Title page

Title -                          “Adolescent
Behaviour and Health”

Author -                      Diana
M.L. Birch

Position -                     Director
Youth Support

Address for correspondence
-           Youth
Support House

13,
Crescent Road

London
BR3 2NF

Tel no - 0181 650 6296   / 0181 659 9926

Fax no - 0181 659 3309

Adolescent Behaviour and
Health

Adolescent health and well-being is inextricably linked with adolescent
behaviour and these behaviour patterns are determined by the stage of emotional
and physical development of the individual influenced by the pressures which
society may exert at a vulnerable stage.

Adolescence is regarded traditionally as a time of
‘delinquency’ and rebellion. It is also a time of energy and
change. Both can be channelled in the healing process and that is what makes
working with young people so exciting.

Rebellion and Identity  -

Adolescence is a time of radical psychological change and readjustment.
The first question to be answered is ‘ Who am I?’ A young person
must find his or her place in the world and establish a personal identity.

Throughout early childhood the tendency is for a ‘false
self’ to be built up - a persona who stands between the individual and
the world - showing adults the child they would like to see. The child may
decide that there are parts of himself which others do not want and do not like
and so learns to hide them from others and from himself.  He lives in a world of denial where he
can try to be all things to other people while real feelings and needs fade
‘out of pain’. This building up of a false self occurs to an extent
in all of us, since we do not have perfect childhoods or perfect mothers. It is
a healthy search for the ‘true self’ which prompts the rebellious
adolescent to alter his appearance, break the family dress code with dirty torn
jeans, studded leather jacket, tattoos, rings in the nose, long hair or shaved
head - whatever goes against the norm - making an outward statement of inner
change “Look, I’m not what you wanted me to be any more!”.

Winnicott once wrote a paper titled ‘Delinquency as a sign of
hope’. Rebelling, pushing out against the injustices that you have
suffered in childhood - that is indeed a sign of hope - a sign that the spirit
is not broken, that there is an individual in there shouting out “Hey!
What about ME!” The beginnings of change, of a sense of one’s own
needs, of self worth. 1

Independence - Moving out of
the nest -

Human development is a series of progressions from total dependence on
the parent or family through a stage of total independence or breaking free and
culminating, hopefully in the mutual interdependence of satisfying
relationships.   The quality of
and nature of the patterns of attachment established in early childhood
fundamentally affect the way that a teenager is able to ‘break
free’ and whether he or she is likely to be harmed by that process.

A teenager with a ‘secure attachment’ fostered by a stable
loving home, will feel able to explore his expanding world  from a ‘secure base’ 2
; he will thus be able to safely ‘test the water’ , gain new
experiences and ‘grow up’ - secure in the knowledge that by
distancing himself a little from parents and indulging in mildly risky
behaviour he will not be rejected and can always - like the prodigal - return
to loving arms.

In contrast an unloved, rejected adolescent with insecure attachment to
his family will have no secure base from which to explore his world, will have
no boundaries or limits to his risk taking, and will be likely to become
involved in harmful experiences which serve to confirm his belief that the
world is a cruel and dangerous place. Such rejected and rejecting  youngsters will often become involved in
crime, violence and drug abuse. Their health will suffer as a direct result of
drug, alcohol or solvent abuse and indirectly by virtue of their lifestyles
which may involve poor diet, sleeping rough and general deprivation.

The tragic reality is that young people who have been abused and spent
their early childhood in care  are
often those who leave the care system for a life of deprivation on the streets.
They constitute a high percentage of homeless youth who may be further exposed
to the abuse of ‘survival sex’ and sexually transmitted
disease  3 . Leaving
‘home’ with the prospect of
family ties and support bears no comparison to leaving
‘care’  when you
are  ‘out on your own’.

Peer group influences -
Replacement families? -

Personal identity involves separation from others, working out what you
believe in as opposed to what your family believes in, deciding on an
‘image’ - which often means choosing which peer group or
‘cult’ figure you will follow.
Teenagers reject their family norms in  search of their own while needing the
approval of the peer group. The chosen group and hence it’s influence can
vary from week to week - resulting in dietary fads and varying dress codes
mainly harmless in the long term although there are casualties - malnourished
‘vegans’; infected ‘piercing’ sites; scarring tattoos;
hepatitis; sexually transmitted disease; unwanted pregnancy ....

Problems arise when group influence is pernicious in gang culture;  in dance schools where desired slimness
may encourage anorexia; in American female college ‘barf parties’
(eat and vomit) sanctioning bulimia or extreme as in cult membership exploiting
the mentally vulnerable; or historically when the followers of Thomas
Chatterton made ‘copycat’ suicide bids.

Self Worth

Self esteem relates to an individuals personal values and not
necessarily to those of his peers, his doctors or his teachers. Skills and
attributes such as being good at maths should not be presumed to be something
valued by the teenager ..... “positive correlations between self esteem
and educational performance are likely to be found only in populations in which
self esteem is bound up with aspirations for achievement. There are no a priori
reasons why academic achievements or anything else, should be of value to all
pupils" 4 .

If indeed self esteem is dependant on a personal value system, change
may be achieved by altering these values, rather than by changing one's
position within the existing hierarchy. If you lower your expectations, you can
fulfil them more easily without having to improve your achievements. This
mechanism appears to be operational in schools where teenagers who have been
conditioned to 'failing' academically form a 'counter culture' of academic
incompetence within whose inverted value system they can succeed and constitute
a model for younger pupils.

Self esteem can be boosted by changing how you view yourself within a
given value system - or by changing the value system altogether. If you are not
measuring up in one club - then join another or form your own. Teenage 'gang'
culture, delinquency and 'drop outs' can all be manifestations of this process.

*          *          *          *          *

Danny never knew his father.
His mother placed him in a children's home at the age of eleven. He had never
been particularly clever at school but was not doing too badly. His behaviour
had not attracted much comment - that was the problem - not attracting much
comment. Danny was nothing special, he did not excel or stand out in any way.

Children's homes are not
easy places to live in, there is always a 'pecking order', bullies, bullied and
care workers 'pets'. Danny did not have a 'niche'. Not until he found something
to excel in, some way to be noticed. He began to be involved in petty crime at
the age of fourteen, at first just a little shoplifting, which he exaggerated
and bragged about. Then as his exploits were not always believed, he made sure
he got caught a few times - not enough to get into serious trouble with the
law, but it improved his image.

As his image became tougher,
he had to keep up with it, so he found himself getting into heavier crime.
Younger boys and then a girlfriend went with him on exploits - so he had to
prove that he really could burgle homes and 'mug' people in the street. Danny
had to be the 'badest of the bad' and for a while his girlfriend acted like his
'moll'. She joined his 'counter culture' - a girl who was bright and doing well
at school pretended not to be so clever around him, 'so as not to show him up'
and convinced herself that her worth too lay in being tough, intimidating
others and getting her name on police files.

The next step was pretending
to get high on drugs - first using solvents and beer and 'acting' stoned. Danny
was afraid to use hard drugs to begin with although he would never admit it.
Finally his bluff was called, doubly - he started using hard drugs, and as his
'alternative value system' of juvenile crime and hard guy image began to slip,
became incapable of maintaining his self image, he turned increasingly to drug
use to boost his flagging ego.

Danny, the violent drug
addict, lost all his followers and his girlfriend. He was now compelled to
continue in crime to fuel his habit, he had lost control and the means by which
he had sought a boost to his self worth had become the means to drag him down.

*          *          *          *          *

The answer to  “who am
I?” can very easily become negative for a deprived teenager with little
chance of achieving adult goals such as doing well at school, getting a job and
setting up their own home. It is easy for the answer to the question to become
“I’m a failure”. Hence the loopholes  “I can be a success if I can be
.... a gang leader  .. a father   ... a mother”.  Schoolgirls who become pregnant
frequently experience academic failure and in becoming young mothers they could
be seen to be 'finding and accepting alternative dimensions of value'  establishing or joining a 'counter
culture' of schoolgirl mothers. Many appear to use their pregnancies as a
source of self worth, seem fulfilled and happy during and soon after the
pregnancy and  do better in their
individual tuition than they had done at school. 5

A self esteem  measure of
pregnant schoolgirls and a comparable group of schoolgirl mothers indicated
that while painful life experiences and deprivation  resulted in an expected fall in self
esteem scores, the girls who were pregnant at the time of the testing felt much
more positive about themselves than the schoolgirl mothers. Pregnancy seemed to
have protective value in conserving self-worth. Girls were finding an alternative
value system by which to judge their lives.  6

“Seen from a young girl’s viewpoint, pregnancy may not be
so undesirable; motherhood is a fulfilment; she takes on a valued role and out
of her loveless world creates a baby who will love her. Pregnancy is thus used
as a source of self-worth and a false solution to problems.  That being so, an alternative solution
must be offered. These young people need an alternative source of self-worth in
order to ensure that when they become parents this is because they desire
parenthood, with all its responsibilities, hardships and joys, not merely as
the only perceived escape from a catalogue of problems.”  7

Risk Taking Behaviour

Risk taking behaviour is an integral part of adolescence. All teenagers
take risks - the variability lies in the degree of risk taking and the length
of this phase. As with other aspects of teenage emotional development - some
‘grow up faster then others’ and come through with fewer
scars.

Risk taking is associated with several factors - Firstly the inability
to accurately perceive risk. For instance it has been suggested that
adolescents may fail to protect themselves from some risks because they cannot
appreciate them as such. This is a time for exploring the world , not for
hiding behind closed doors, hence teens do not expect to be harmed while
pushing out the boundaries. Some girls may expose themselves to risk of sexual
assault because they are unable to estimate the risk posed by ‘predatory
men’.

Denial of risk. Many girls deny that they can become pregnant. They
believe they are too young. Belief in the impossibility of pregnancy tends to
become almost a magical protection like a lucky charm  “It won’t happen to
me”.  These teenagers are
still at the stage of  concrete
reasoning and cannot identify  with
the experiences of others. 8 This explains why health education
methods based on shock tactics do not work with this age group.

Adolescents believe in their own invincibility  and hence are unable to appreciate the
consequences of behaviours which pose a health risk. Development of a future
time perspective is another aspect of adolescent development.  9   Couple a belief of invincibility
with a delay in the cause and effect sequence and the possibility of harm
becomes even more remote. Hence teenagers cannot link smoking with cancer
(which may not strike for 20 years); sex with the birth of a child (9 months
later) or unprotected sex with HIV infection and with death from AIDS.

The adolescent psyche is geared not to hear traditional health
education messages and the approach to HIV prevention is a good example of how
the ‘message’ can be misinterpreted. In this respect professionals
must take care to distinguish good education from good advertising. A campaign
based on cult rock ‘heroes’ who have died of AIDS - and are thus
‘martyrs’ to ‘the cause’ - can engender a heightened
feeling of ‘separateness’; an alternative culture; living life in
the fast lane and “who wants to be thirty anyway?” rather than an
educated group of young people wishing to practice safe sex. This is similar to
the drug culture promoted by rock musicians in the sixties and seventies. Young
people were more likely to smoke cannabis like John Lennon or try drugs to be
like Eric Clapton than to be put off by the deaths of Janis Joplin and Jimi
Hendrix.

Sexual behaviour -

Each year in England and Wales approximately 10,000 schoolgirls become
pregnant. Conception rates for
girls aged 14 and under rose by 27% in the decade 1978-88 indicating
that  the very young, most
vulnerable, girls and boys needing most support are being failed by preventive
and educational programmes.

By understanding  the belief
systems of the adolescent and his or her peer group we can more effectively
interact with that young person in a way which has relevance and meaning.   Parental, cultural and religious
beliefs or myths form a basis upon which more contemporary, up-market, peer
group beliefs are built.
These basic belief systems, can to some extent be modified  with sex education. For instance, peer
group beliefs such as “You can’t get pregnant standing up”
can be confronted with factual knowledge such as sperm can swim uphill!

At a deeper level the adolescent has ‘magical beliefs’.
Intrinsic ideals with a high emotional content, a feeling of instinct and
intuition which may have no perceivable basis in current reality. Magical
beliefs centre on fundamental concepts such as feelings about self, body and
control and on the nature of life itself.
Beliefs which conjure the ‘autonomous womb’ and give rise to
statements such as “Well I knew
someone was pregnant, but I didn’t know it was me”.  10

We have discussed how the adolescent during psychological development
is much preoccupied with the question “Who am I?”  Confusion inevitably arises when
“Who am I?” becomes “Who are we?” Establishing a
personal identity may thus  be an
impossible task for a pregnant adolescent who suddenly finds that her
identity  is changing beyond her control.
She is no longer a little girl, she is a fertile woman.  The role of a mother is thrust upon her
before she establishes her own identity, hence the belief that she cannot get
pregnant and  her  frequent denial of pregnancy. “I knew about sex and how girls could
get pregnant, but I never thought it could happen to me”.

Many factors interact in limiting contraceptive use. For young
teenagers under the age of 16, it is
not so much a matter of availability of contraceptive services which
affects sexual practices and conception rates. Much more important is the
social situation and life experiences which affect their emotional maturity, motivation
and their value systems.

Locus of Control

Teenage behaviour, particularly with regard to sexuality is profoundly
affected by beliefs about control. Lack of control is at the basis of young
teenager’s notoriously poor use of contraception. Only 7% of London
pregnant schoolgirls ever used contraception.  5   Young girls deny to themselves
that they are having sex, and convince themselves that if they do end up in bed
with a boy it is a one-off event. This denial is a protective mechanism. Unplanned sex is an accident. Nobody
can be blamed for the occasional slip however,  premeditated planned sex is inexcusable.

Emotional development involves internalising  the
“locus of control”, assuming responsibility for one’s
actions and one’s body.  Those
maintaining an external locus of control are not in control of when they have
sex or whether they get pregnant, are not responsible for their actions or
their bodies - pregnancy is something that happens
to them. It is a matter of fate.

The same applies to many other aspects of adolescent behaviour.
Assuming responsibility for one’s own actions and thus being able to
decide whether to ‘say no’ to drugs implies awareness of the
consequences of those actions,
ability to appreciate ‘cause and effect’ and  ability to accept feasibility of
control. The adolescent who cannot relate to these concepts remains buffeted by
fate and places responsibility on external control.

Our responsibility is to ensure that children can be raised with enough
self confidence and self worth so that as teenagers they are able to seek help
and guidance in facing the challenges, thrills and risks of adolescence without
suffering irrevocable harm.

References:

1. Winnicott
D.W.  "Delinquency as a sign of
hope"  in - Davis D.,
Wallbridge D. 'Boundary and
space'  Karnac Books 1981

2.  Bowlby J. 'A secure
Base'  Routledge 1988.

3. MacKenzie R, Pennbridge J., David T., Yeates G. “Runaway and
Homeless Youth in Los Angeles county California”  Journal of Adolescent Health Care 1990;
11 : 159-165.

4.  Robinson J. "Self
Esteem, Identity and achievement in secondary school pupils" Bristol
University Press 1989.

5. Birch, D.M.L. “Unwillingly to School - Education of Pregnant
schoolgirls” in “Are you my Sister, Mummy?”, Youth Support
Publications 1987 : 18 : 199-205.

6. Birch, D.M.L. “Challenges to self worth” in “Inner
worlds & Outer Challenges”
Youth Support Publications1992 : 80-99.

7. Birch, D.M.L. “Schoolgirl Pregnancies” in
‘Progress in Obstetrics & Gynaecology Vol.7’ 1989; Chapter 5 :
75-90.

8. Coleman J. “Identity in adolescence; Present and Future
Self-concept”. Human Development. 1972 15: 1.

9. Blum R.W., Resnick M.D. “Adolescent Sexual Decision-making;
contraception, pregnancy, abortion, motherhood.” Pediatric Annals 1982
11:10  797-805

10. Birch, D.M.L. “That Old Black Magic. Teenage Sexual Belief
Systems” International Journal of Adolescent Medicine and Health
1991;  5 :1 37-47