. He is also a strong proponent of adolescent groups where "social energy" is mutually supportive and growth promoting. Unilateral power assertion and dominance is fraught with the potential for exacerbation of violent and antisocial behavior, according to Garbarino (1999), despite the temptation for a "boot camp" model to separate and contain troublesome young people who need to become socially engaged.

And finally, Pollack (1998) strives to revise the "boy code" and temper the backlash of the "Columbine Syndrome" in favor of empathic connection and encouragement for boys to exhibit a full range of emotions with pride, not fear or shame. It is evident from the research and practice of these scholars that the active mutuality inherent in alliance building with adolescents is not a new idea. However, it needs the stimulus of public, private, judicial, and fiscal policy that reaches beyond the superficial commitment to political correctness, including a resurrection of penal rehabilitation instead of incarceration without goals. To neglect this is to risk allowing the next generation to slip into a cloak of alienation and pseudo-maturity instead of genuine growth.

This article does not aim to reinvent the biopsychosocial wheel of adolescent development. It attempts to invigorate a concept that promotes the efficacy of consistent building of behavior that accomplishes the tasks necessary for successful entry into adulthood. It aims to alter attitudes in order to motivate a different and more fruitful kind of interaction with teens that stresses engagement ("let's sit down and discuss this problem"), involvement ("what is it about this rule that you don't agree with?"), and mutual consultation ("what needs to change here?") (Kindlon & Thompson, 1999). These young people need to be full participants in the timeline of their journey through the critical and formative years from puberty to full maturity and to be consulted about the purposes and plans for their lives and the beliefs that make sense for them and to them (Hicks, 1997). Adolescents should be viewed as capable of participating in self-reflection, agency, and dialogue that truly determines the outcome of actions that affect them. In an atmosphere of genuine alliance building and its application, these young people possess the opportunity to emerge as the assets of the next generation instead of as its problems.

This article is approved by the following for continuing education credit:

The American Psychotherapy Association provides this continuing education credit for Diplomates and certified members, whom we recommend obtain 15 CEs per year to maintain their status.

After studying this article, participants should be better able to do the following:

1. Increase understanding of the historical dimensions influencing adolescent development.

2. Review examples of differing attitudes among cultures toward adolescent alliance building by authoritative or collaborative means.

3. Advance understanding of the efficacies of interactive and participative alliance building between adolescents and their significant adults.

KEY WORDS: adolescence, alliance building, developmental tasks, historical context

AUDIENCE: Mental health professionals

PROGRAM LEVEL: Basic

DISCLOSURE: The author has nothing to disclose.

PREREQUISITES: None

POST CE TEST QUESTIONS (Answer the following questions after reading the article, pages 10-15)

1. What percentage of teenagers in Offer and Sabshin's research were found to experience a relatively smooth adolescence rather than one with a great deal of turmoil?

a) Less than 25%

b) 75%

c) About half of teenagers

2. In medieval times, behavior and attitudes toward adolescents were about the same as they are today.

a) True

b) False

3. What are the three leading causes of death among contemporary youths?

a) Drug overdoses, suicide, and drowning

b) Homicide, binge drinking, and motorcyle accidents

c) Accidents, homicide, and suicide

4. When do the most dramatic changes occur in the brain?

a) In utero, during the first 18 months of life, and at the onset of puberty

b) At the beginning of adulthood (about 21 years)

c) At the onset of elementary school attendance

5. The primary purpose of the adolescent stage of development is to preserve the excitement of childhood experiences.

a) True

b) False

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Earn CE Credit

To earn CE credit, complete the exam for this article on page 16 or complete the exam online at www.americanpsychotherapy.com (select "Online CE").

By Alexandra O. Eliot, PhD, LICSW

Alexandra Eliot was Chief Social Worker of Adolescent/Young Adult Medicine at Boston Children's Hospital from 1972 to 1996 and Instructor in Psychiatry at the Harvard Medical School from 1988 to 1997. In 1979, Dr. Eliot co-founded and co-directed the outpatient clinic for eating-disordered adolescents at Children's Hospital. This was a collaborative effort between the Division of Adolescent/Young Adult Medicine and the Department of Psychiatry. In 2003-04 she served as the first Consultation Officer to the Children's Placement Services in the westernmost borough of London, England.

She received her bachelor's degree from McGill University in Montreal, Canada, and her master's and doctoral degrees from the Simmons School of Social Work in Boston, where she is currently an Academic Advisor and Instructor. She teaches a course in Advanced Clinical Practice on Adolescence, "Lives in Progress," and has a private practice in Belmont, Massachusetts.
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