1. Independence

The move for independence creates the largest amount of distress for parents. Early adolescents begin to pull away from their parents and show less interest in family activities. For example, the teen may refuse to go with the family to the movies or may demonstrate his or her own will by refusing to do chores on the parent's schedule. Early adolescents are often moody, alternating between being pleasant and nasty toward their families. Usually, the teen is mainly antagonistic towards the most "controlling" parent. Early adolescents crave privacy and desire to control their personal information as they carve out a life separate from that of their parents.

Middle adolescents are often hostile towards parents and authority figures. Some openly rebel while others assert their independence secretively when not under adult supervision. Adults, including physicians, find that many decisions teens make are disturbing and the adults feel frustrated at their lack of control over the teen. Because of their rebellious nature and risk behaviors, middle adolescents are the group that society "loves to hate."

By late adolescence, most families are comfortable with the youth's individuality and decision making skills. The teen, gaining confidence with the change in stature, increasingly turns to the parents for advice and guidance in decision-making, though this doesn't mean they always do what the parent wants. The parent-adolescent interaction is more on an adult-adult level.

The physician should take into account this move toward independence and help parents appropriately give the teen responsibility for medical care. For instance, an early adolescent may need to be reminded to take his daily medication while a middle adolescent should not. By late adolescence, the patient should be encouraged to make his own appointments, monitor medication needs and get prescriptions filled. Failing to recognize this move towards independence makes the physician prone to appearing as an "agent of the parent" and may make it more difficult to gain the confidence of the teen.

2. Body Image

Adolescents become aware of their physical development and the fact that it portends adulthood. Most early adolescents are not sure what to think of the changes in their body and accompanying hygienic responsibilities. Body odor, axillary hair, acne and menstrual cramps are not exactly thrilling. Being "normal" is a huge concern to early adolescents and leads to constant comparisons to others. Common questions include "is my penis long enough?", "are my breasts large enough?", and "is it normal for one testicle to hang lower than the other?" Pubertal gynecomastia or physiologic vaginal discharge can be terrifying to a teen.

Middle adolescents are more at ease with the changes and want to make the most of their "new" body. Clothing, jewelry and makeup become big with this group. Taking care of issues such as acne or unwanted hair (e.g., eyebrows) becomes paramount. Weightlifting and dieting become important as well. With the gain in confidence comes increased interest in the opposite sex. This is often the onset of dating and the development of skills and behaviors related to sexual relationships.

By late adolescence, teens are comfortable with the changes in their body. Pelvic exams or hernia checks are not as stressful. Many adolescents are now ready to deal with issues such as birth control. Sexual relationships become less exploring and exploitative and more loving and sharing.

3. Peer Relations

Peers become extremely important during adolescence. As they pull away from their family, early adolescents are not strong enough to stand on their own and they turn to their peers for guidance and support. By mid-adolescence, the peer group exerts a huge influence over the teen. At this time, peer groups demand that members conform as this reduces stress related to decision-making. If the group wears black clothing and lipstick, then the all the members must do the same. To do otherwise would risk exclusion from the group. Unfortunately, this also includes risk behaviors such as sexual activity or substance use, and participation in gangs.

Middle adolescents may share intense personal relationships with the group. As teens become more comfortable with their own decision making and independence, peer groups hold less sway. By late adolescence, peer groups do not demand the same level of conformity. It is all right to attend a party and not drink when others are drinking. Individuality is more acceptable. Often times, late adolescents will grieve over the fact that their relationships with friends are not as close and have become less intense.

A useful strategy for providers is to ask about the risk behaviors of the teen's friends, since teens are often more comfortable sharing information about friends than about themselves. This enables the physician to explore the adolescent's feelings and knowledge of risk behaviors.

4. Identity

Identity development includes the emergence of abstract reasoning along with personal values and morals. Early adolescents tend to be concrete and see things in black and white. A girl, taught that she will get pregnant if she has sex, assumes she does not have to worry about birth control because she had unprotected sex once and did not get pregnant. The limited ability to think abstractly makes it hard for a teen to see another's point of view and also makes compromise difficult. Lack of abstract thinking also encourages feelings of invulnerability. Teens believe that nothing bad will happen to them no matter what. They trust that they can have sex, use drugs, smoke, or drive recklessly without consequence.

The values and morals of the early adolescent are those of the parents. As they attempt to pull away from the family and move closer to peers, teens' values mirror those of their friends. Usually by the end of adolescence, the teens' morals and values come back in line with those of their family.

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