Mary E. Muscari, PhD, CPNP, APRN-BC,CFNS


December 21, 2004


A mother in my practice is concerned because her 14-year-old daughter screamed, "I wish I was dead" after her mother refused to let her get her tongue pierced. How can I help parents know when they really need to be concerned about these types of comments?

Response from Mary E. Muscari, PhD, CPNP, APRN-BC,CFNS

Adolescent angst, an acute feeling of anxiety or apprehension that is often accompanied by depression,[1] is a frustrating, painful, and occasionally frightening dilemma for teens and parents alike. However, nurse practitioners (NPs) can help by assisting parents in differentiating normal mood swings from potentially dangerous disorders.

Response from Mary E. Muscari, PhD, CPNP, APRN-BC,CFNS

Normal behavior at age 12 years differs from normal behavior at age 15 years or age 21 years. Adolescence covers 3 stages, each with its own variations in moodiness and parental interaction.[2,3]

Early Adolescents. (females: 11-13 years; males: 12-14 years) experience wide mood swings that can hurl them from euphoria to sadness in minutes, without obvious predisposing factors. These changes last for hours or days and are characteristic to this stage of development. The transient nature of these mood swings and their relationship to normal developmental processes distinguish them from the unremitting, long-standing mood and behavior changes of serious depression.

Friends are in; parents are out, and many young teens dread even the thought of being seen with their parents. Young teens may argue and disregard rules to challenge parental authority in an attempt to assert their independence and to try the different value systems that they are exposed to at school and in the community. Same-sex best friends are crucial, and some early teens may engage in transient homosexual experimentation. Sexual feelings develop in general, creating desires to watch sexually explicit movies or televisions shows, read sexually explicit magazines, tell sex-related jokes, and use foul language.

This is the stage when teens are intensely preoccupied with "being normal" and with privacy. Young teens spend hours in front of mirrors scrutinizing their appearance and grooming. The changes of puberty cause them to become extremely body conscious, creating worries about acne, menstruation, nocturnal emissions, and body size. They become hypercritical of themselves as they compare themselves to friends and the unrealistic images portrayed in the media. Emotional reactions may overwhelm the early adolescent's ability to understand and cope. Young teens can easily become confused and frightened by the changes they are experiencing.

Great daydreamers, early adolescents live in a fantasy world similar to that of preschoolers. They daydream about unrealistic goals, wanting to be a supermodel one day, a lawyer the next. They look to celebrities as heroes and fantasy mates -- grounds for poster-covered bedroom walls and their sometimes lost-in-space appearance. This interest, as well as their preoccupation with peers, may result in a temporary drop in academic performance during junior high or middle school.

Middle Adolescents. (females: 13-16 years; males: 14-20 years) sever their umbilical cords as parental conflict peaks, consistently challenging authority and attempting to renegotiate rules. Peer group conformity becomes the norm, launching urges for designer gear, outlandish hairstyles, and body art. The peer group dictates communication style and conduct, and peer pressure climaxes. Sexual drives lead many into dating and sexual experimentation, with intercourse starting at earlier ages. Risk-taking behaviors like experimentation with sex, drugs, and dangerous activities occur more often at this stage of adolescence than the other 2 stages. These behaviors result from feelings of omnipotence and infallibility. Middle adolescents are egotistic and have their own personal fable. That is, besides feeling invincible, they believe that their thoughts and actions are special or unique; thus, "no one understands them." This adds to their persistent mirror time, the need for privacy, frequent embarrassment, and arrogant behavior.

Middle adolescents demonstrate increased thinking ability and creativity; however, they can also demonstrate "pseudostupidity" by overthinking. Overthinking can lead to lack of decisiveness and the assigning of complicated explanations to simple situations. They may even distort a parental suggestion into an intention to undermine their independence or competence.

Late Adolescents. (both sexes: 17-25 years) are on the verge of adulthood. Their level of peer relationships changes, and they rekindle their relationships with parents in a more adult-like manner. Many establish their sexual identity and commit to an intimate relationship.

Reasoning skills are at an adult level, allowing them to understand the consequences of their actions, make sophisticated judgments, and comprehend inner motivations. Late adolescents are future oriented. Some enter careers and/or marriages; some enter the military; others enter college to complete their developmental tasks in a supportive, structured environment.

Response from Mary E. Muscari, PhD, CPNP, APRN-BC,CFNS

Adolescence has periodic roadblocks, but the route is generally smooth and successful. Since there is a fine line between angst and problems like violence, depression, and substance abuse, NPs and parents should suspect problems when any of the following occur:[4,5]

  • Lack of peer group or best friend (confidant);

  • Moodiness that persists more than a couple of days;

  • Extreme mood swings;

  • Constant complaints of boredom or being treated unfairly;

  • Spending prolonged periods of time in their rooms or withdrawing from social contacts;

  • Lack of concern over appearance;

  • Decreased energy levels or fatigue;

  • Persistent defiance; lying; stealing, and other delinquent behaviors;

  • Gang membership;

  • Diminished ability to think clearly and make decisions;

  • Feeling worthlessness or hopelessness;

  • Self-destructive behaviors;

  • Unreciprocated romantic obsession;

  • Signs of substance abuse (paraphernalia, secretive peers, school failure or absence, aggression, apathy);

  • Preoccupation with violence or death themes (thoughts, music, art, movies, television shows, video/computer games);

  • Animal cruelty;

  • Reliance on violence to solve problems; or

  • Fascination with weaponry or explosives.

Response from Mary E. Muscari, PhD, CPNP, APRN-BC,CFNS

NPs can help parents cope with adolescent angst by teaching them to:

  • Stay calm.

  • Praise more than criticize.

  • Overlook little mistakes.

  • Use "I" statements -- "I feel angry when you..."

  • Listen carefully to opinions and foster decision-making skills by providing opportunities and choices, but set limits. Oppositional behaviors may relate to egocentrism and independence seeking, but they are not socially acceptable. Despite protest, most adolescents recognize discipline as a sign of caring.

  • Respect privacy needs.

  • Take their teens' concerns seriously, no matter how trivial they sound.

  • Encourage interaction with friends and get to know their teens' friends and parents.

  • Tolerate peer-imitating behaviors within reason. Behaviors should be safe and permissible under family/house rules.

  • Nurture independence and self-esteem by encouraging responsibilities, such as chores and volunteering.

  • Spend time with their teens. Engage in mutually enjoyable activities. Have frequent heart-to-heart talks, letting their teens know that they're always there when needed.

When parents suspect that their teens are exhibiting behaviors beyond normal angst, they need to seek help and support. Unless NPs are educated to manage long-term psychiatric issues, they should refer these teens for psychiatric evaluation and treatment. NPs should also suggest that the parents also get counseling since dealing with a psychiatrically ill teen can be challenging at best. Parents can also be referred to appropriate self-help and parent groups.


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