case study of cognitive development of an adolescent

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Adolescent Brain and Cognitive Developments

Adolescence is a time of significant physical, social, and emotional developments, accompanied by changes in cognitive and language skills. Underlying these are significant developments in brain structures and functions including changes in cortical and subcortical gray matter and white matter tracts. Among the brain regions that develop during adolescence are areas that are commonly damaged as a result of a traumatic brain injury (TBI). This paper summarizes major brain changes during adolescence and evidence linking maturation of these cognitive and language functions to brain development, placing consideration of both areas of development in the context of rehabilitation for adolescents with TBI.

Adolescence spans the developmental period from preadolescence, beginning from about age 9 years, through the end of late adolescence in the early 20s ( Table 1 ). It is a time of significant physical, social, and emotional changes, accompanied by changes in cognitive and language skills. Intervention for adolescents with traumatic brain injury (TBI) must take into account not only important changes at this stage but also the interaction of development and injury effects on brain functions and structures.

Stages of adolescence

From “Adolescence Terminable and Interminable: When Does Adolescence End?” J. J. Arnett and S. Taber, 1994, Journal of Youth and Adolescence, 23 (5), pp. 517–537. Copyright 1994 by Springer. Reprinted with permission; Adolescence (5th ed.), by L. Steinberg, 1999, Boston: McGraw-Hill College. Copyright 1999 by McGraw-Hill College. Reprinted with permission; “Should My Shirt Be Tucked In or Left Out? The Communication Context of Adolescence,” L. S. Turkstra, 2000, Aphasiology, 14(4), pp. 349–346. Copyright 2000 by University of Pittsburgh. Reprinted with permission.

In this paper, we review recent research on brain development in adolescence and its relation to cognitive and language developments. The effects of injury are discussed, and the combination of developmental events and injury effects are considered in light of current rehabilitation practices.

ADOLESCENT BRAIN DEVELOPMENT

Recent structural and functional imaging studies have characterized brain development from childhood to early adulthood. The results are summarized in several research reviews (e.g., Durston et al., 2001 ; Paus et al., 1999 , 2001 ). The consensus of the reviewers is that although overall brain volume is relatively constant or increases slightly through the teen years, total volume measures mask significant regional changes in gray and white matter distribution (see Table 2 for definitions of neuroanatomical terms).

Review of neuroanatomical terms

From Neuroscience for the Study of Communicative Disorders (3rd ed.), by S. C. Bhatnagar, 2008, Baltimore. Lippincott Williams & Wilkins. Copyright 2008, 2000, 1997 by Lippincott Williams & Wilkins, a Wolters Kluwer business. Adapted with permission.

White matter volume increases linearly with age until adulthood, with a net increase of about 12% from age 4 to 22 years and a greater increase in males than in females ( Giedd et al., 1999 ). Specific white matter volume changes have been described in the internal capsule and arcuate fasciculus bilaterally ( Paus et al., 1999 ), as well as the corpus callosum ( Durston et al., 2001 ), and the frontal, parietal, and occipital lobes ( Sowell, Trauner, Gamst, & Jernigan, 2002 ).

Paus et al. (1999) postulated that increases in white matter volume reflect an increase in either the diameter or myelination of axons and underlie improvements in fine motor performance, processing of auditory information, and transfer of sensory information between anterior and posterior language areas. In addition, white matter tract size has been correlated with body height ( Eyre, Miller, & Ramesh, 1991 ), which is increasing rapidly during this stage, so, in part, white matter tract changes might be a by-product of overall body growth. Although numerous studies address functional connectivity via white matter tracts in adults, relatively little is known about how changes in connections between brain regions relate to developments in specific cognitive functions ( Paus et al., 2001 ), especially during adolescence.

In contrast to white matter, cortical gray matter increases steadily in volume until adolescence in most regions studied, followed by a decline that continues across the lifespan ( Giedd et al., 1999 ). This trajectory varies by lobe of the brain, with parietal lobe gray matter reaching a peak volume at about age 10 years in girls and 12 years in boys, frontal lobe volume peaking at about age 11 years in girls and 12 years in boys, and a late peak in temporal lobe volume at about age 16 years in adolescent boys and girls ( Giedd et al., 1999 ). The exception is occipital lobe gray matter, which continues to increase in volume throughout adolescence and the early adult years, without evidence of a plateau or decline.

Changes in cortical gray matter are thought to reflect a second wave of overproduction of synapses in the preadolescent years, followed by pruning that may be related to environmental input ( Giedd et al., 1999 ). Thatcher (1997) found that these cycles of synaptic overproduction and pruning were associated with an increase in the synchrony of neuronal firing patterns (i.e., increased coherence of brain electrical activity). Thatcher identified three cycles of increasing electroencephalographic coherence in postnatal development, the last of which occurs during early adolescence.

Total subcortical gray matter volume declines through adolescence, with significant decreases in the volume of the thalamus, caudate nucleus, nucleus accumbens, and basomedial diencephalon ( Sowell et al., 2002 ). Subcortical gray matter volume continues to decline at least into the third and fourth decades of life ( Sowell, Thompson, Holmes, Jernigan, & Toga, 1999 ).

Mesial temporal structures such as the hippocampus and amygdala have been found to increase in volume with age in some studies ( Durston et al., 2001 ) and decrease in others ( Sowell et al., 2002 ). The difference in findings may be attributable to limitations of anatomical research ( Durston et al., 2001 ), as the influence of total volume measures mask significant regional changes in gray and white matter distribution.

Although findings of changes in brain morphology through imaging research have increased the awareness of adolescence as a developmental period, it should be noted that there are limitations in imaging research as in all research. These issues include reliability and validity of anatomical and functional measures, bias in participant selection (e.g., exclusion of particular socioeconomic groups), and sample size. In addition, macroscopic measures such as magnetic resonance imaging (MRI) do not reveal the cellular morphology that may be responsible for gross anatomical differences ( Durston et al., 2001 ). These limitations should be considered when contemplating the application of the research described in the following text to individual adolescents.

Variability in adolescent brain development

As at other stages of development, variability occurs among adolescents in the timing and extent of brain changes. Although the mechanisms of this individual variability are unknown, there are several possible candidates. For example, brain growth is correlated with body growth in humans ( Peters et al., 1998 ) and body growth is highly variable among adolescents, particularly in early adolescence ( Steinberg, 1999 ). This is evident when one considers the range of sizes and shapes among middle-school students. It has been suggested that the diameter of fibers in the corticospinal tract increases as a function of height ( Eyre et al., 1991 ), and this may be true of cortical white matter as well.

Electroencephalographic studies of children and adolescents show age-related increases and sex differences in structural and functional differentiation of the cerebral cortex, particularly in the left hemisphere ( Anokhin, Lutzenberger, Nikolaev, & Birbaumer, 2000 ). Thus, neurophysiological changes are likely to play a role in individual differences. Individual variation in regional neurochemistry and resultant effects on brain structure and function might also contribute to functional heterogeneity, particularly during puberty ( Grumbach, 2002 ; McEwen, 2001 ; Muneoka, Shirayama, Minabe, & Takigawa, 2002 ), although, as Cameron (2001) noted, this is a relatively new area of inquiry.

A final possible contributor to within-subject variability is environmental input. This may be particularly true for the prefrontal cortex (PFC). Because of its prolonged developmental trajectory, it is thought that the PFC has the greatest plasticity of any brain structure ( Casey, Giedd, & Thomas, 2000 ). Thus, it may be the most vulnerable to both environmental stimulation and the effects of toxins, hormones, and other internal and external factors ( Casey et al., 2000 ). Perhaps, as a result of these influences, it has been hypothesized that some individuals never attain the distribution of PFC gray and white matter characteristic of most adults ( Rabinowicz, 1986 ).

COGNITIVE AND COMMUNICATION DEVELOPMENTS DURING ADOLESCENCE

Adolescence is a time of significant development in cognition and communication. An overall increase occurs in speed of processing, with a steep trajectory from ages 5 to 11 years followed by a slower rate of improvement from 11 to 18 years ( Kail & Ferrer, 2007 ). Changes also appear in specific aspects of cognition, primarily in functions that depend on the speed of processing and executive functions (EFs). Development in 3 areas of particular relevance to adolescents is discussed next: executive functions, social cognition, and language.

Executive function development

Executive functions have been defined as “supervisory functions” that control other modular cognitive functions ( Levin & Hanten, 2005 ). They include self-control, abstraction, and temporal estimation and sequencing ( Lezak, 1982 ). The coordination of these three core processes under the guidance of goal-directed behavior provides the ability to create a plan and follow that plan through to completion, making corrections as needed and modifying future behavior based on the results. Executive functions are the basis for metacognitive skills such as the ability to self-monitor performance on complex and demanding tasks (e.g., in social interactions), which undergo significant changes during later childhood and adolescence ( Hanten, 2004 ; Steinberg, 2004 ). Executive functions also underlie functions such as attentional control and processing, which continue to develop throughout adolescence ( Crone et al., 2006 ).

Some evidence suggests that executive function-related functions, such as cognitive flexibility and goal setting, remain relatively stable following rapid preadolescent growth ( Anderson, Anderson, Northam, Jacobs & Catroppa, 2001 ; De Luca et al., 2003 ). What changes significantly is the functional integration of these components. For example, performance on tests such as the Tower of London, which measure complex problem solving, shows improvements into later adolescence ( Asato, Sweeney, & Luna, 2006 ; De Luca et al., 2003 ). Overall, adolescence may be characterized as a stage at which qualitative differences in executive functions combine with increased speed and capacity for dealing with multiple, competing concepts and stimuli. The net result is an increase in the ability to achieve complex, integrated thought and action.

Social cognition development

The predominance of social concerns is a defining characteristic of preadolescence and adolescence. Although parents continue to exert an indirect influence at this stage ( Brown, Mounts, Lamborn, & Steinberg, 1993 ), the main focus is on peer social relationships ( Blakemore, 2008 ). By age 10 or 11 years, preadolescents are acutely aware of themselves and others in their social world, and this awareness is associated with a variety of positive social outcomes ( Bosacki, 2003 ).

Many of the skills required to execute social behaviors successfully are included under the umbrella term of social cognition , which refers to a set of cognitive processes that are thought to be specific to social functioning ( Schulkin, 2000 ). Although the specific cognitive functions that are included in social cognition continue to be debated ( Beer & Ochsner, 2006 ), most authors agree that they include, at minimum, the ability to recognize emotions using affective cues, as well as theory of mind (ToM). Theory of mind is defined as the ability to make inferences about the mental states of others and use these inferences to interpret others’ behaviors ( Premack & Woodruff, 1978 ). The development of ToM is thought to be complete in preadolescence, signaled by the comprehension of faux pas ( Bosacki, 2000 ). A full understanding of faux pas requires the recognition that one’s words were inappropriate, given the knowledge and feelings of others, and that this necessitates some form of conversational repair ( Baron-Cohen et al., 1999 ; Bosacki, 2000 ). Emotion recognition continues to develop into later adolescence ( Tonks, Williams, Frampton, Yates, & Slater, 2007 ), and this might improve social cognition performance as well. Social performance as a whole continues to improve into adulthood, but it is unclear if this reflects changes in social cognition per se or the continued development of cognitive functions that are not specific to social behavior, such as declarative knowledge, metacognition, speed of processing, and working memory. Our understanding of ToM development after early childhood—including when development ends, what aspects change, and how it should be measured—is still in a primitive stage, with much remaining to be learned.

Language development

The preadolescent and adolescent years are characterized by major development in language form, content, and use ( Nippold, 1998 , 2000 ). It is during these years that speakers master sophisticated syntactic functions such as appositive constructions, postmodification of noun phrases, perfect and passive tenses, and modals ( Scott, 1988 ). Sentence length and clause subordination also increase ( Scott, 1988 ), and skills emerge in genres such as persuasive writing ( Nippold, 2000 ). With regard to language form, adolescents are developing a “literate lexicon” ( Nippold, 1988 ), which includes the vocabulary they will need in academic and employment settings. While some of these developments appear to reflect declarative knowledge gains (e.g., in vocabulary and knowledge about language), others, such as the use of complex embedded clause structures, the ability to resolve ambiguous sentences, and the comprehension of proverbs in written text, have been linked to improvements in working memory and abstract reasoning ( Felser, Marinis, & Clahsen, 2003 ; Moran, Nippold, & Gillon, 2006 ). Evidence suggests that improvements in language processes such as metaphor comprehension and inference reflect gains in working memory ( Moran et al., 2005 ), but they also likely reflect improvements in executive functions such as abstraction and cognitive flexibility.

With regard to language use, adolescents are developing the skills required to communicate in the increasingly diverse social, vocational, and educational contexts in which they are expected to interact. They are learning to regulate their own verbal behavior, negotiate, and use language to achieve complex goals ( Turkstra, McDonald, & Kaufmann, 1996 ). Taken together, these skills typically are considered “higher level language functions,” and increasingly they are viewed as reflecting developments in cognitive abilities that are not specific to language, but also to executive functions and social cognition ( Blakemore, 2008 ; Blakemore & Choudhury, 2006 ). These cognitive abilities, in turn, appear to depend on environmental mediation over time to mature fully ( Klahr, McClelland, & Siegler, 2001 ).

Relation of brain changes to cognitive changes

Maturation of cognitive, emotional, and behavioral processes has been linked to the observed gray and white matter developments described earlier in this paper ( Barnea-Goraly et al., 2005 ; Paus et al., 1999 ; Shaw et al., 2006 ; Sowell, Delis, Stiles, & Jernigan, 2001 ; Sowell et al., 1999 ). Spear (2000) increased axon size and myelination improve signal transduction between neurons and improve the networking capability and cross talk among areas of the brain. It is this improved organization of white matter tracts that is believed to underlie the behavioral developments observed in adolescence ( Barnea-Goraly et al., 2005 ), including improvements in functions such as response inhibition, emotional regulation, planning, and organization ( Sowell et al., 1999 ). A few studies have also revealed correlations between specific anatomical changes and improvements in cognitive functions. The most consistent finding is that executive functions are closely linked to the development of the PFC. For example, functional imaging has shown increased activation of dorsolateral PFC with increasing age in children, associated with improvements in working memory task performance ( Crone et al., 2006 ). Activation in this same region has been shown to increase with age on tasks that require response inhibition and switching rules, with continued development into early adolescence ( Crone, Zanolie, van Leijenhorst, Westenberg, & Rombouts, 2008 ). Although these studies suggest that executive functions can be localized to specific subparts of the PFC, several researchers have theorized that the integrity of the entire brain is necessary for efficient executive functions ( Anderson, 1998 ; Spanos et al., 2007 ), particularly given the presence of executive function impairments in a wide variety of clinical groups. This has been supported by imaging data from adults with TBI, in whom executive function impairments were more correlated with overall white matter loss than with the presence of focal frontal lesions ( Kennedy et al., 2009 ).

Other cognitive functions have been studied using structural and functional imaging techniques. Structural studies in children have provided evidence that changes in cortical thickness are correlated with improvements in visuospatial memory ( Sowell et al., 2001 ) and general intelligence ( Shaw et al., 2006 ). It also has been shown that changes in myelination (measured as white matter volume) are the main predictors of increased processing speed with age ( Mabbott, Noseworthy, Bouffet, Laughlin, & Rockel, 2006 ).

Improvements in social cognition have been linked to changes in what Brothers (1990) referred to as the “social brain,”which includes frontal, medial temporal, and parietal lobe regions in a densely connected network. Kolb, Wilson, and Taylor (1992) observed that improvements in emotion recognition, which occur at about age 10 years and then again at age 14 years, are associated with periods of brain growth spurts identified by Thatcher (1997) . Baron-Cohen, Wheelwright, Hill, Raste, and Plumb (2001) observed similar phases of improvement in the ability to read emotion from eyes.

Although research linking specific behaviors to brain regions and networks is in the early stages, the findings to date support the notion that structural changes provide the architecture for specific changes in cognitive abilities. As is discussed later, current research has also shown how disruption to this architecture can lead to disruption of normal development in adolescent cognition and behavior.

INJURY EFFECTS ON THE BRAIN

Effects of preadolescent tbi on brain structure and function.

On the basis of the “Kennard principle” ( Kennard, 1940 ), it was widely accepted until fairly recently that an early brain injury would result in better outcome than a similar acquired lesion in an adult. This idea was challenged earlier by Hebb (as reviewed by Kolb et al., 2000 ) and has been further challenged with recent findings regarding the trajectory of brain development and factors that influence plasticity (reviewed by Kolb et al., 2000 ). Specifically, the idea has been reconsidered that all aspects of language and cognition are affected uniformly by an early lesion ( Tranel & Eslinger, 2000 ). Growing evidence indicates that early damage, especially to prefrontal areas, can have drastic consequences for the continued development of brain structures and functions ( Jacobs, Harvey, & Anderson, 2007 ), including effects on the development of personality, moral reasoning, social cognition, and executive functions ( Hanten, Bartha, & Levin, 2000 ; Tranel & Eslinger, 2000 ). In a few extreme cases (e.g., Anderson, Bechara, Damasio, Tranel, & Damasio, 1999 ), adolescents with early focal lesions have presented with a profile of behavior described as “acquired sociopathy,” in which moral reasoning had failed to develop. Although the potential effects of TBI on moral reasoning and personality in adults are well documented (see discussion that follows), the link between these functions and frontal lobe injury in a developing system is only beginning to be understood, and the effects of subtler lesions are not well known.

The use of structural and functional imaging techniques in the pediatric population, including adolescents, has provided a framework to investigate the impact of TBI on brain–behavior relationships during this critical period. Structural imaging techniques, including computerized tomography (CT) and MRI, have been used for some time in both the acute diagnosis of TBI ( Munson, Schroth, & Ernst, 2006 ) and attempts to predict longterm outcomes ( Bigler, 1999 ). More recently, functional imaging techniques, such as functional magnetic resonance imaging (fMRI), have emerged as a promising tool for identifying recovery mechanisms that are specific to pediatric TBI ( Munson et al., 2006 ), investigating issues of plasticity, and measuring the impact of behavioral interventions on brain function ( Strangman et al., 2005 ). In theory, the use of imaging technology will also support the exploration of the relationship between brain development and age of injury, although to date this relationship has received relatively little research attention.

Structural imaging studies

The use of structural imaging in TBI, outside of the realm of clinical diagnosis and medical management, has provided a good foundation of information regarding patterns of brain injury (including focal vs. diffuse damage) and injury mechanisms, and their relation to outcome. For example, Wilde et al. (2005) conducted an MRI volumetric study to evaluate brain volume differences between the whole brain and prefrontal, temporal, and posterior regions of the brain of children after moderate to severe TBI. Compared with a control group that was matched for age, the TBI group had significantly reduced whole-brain volume as well as reduced prefrontal and temporal region tissue volumes, accompanied by an increase in cerebrospinal fluid volume. More detailed analysis of each of these regions revealed differences in both gray and white matter volumes in the superior medial and ventromedial PFC (also found by Berryhill et al., 1995 ), white matter differences in the lateral PFC, and gray matter, white matter, and cerebrospinal fluid differences in the temporal regions. In this study, the location of the lesion was an important variable in that gray matter loss in the frontal areas was primarily attributed to focal injury, whereas the white matter loss in frontal and temporal regions was related to both diffuse axonal injury and focal lesions. The degree of PFC atrophy, related to either focal or diffuse injury, was related inversely to functional recovery. While recognizing that further research was needed to relate these findings to specific behaviors, the authors speculated that the specific cognitive and behavioral difficulties that follow frontotemporal lesions might result in a decreased adaptive ability, reflecting impairments in executive functions. In light of the differences between gray versus white matter volume changes, the authors noted the need for further consideration of the effects of TBI on the developmental time course of myelination in the frontal and temporal lobes. This highlights the potential impact of TBI in preadolescence on the developing brain and supports the idea that mechanism of injury and site of lesion are important factors in predicting outcome.

In addition to the structural images that are obtained by CT or MRI scans, diffusion tensor imaging (DTI) is a technique that allows an in vivo view of brain connections. Specifically, DTI is an imaging technique that assesses the microstructure of cerebral white matter on the basis of the movement of water molecules and has been used to characterize damage to white matter in a wide variety of clinical disorders, including pediatric TBI ( Hanten et al., 2008 ; Kraus et al., 2007 ; Wilde et al., 2006 ). Researchers have used DTI as a tool not only to describe the integrity of white matter but also to explore the relationship between white matter integrity and behavioral performance. A study conducted by Wilde et al. (2006) focused specifically on the corpus callosum. The results reflected those found in the adult TBI literature, that is, children and adolescents with TBI showed decreased integrity of the corpus callosum compared with typical peers as indicated by a decrease in fractional anisotropy (i.e., anisotropic diffusion of water molecules along white matter tracts). This finding was independent of the presence of any overt structural lesion. This measure of the integrity of the corpus callosum correlated significantly with functional outcome as measured by the Glasgow Outcome Scale ( Jennett et al., 1981 ) and with the performance on a measure of reaction time with interference. Similarly, Kraus et al. (2007) found that DTI changes correlated significantly with the performance on measures of executive function, memory, and attention, even in children and teens with mild TBI.

In a different study using DTI, Wilde et al. (2006) examined white matter integrity and postconcussive symptoms in adolescents with mild TBI. This study demonstrated that DTI techniques are better suited to examine clinically meaningful cognitive, somatic, and emotional changes than traditional imaging measures (i.e., CT and MRI). Measures of fractional anisotropy and radial diffusivity (i.e., diffusion of water perpendicular to white matter tracts) along the corpus callosum were found to correlate significantly with postconcussive and emotional distress levels. These findings indicate that compromise to white matter tracts along the corpus callosum can be associated with mild TBI in adolescents.

In a study that specifically focused on young adolescents (mean age = 13.87 years) at 3 months postinjury, Hanten et al. (2008) found a strong relationship between white matter integrity in the cingulate gyrus bilaterally, dorsolateral PFC bilaterally (although left more than right), and left temporal lobe to performance on the interpersonal negotiation strategies (INS) task, which measures social problem solving. The scores on INS were related to the presence of focal frontal lesions in younger participants but not in older adolescents. These findings speak to both the specific vulnerability of the late-developing frontal lobes and the importance of white matter integrity to cognitive processing, a point that was mentioned previously in this paper when discussing the development of executive functions.

Together, these structural studies provide a foundation for understanding the most likely areas of damage in TBI and how these areas are affected specifically by the injury. Additional well-documented neuropathological changes after TBI include (1) damage to and associated atrophy of the frontal and temporal lobes; (2) diffuse axonal injury and related exvacuo dilation of the ventricles (dilation that is a result of brain tissue loss); (3) decreased volume of the corpus callosum; and (4) generalized cerebral atrophy in the chronic phase, even in the absence of structural findings at the time of the injury ( Barkley, Morales, Hayman, & Diaz-Marchan, 2007 ; and see review in Bigler, 1999 ). Such structural changes have been observed in both pediatric and adult populations, with adolescents included in both types of studies. Additional structural differences, specifically after moderate to severe TBI, include (1) reduced growth of the corpus callosum 3 years postinjury ( Levin et al., 2000 ); and (2) decreased hippocampal volume, specifically following pediatric TBI ( Di Stefano et al., 2000 ). In addition, Tasker et al. (2006) found that when pediatric TBI was complicated by increased intracranial pressure, there was a disproportionate hippocampal growth reduction 5 years postinjury, which was most notable on the ipsilateral side to the site of impact. These results indicate that there are widespread, yet consistent, areas of structural damage following TBI, providing a foundation from which to consider links between lesion location and performance on tasks that are specific to adolescents.

Functional imaging studies

Although structural imaging does provide vital information, there are instances in which a person with behavioral deficits after TBI does not present with identifiable structural lesions on either a CT scan or an MRI scan. A “normal” structural scan during the acute phase of injury does not rule out subsequent structural or functional damage ( Munson et al., 2006 ). In these instances, functional imaging begins where structural imaging leaves off. Functional imaging , as indicated by the term, refers to a group of techniques that provide information about brain function, typically by measuring blood flow, brain electrical activity, or brain chemistry. For the study of adolescents, functional imaging has the added benefit of providing insight beyond what might be possible when pairing structural imaging with performance on behavioral measures, by providing a more complete window into the function of a developing system.

The use of functional imaging techniques has become increasingly common in research on typical populations and has begun to be used to study issues related to plasticity and relearning in clinical populations. In contrast to structural imaging techniques, which have a long history of use in clinical settings, functional imaging currently is used most frequently as a research tool ( Ricker & Arenth, 2007 ). The functional imaging technique that appears most frequently in the pediatric TBI literature is fMRI, which is reported to be a powerful tool for investigating biological models of recovery and rehabilitation ( Matthews, Johansen-Berg, & Reddy, 2004 ). Although functional imaging research in general has grown, few studies have been published on use of this technology in the TBI population, and even fewer studies have used functional imaging to focus on pediatric injury or to consider adolescents as a distinct population. Of the pediatric studies that have been conducted, most have focused primarily on working memory, language, and social cognition.

A case study of working memory in pediatric TBI recovery used a combination of fMRI and behavioral measures to examine recovery of function following brain injury ( Williams, Rivera, & Reiss, 2005 ). In this study, a 9-yearold boy with severe TBI was tested at 30 days and 15 months postinjury on measures of intelligence and behavior and then completed a working memory task during functional imaging. At 30 days postinjury, the fMRI results revealed a significant decrease in areas of brain activation between an easier version of the working memory task versus a more difficult version; however, at the second follow-up visit, the patterns of activation resembled those of typical individuals. These improved patterns of performance were accompanied by improved behavioral performance, demonstrating the possible uses of functional imaging for understanding recovery processes for preadolescents including plasticity. It is important to note, however, that this was a single case study, the results of which are not easily generalizable.

Two functional imaging studies have focused on language skills after pediatric TBI ( Chiu Wong et al., 2006 ; Karunanayaka et al., 2007 ). Karunanayaka et al. (2007) used fMRI to study patterns of brain activity during a verb generation task and found differences in activation patterns in the perisylvian language zones between young children with TBI ( n = 8; mean age = 7.9 years) and their peers who were matched for age and sex but who had sustained only orthopedic injuries ( n = 9; mean age = 7.1 years). In the TBI group, there was a significant association between fMRI results and behavioral measures, such as verbal fluency and Glasgow Coma Scale scores. This association was present even in the absence of focal lesions because more than half of the participants had no evidence of lesions on structural imaging ( Karunanayaka, et al., 2007 ). The second study, conducted by Chiu Wong et al. (2006) , used single photon emission computed tomography to study eight pediatric TBI patients 3 years postinjury with scans obtained during a complex discourse task. The results of this study revealed positive correlations between discourse abstraction abilities and amount of right frontal perfusion (blood flow). In addition, increased perfusion to the left frontal regions was associated with decreased discourse abstraction abilities, indicating that a pattern of supportive plasticity-induced change would involve preferential recovery of right frontal perfusion versus maladaptive plasticity-induced change that appeared to be associated with increased left frontal perfusion.

Together, these functional imaging studies provide a foundation to consider issues of plasticity and associations among behavioral performance, patterns of brain activation, and injury severity. Although this is a new area of inquiry and not yet directly applicable to clinical intervention for individual clients, a group picture is beginning to emerge regarding injury in the developing nervous system. Studies that include older children have focused thus far on preadolescents, but the results provide a starting point to understand the potential delayed effects that TBI can have on brain development during adolescence. The limitations of these studies, however, must be addressed before applying specific results to individual patients. To date, no studies have been large enough to explore the combined effects of development and brain injury to show how development, injury severity, and outcome are related to patterns of brain function and recovery of function. Furthermore, no studies have considered adolescents as a unique group.

Because the application of these techniques is so new, there are additional limitations that must be addressed, including issues such as within-age variability and possible interactions of age with sex ( Blakemore, 2008 ; Chiu Wong et al., 2006 ; DeBellis et al., 2001 ). Other issues relate to the limited inclusion of individuals from groups such as children in poverty, who are at risk for negative environmental influences on development. There also are limitations that are common in the TBI literature in general, such as the exclusion of individuals with developmental learning disabilities, who are overrepresented in the TBI population and may have a complex interaction of developmentally atypical function and acquired impairments ( Donders & Strom, 1997 ). Growing evidence shows differences in brain structures and functions between children with learning disabilities and their typically developing peers ( Holland et al., 2007 ); however, to the authors’ knowledge, only one study ( Donders & Strom, 1997 ) described outcome in children with a combined diagnosis of TBI and learning disability, and this study included only 10 children.

IMPLICATIONS FOR THE ASSESSMENT OF COGNITIVE--COMMUNICATION SKILLS

As discussed, changes in social, emotional, and cognitive functions during adolescence reflect the interaction of neural maturation and environmental factors. Traumatic brain injury clearly has the potential to cause deviations in the expected neurodevelopmental trajectory; this, combined with typical adolescent heterogeneity, variation in the general population in the types of skills that are developing in adolescence (e.g., executive functions), and variability among adolescents in the timing, location, and magnitude of brain damage, pose significant challenges for assessment ( Blosser & DePompei, 1994 ; Ciccia & Turkstra, 2002 ; Snow & Douglas, 2000 ; Turkstra, 1999 ). In short, it can be exceptionally challenging to distinguish “different”from “disordered” when it comes to adolescents. Although brain development in adolescence is a relatively new area of inquiry, the literature reviewed here suggests three factors to consider when assessing adolescents with TBI: (1) the nature of brain and cognitive developments during adolescence (i.e., what to test), (2) the identification of age-appropriate contexts in which to assess performance (i.e., how to test); and (3) the timing of assessment relative to ongoing brain and cognitive developments (i.e., when to test).

What cognitive--communication functions should be assessed?

Most of the aspects of language, executive functions, and social cognition that can be measured reliably with existing standardized tests are those that mature at around the onset of puberty. These include functions such as basic spoken language forms, emotion recognition, and self-regulation in structured environments. As the review of cognitive developments earlier in this paper indicates, adolescence is characterized by further development of skills in integrating and applying basic cognitive, language, and social functions in progressively more complex contexts, and these are much more difficult to measure than are changes in language skills such as vocabulary.

The assessment of adolescent communication ability must address complex skills such as higher level written language skills, which improve, in part, as a function of developments in working memory and complex social cognition ( Kamhi et al., 2007 ; Proctor, Wilson, Sanchez, & Wesley, 2000 ; Singer, 2007 ), as well as self-regulation, self-monitoring, and motivation ( Singer, Kamhi, Masterson, & Apel, 2007 ). For this reason, tasks such as homework assignments, peer conversations, and daily scheduling are likely to be more revealing of challenges in students with TBI than scores on standardized language tests. Given the wide variability in what is considered successful, or typical, performance on these tasks, it is critical to have comparison data from peers, which should be possible when authentic curriculum-based contexts are used for assessment and classroom data are available.

How and where should cognitive--communication skills be evaluated?

The limitations of most standardized tests for the assessment of cognitive, language, and social skills in adolescents apply equally to the assessment context, that is, skills related to the integration and application of information must be assessed in contexts in which they will be used. This includes activities and contexts of daily living, including social contexts and real-world academic situations. This will help identify deficits that clinical testing may mask owing to the artificial structure of many clinical tests and the absence of competing stimuli ( Lezak, 1982 ; Sohlberg & Mateer, 2001 ). By observing students in classroom contexts, clinicians can gain appreciation of the scope of the impact of the injury. It is the convergence of multiple processes, including working memory and response inhibition, as well as judgment of performance and flexibility of applying newly acquired information, that are important for successful communication functioning in everyday life. In other words, the ability to balance the demands of an adolescent life successfully and the ability to meet these demands in facilitative environments with adequate structure are two separate skill sets. This is particularly true for adolescents with TBI because of the high prevalence of executive function impairments in this group and the high risk for failure to advance in age-typical executive function development postinjury. If a new injury has impaired the ability to use previously learned information in novel contexts, then performance on tests of preinjury knowledge in structured contexts is likely to cause teachers and others to overestimate the adolescent’s capacity for succeeding in everyday life.

When should cognitive--communication skills be evaluated?

The evidence supporting a reciprocal relationship between brain and behavioral developments during the teen years suggests that ongoing reevaluation is warranted when a child or adolescent sustains a TBI, even if he or she has been discharged from services after meeting goals at one point in development. Increasing environmental demands and expectations for cognitive functioning necessitate ongoing reevaluation of the adolescent’s ability to communicate and interact successfully. The environment can influence not only expectations but also actual skill development, as evidenced by the finding that “higher”cognitive skills—including social cognition, executive functions, and metacognitive skills— depend on environmental input over time to mature fully ( Klahr et al., 2001 ).

The protracted developmental time course for the frontal lobes and the high sensitivity of developing neural structures to environmental influences necessitate a shift to a life-span approach to intervention. There is growing recognition that the effects of TBI are revealed at later points in development and that the injury may derail neural development in progress so that negative effects are not fully apparent for months or years afterward ( Kolb, Gibb, & Gorny, 2000 ). Early injury may change not only the capacity for brain development but also the brain’s ability to respond to environmental input, which, in turn, may limit future developments. Thus, an adolescent who cannot control his or her attention on a task might fail to develop complex divided attention skills as well as miss learning the information on which he or she is meant to focus. Our approach must take into consideration not only disorder-specific effects but also the complex relationship of neurodevelopmental changes and continuously changing environmental demands. Thus, in planning assessment and treatment, clinicians working with adolescents with TBI must consider existing functions that are affected by the injury as well as functions that are dependent on the development of injured regions in the future.

The research presented here also indicates that adolescence, as a period of natural change, provides a particularly important window of opportunity for intervention. As noted earlier in this paper, preadolescence is characterized by a new wave of synaptogenesis and subsequent pruning. Clinicians may be able to capitalize on this plasticity to focus on the development of complex cognitive skills. At a minimum, the research to date suggests that there are potential risks to not treating children who have sustained TBI during their adolescence.

Barriers to providing services in a life-span framework include current service delivery and reimbursement models, which do not readily allow for this type of approach. However, as research begins to expand in the area of adolescent brain development and clinical disorders, it is possible that the evidence would contribute to a paradigm shift in service delivery models and policy changes to support them. The adolescent brain is a work in progress, and the opportunities for intervention at this stage are likely to outweigh the challenges.

FUTURE DIRECTIONS FOR CLINICALLY BASED RESEARCH

It is a very exciting time in the area of clinical intervention for adolescents. The connection of imaging and behavioral research has allowed questions to be asked and answered that previously could not have been addressed ( Munson et al., 2006 ). While the current research evidence suggests only preliminary recommendations for clinical intervention with individual clients, the results provide an exciting base upon which to ask future clinical questions. Longitudinal studies are needed that combine imaging and behavioral measures over time to increase understanding of the complex interactions among brain development, brain injury, and outcome. A critical need also exists for studies that link brain recovery mechanisms to behavioral outcomes and specific interventions, as currently is being done in studies of adults with neurological disorders ( Raymer et al., 2008 ). The results of this research will arm clinicians with powerful information that truly encompasses the complexities of treating adolescents with TBI.

CONCLUSIONS

The physical developments of adolescence are accompanied by dynamic changes in multiple cognitive, language, and social domains. These include improvements in executive functions, working memory, efficiency of information processing, social cognition, and emotion recognition. When a TBI occurs during the preadolescent and adolescent years, or even earlier, it may affect not only skills that are emerging at that time but also skills that are expected to develop in the future. The impact of injury during adolescence is exacerbated by the type of damage that is most common in TBI, including diffuse axonal injury and reduction in cortical volume and associated brain functions, particularly in the frontal lobes—the very regions that are developing during this stage.

Given the dynamic and protracted nature of both behavioral and brain changes that occur during adolescence, the interconnections of these two aspects of development, and the role that environment plays in development and rehabilitation, one can begin to understand how an injury that interrupts this intricate process can have effects at the time of injury and also many years later. Clinical intervention for adolescents with TBI requires an understanding of the typical trajectory of adolescent brain and cognitive developments and the ability to use this information to inform the “when,” “what,” and “how”of clinical assessment and intervention. In the future, the results of research combining imaging techniques with behavioral approaches have the power to change how clinical services are provided to adolescents with TBI.

Acknowledgments

This work was supported in part by an American Speech-Language-Hearing Foundation New Century Scholar’s grant to Dr. Ciccia and the Wisconsin Alumni Research Foundation and the Walker Foundation at the University of Wisconsin-Madison to Dr. Turkstra.

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Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program

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Jason Scott Frydman, Christine Mayor, Trauma and Early Adolescent Development: Case Examples from a Trauma-Informed Public Health Middle School Program, Children & Schools , Volume 39, Issue 4, October 2017, Pages 238–247, https://doi.org/10.1093/cs/cdx017

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Middle-school-age children are faced with a variety of developmental tasks, including the beginning phases of individuation from the family, building peer groups, social and emotional transitions, and cognitive shifts associated with the maturation process. This article summarizes how traumatic events impair and complicate these developmental tasks, which can lead to disruptive behaviors in the school setting. Following the call by Walkley and Cox for more attention to be given to trauma-informed schools, this article provides detailed information about the Animating Learning by Integrating and Validating Experience program: a school-based, trauma-informed intervention for middle school students. This public health model uses psychoeducation, cognitive differentiation, and brief stress reduction counseling sessions to facilitate socioemotional development and academic progress. Case examples from the authors’ clinical work in the New Haven, Connecticut, urban public school system are provided.

Within the U.S. school system there is growing awareness of how traumatic experience negatively affects early adolescent development and functioning ( Chanmugam & Teasley, 2014 ; Perfect, Turley, Carlson, Yohannan, & Gilles, 2016 ; Porche, Costello, & Rosen-Reynoso, 2016 ; Sibinga, Webb, Ghazarian, & Ellen, 2016 ; Turner, Shattuck, Finkelhor, & Hamby, 2017 ; Woodbridge et al., 2016 ). The manifested trauma symptoms of these students have been widely documented and include self-isolation, aggression, and attentional deficit and hyperactivity, producing individual and schoolwide difficulties ( Cook et al., 2005 ; Iachini, Petiwala, & DeHart, 2016 ; Oehlberg, 2008 ; Sajnani, Jewers-Dailley, Brillante, Puglisi, & Johnson, 2014 ). To address this vulnerability, school social workers should be aware of public health models promoting prevention, data-driven investigation, and broad-based trauma interventions ( Chafouleas, Johnson, Overstreet, & Santos, 2016 ; Johnson, 2012 ; Moon, Williford, & Mendenhall, 2017 ; Overstreet & Chafouleas, 2016 ; Overstreet & Matthews, 2011 ). Without comprehensive and effective interventions in the school setting, seminal adolescent developmental tasks are at risk.

This article follows the twofold call by Walkley and Cox (2013) for school social workers to develop a heightened awareness of trauma exposure's impact on childhood development and to highlight trauma-informed practices in the school setting. In reference to the former, this article will not focus on the general impact of toxic stress, or chronic trauma, on early adolescents in the school setting, as this work has been widely documented. Rather, it begins with a synthesis of how exposure to trauma impairs early adolescent developmental tasks. As to the latter, we will outline and discuss the Animating Learning by Integrating and Validating Experience (ALIVE) program, a school-based, trauma-informed intervention that is grounded in a public health framework. The model uses psychoeducation, cognitive differentiation, and brief stress reduction sessions to promote socioemotional development and academic progress. We present two clinical cases as examples of trauma-informed, school-based practice, and then apply their experience working in an urban, public middle school to explicate intervention theory and practice for school social workers.

Impact of Trauma Exposure on Early Adolescent Developmental Tasks

Social development.

Impact of Trauma on Early Adolescent Development

Traumatic experiences may create difficulty with developing and differentiating another person's point of view (that is, mentalization) due to the formation of rigid cognitive schemas that dictate notions of self, others, and the external world ( Frydman & McLellan, 2014 ). For early adolescents, the ability to diversify a single perspective with complexity is central to modulating affective experience. Without the capacity to diversify one's perspective, there is often difficulty differentiating between a nonthreatening current situation that may harbor reminders of the traumatic experience and actual traumatic events. Incumbent on the school social worker is the need to help students understand how these conflicts may trigger a memory of harm, abandonment, or loss and how to differentiate these past memories from the present conflict. This is of particular concern when these reactions are conflated with more common middle school behaviors such as withdrawing, blaming, criticizing, and gossiping ( Card, Stucky, Sawalani, & Little, 2008 ).

Encouraging cognitive discrimination is particularly meaningful given that the second social developmental task for early adolescents is the re-orientation of their primary relationships with family toward peers ( Henderson & Thompson, 2010 ). This shift may become complicated for students facing traumatic stress, resulting in a stunted movement away from familiar connections or a displacement of dysfunctional family relationships onto peers. For example, in the former, a student who has witnessed and intervened to protect his mother from severe domestic violence might believe he needs to sacrifice himself and be available to his mother, forgoing typical peer interactions. In the latter, a student who was beaten when a loud, intoxicated family member came home might become enraged, anxious, or anticipate violence when other students raise their voices.

Cognitive Development and Emotional Regulation

During normative early adolescent development, the prefrontal cortex undergoes maturational shifts in cognitive and emotional functioning, including increased impulse control and affect regulation ( Wigfield, Lutz, & Wagner, 2005 ). However, these developmental tasks can be negatively affected by chronic exposure to traumatic events. Stressful situations often evoke a fear response, which inhibits executive functioning and commonly results in a fight-flight-freeze reaction. If a student does not possess strong anxiety management skills to cope with reminders of the trauma, the student is prone to further emotional dysregulation, lowered frustration tolerance, and increased behavioral problems and depressive symptoms ( Iachini et al., 2016 ; Saltzman, Steinberg, Layne, Aisenberg, & Pynoos, 2001 ).

Typical cognitive development in early adolescence is defined by the ambiguity of a transitional stage between childhood remedial capacity and adult refinement ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Casey and Caudle (2013) found that although adolescents performed equally as well as, if not better than, adults on a self-control task when no emotional information was present, the introduction of affectively laden social cues resulted in diminished performance. The developmental challenge for the early adolescent then is to facilitate the coordination of this ever-shifting dynamic between cognition and affect. Although early adolescents may display efficient and logically informed behaviors, they may struggle to sustain these behaviors, especially in the presence of emotional stimuli ( Casey & Caudle, 2013 ; Van Duijvenvoorde & Crone, 2013 ). Because trauma often evokes an emotional response ( Johnson & Lubin, 2015 ), these findings insinuate that those early adolescents who are chronically exposed will have ongoing regulation difficulties. Further empirical findings considering the cognitive effects of trauma exposure on the adolescent brain have highlighted detriments in working memory, inhibition, memory, and planning ability ( Moradi, Neshat Doost, Taghavi, Yule, & Dalgleish, 1999 ).

Using a Public Health Framework for School-Based, Trauma-Informed Services

The need for a more informed and comprehensive approach to addressing trauma within the schools has been widely articulated ( Chafouleas et al., 2016 ; Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011 ; Jaycox, Kataoka, Stein, Langley, & Wong, 2012 ; Overstreet & Chafouleas, 2016 ; Perry & Daniels, 2016 ). Overstreet and Matthews (2011) suggested that using a public health model to address trauma in schools will promote prevention, early identification, and data-driven investigation and yield broad-based intervention on a policy and communitywide level. A public health approach focuses on developing interventions that address the underlying causal processes that lead to social, emotional, and cognitive maladjustment. Opening the dialogue to the entire student body, as well as teachers and administrators, promotes inclusion and provides a comprehensive foundation for psychoeducation, assessment, and prevention.

ALIVE: A Comprehensive Public Health Intervention for Middle School Students

Note: ALIVE = Animating Learning by Integrating and Validating Experience.

Psychoeducation

The classroom is a place traditionally dedicated to academic pursuits; however, it also serves as an indicator of trauma's impact on cognitive functioning evidenced by poor grades, behavioral dysregulation, and social turbulence. ALIVE practitioners conduct weekly trauma-focused dialogues in the classroom to normalize conversations addressing trauma, to recruit and rehearse more adaptive cognitive skills, and to engage in an insight-oriented process ( Sajnani et al., 2014 ).

Using a parable as a projective tool for identification and connection, the model helps students tolerate direct discussions about adverse experiences. The ALIVE practitioner begins each academic year by telling the parable of a woman named Miss Kendra, who struggled to cope with the loss of her 10-year-old child. Miss Kendra is able to make meaning out of her loss by providing support for schoolchildren who have encountered adverse experiences, serving as a reminder of the strength it takes to press forward after a traumatic event. The intention of this parable is to establish a metaphor for survival and strength to fortify the coping skills already held by trauma-exposed middle school students. Furthermore, Miss Kendra offers early adolescents an opportunity to project their own needs onto the story, creating a personalized figure who embodies support for socioemotional growth.

Following this parable, the students’ attention is directed toward Miss Kendra's List, a poster that is permanently displayed in the classroom. The list includes a series of statements against adolescent maltreatment, comprehensively identifying various traumatic stressors such as witnessing domestic violence; being physically, verbally, or sexually abused; and losing a loved one to neighborhood violence. The second section of the list identifies what may happen to early adolescents when they experience trauma from emotional, social, and academic perspectives. The practitioner uses this list to provide information about the nature and impact of trauma, while modeling for students and staff the ability to discuss difficult experiences as a way of connecting with one another with a sense of hope and strength.

Furthermore, creating a dialogue about these issues with early adolescents facilitates a culture of acceptance, tolerance, and understanding, engendering empathy and identification among students. This fostering of interpersonal connection provides a reparative and differentiated experience to trauma ( Hartling & Sparks, 2008 ; Henderson & Thompson, 2010 ; Johnson & Lubin, 2015 ) and is particularly important given the peer-focused developmental tasks of early adolescence. The positive feelings evoked through classroom-based conversation are predicated on empathic identification among the students and an accompanying sense of relief in understanding the scope of trauma's impact. Furthermore, the consistent appearance of and engagement by the ALIVE practitioner, and the continual presence of Miss Kendra's list, effectively counters traumatically informed expectations of abandonment and loss while aligning with a public health model that attends to the impact of trauma on a regular, systemwide basis.

Participatory and Somatic Indicators for Informal Assessment during the Psychoeducation Component of the ALIVE Intervention

Notes: ALIVE = Animating Learning by Integrating and Validating Experience. Examples are derived from authors’ clinical experiences.

In addition to behavioral symptoms, the content of conversation is considered. All practitioners in the ALIVE program are mandated reporters, and any content presented that meets criteria for suspicion of child maltreatment is brought to the attention of the school leadership and ALIVE director. According to Johnson (2012) , reports of child maltreatment to the Connecticut Department of Child and Family Services have actually decreased in the schools where the program has been implemented “because [the ALIVE program is] catching problems well before they have risen to the severity that would require reporting” (p. 17).

Case Example 1

The following demonstrates a middle school classroom psychoeducation session and assessment facilitated by an ALIVE practitioner (the first author). All names and identifying characteristics have been changed to protect confidentiality.

Ms. Skylar's seventh grade class comprised many students living in low-income housing or in a neighborhood characterized by high poverty and frequent criminal activity. During the second week of school, I introduced myself as a practitioner who was here to speak directly about difficult experiences and how these instances might affect academic functioning and students’ thoughts about themselves, others, and their environment.

After sharing the Miss Kendra parable and list, I invited the students to share their thoughts about Miss Kendra and her journey. Tyreke began the conversation by wondering whether Miss Kendra lost her child to gun violence, exploring the connection between the list and the story and his own frequent exposure to neighborhood shootings. To transition a singular connection to a communal one, I asked the students if this was a shared experience. The majority of students nodded in agreement. I referred the students back to the list and asked them to identify how someone's school functioning or mood may be affected by ongoing neighborhood gun violence. While the students read the list, I actively monitored reactions and scanned for inattention and active avoidance. Performing both active facilitation of discussion and monitoring students’ reactions is critical in accomplishing the goals of providing quality psychoeducation and identifying at-risk students for intervention.

After inspection, Cleo remarked that, contrary to a listed outcome on Miss Kendra's list, neighborhood gun violence does not make him feel lonely; rather, he “doesn't care about it.” Slumped down in his chair, head resting on his crossed arms on the desk in front of him, Cleo's body language suggested a somatized disengagement. I invited other students to share their individual reactions. Tyreke agreed that loneliness is not the identified affective experience; rather, for him, it's feeling “mad or scared.” Immediately, Greg concurred, expressing that “it makes me more mad, and I think about my family.”

Encouraging a variety of viewpoints, I stated, “It sounds like it might make you mad, scared, and may even bring up thoughts about your family. I wonder why people have different reactions?” Doing so moved the conversation into a phase of deeper reflection, simultaneously honoring the students’ voiced experience while encouraging critical thinking. A number of students responded by offering connections to their lives, some indicating they had difficulty identifying feelings. I reflected back, “Sometimes people feel something, but can't really put their finger on it, and sometimes they know exactly how they feel or who it makes them think about.”

I followed with a question: “How do you think it affects your schoolwork or feelings when you're in school?” Greg and Natalia both offered that sometimes difficult or confusing thoughts can consume their whole day, even while in class. Sharon began to offer a related comment when Cleo interrupted by speaking at an elevated volume to his desk partner, Tyreke. The two began to snicker and pull focus. By the time they gained the class's full attention, Cleo was openly laughing and pushing his chair back, stating, “No way! She DID!? That's crazy”; he began to stand up, enlisting Tyreke in the process. While this disruption may be viewed as a challenge to the discussion, it is essential to understand all behavior in context of the session's trauma content. Therefore, Cleo's outburst was interpreted as a potential avenue for further exploration of the topic regarding gun violence and difficulties concentrating. In turn, I posed this question to the class: “Should we talk about this stuff? I wonder if sometimes people have a hard time tolerating it. Can anybody think of why it might be important? Sharon, I think you were saying something about this.” While Sharon continued to share, Cleo and Tyreke gradually shifted their attention back to the conversation. I noted the importance of an individual follow-up with Cleo.

Natalia jumped back in the conversation, stating, “I think we talk about stuff like this so we know about it and can help people with it.” I checked in with the rest of the class about this strategy for coping with the impact of trauma exposure on school functioning: “So it sounds like these thoughts have a pretty big impact on your day. If that's the case, how do you feel less worried or mad or scared?” Marta quickly responded, “You could talk to someone.” I responded, “Part of my job here is to be a person to talk to one-on-one about these things. Hopefully, it will help you feel better to get some of that stuff off your chest.” The students nodded, acknowledging that I would return to discuss other items on the list and that there would be opportunities to check in with me individually if needed.

On reflection, Cleo's disruption in the discussion may be attributed to his personal difficulty emotionally managing intrusive thoughts while in school. This clinical assumption was not explicitly named in the moment, but was noted as information for further individual follow-up. When I met individually with Cleo, Cleo reported that his cousin had been shot a month ago, causing him to feel confused and angry. I continued to work with him individually, which resulted in a reduction of behavioral disruptions in the classroom.

In the preceding case example, the practitioner performed a variety of public health tasks. Foremost was the introduction of how traumatic experience may affect individuals and their relationships with others and their role as a student. Second, the practitioner used Miss Kendra and her list as a foundational mechanism to ground the conversation and serve as a reference point for the students’ experience. Finally, the practitioner actively monitored individual responses to the material as a means of identifying students who may require more support. All three of these processes are supported within the public health framework as a means toward assessment and early intervention for early adolescents who may be exposed to trauma.

Individualized Stress Reduction Intervention

Students are seen for individualized support if they display significant externalizing or internalizing trauma-related behavior. Students are either self-referred; referred by a teacher, administrator, or staff member; or identified by an ALIVE practitioner. Following the principle of immediate engagement based on emergent traumatic material, individual sessions are brief, lasting only 15 to 20 minutes. Using trauma-centered psychotherapy ( Johnson & Lubin, 2015 ), a brief inquiry addressing the current problem is conducted to identify the trauma trigger connected to the original harm, fostering cognitive discrimination. Conversation about the adverse experience proceeds in a calm, direct way focusing on differentiating between intrusive memories and the current situation at school ( Sajnani et al., 2014 ). Once the student exhibits greater emotional regulation, the ALIVE practitioner returns the student to the classroom in a timely manner and may provide either brief follow-up sessions for preventive purposes or, when appropriate, refer the student to more regular, clinical support in or out of the school.

Case Example 2

The following case example is representative of the brief, immediate, and open engagement with traumatic material and encouragement of cognitive discrimination. This intervention was conducted with a sixth grade student, Jacob (name and identifying information changed to ensure confidentiality), by an ALIVE practitioner (the second author).

I found Jacob in the hallway violently shaking a trash can, kicking the classroom door, and slamming his hands into the wall and locker. His teacher was standing at the door, distressed, stating, “Jacob, you need to calm down and go to the office, or I'm calling home!” Jacob yelled, “It's not fair, it was him, not me! I'm gonna fight him!” As I approached, I asked what was making him so angry, but he said, “I don't want to talk about it.” Rather than asking him to calm down or stop slamming objects, I instead approached the potential memory agitating him, stating, “My guess is that you are angry for a very good reason.” Upon this simple connection, he sighed and stopped kicking the trash can and slamming the wall. Jacob continued to demonstrate physical and emotional activation, pacing the hallway and making a fist; however, he was able to recount putting trash in the trash can when a peer pushed him from behind, causing him to yell. Jacob explained that his teacher heard him yelling and scolded him, making him more mad. Jacob stated, “She didn't even know what happened and she blamed me. I was trying to help her by taking out all of our breakfast trash. It's not fair.”

The ALIVE practitioner listens to students’ complaints with two ears, one for the current complaint and one for affect-laden details that may be connected to the original trauma to inquire further into the source of the trigger. Affect-laden details in case example 2 include Jacob's anger about being blamed (rather than toward the student who pushed him), his original intention to help, and his repetition of the phrase “it's not fair.” Having met with Jacob previously, I was aware that his mother suffers from physical and mental health difficulties. When his mother is not doing well, he (as the parentified child) typically takes care of the household, performing tasks like cooking, cleaning, and helping with his two younger siblings and older autistic brother. In the past, Jacob has discussed both idealizing his mother and holding internalized anger that he rarely expresses at home because he worries his anger will “make her sick.”

I know sometimes when you are trying to help mom, there are times she gets upset with you for not doing it exactly right, or when your brothers start something, she will blame you. What just happened sounds familiar—you were trying to help your teacher by taking out the garbage when another student pushed you, and then you were the one who got in trouble.

Jacob nodded his head and explained that he was simply trying to help.

I moved into a more detailed inquiry, to see if there was a more recent stressor I was unaware of. When I asked how his mother was doing this week, Jacob revealed that his mother's health had deteriorated and his aunt had temporarily moved in. Jacob told me that he had been yelled at by both his mother and his aunt that morning, when his younger brother was not ready for school. I asked, “I wonder if when the student pushed you it reminded you of getting into trouble because of something your little brother did this morning?” Jacob nodded. The displacement was clear: He had been reminded of this incident at school and was reacting with anger based on his family dynamic, and worries connected to his mother.

My guess is that you were a mix of both worried and angry by the time you got to school, with what's happening at home. You were trying to help with the garbage like you try to help mom when she isn't doing well, so when you got pushed it was like your brother being late, and then when you got blamed by your teacher it was like your mom and aunt yelling, and it all came flooding back in. The problem is, you let out those feelings here. Even though there are some similar things, it's not totally the same, right? Can you tell me what is different?

Jacob nodded and was able to explain that the other student was probably just playing and did not mean to get him into trouble, and that his teacher did not usually yell at him or make him worried. Highlighting this important differentiation, I replied, “Right—and fighting the student or yelling at the teacher isn't going to solve this, but more importantly, it isn't going to make your mom better or have your family go any easier on you either.” Jacob stated that he knew this was true.

I reassured Jacob that I could help him let out those feelings of worry and anger connected to home so they did not explode out at school and planned to meet again. Jacob confirmed that he was willing to do that. He was able to return to the classroom without incident, with the entire intervention lasting less than 15 minutes.

In case example 2, the practitioner was available for an immediate engagement with disturbing behaviors as they were happening by listening for similarities between the current incident and traumatic stressors; asking for specific details to more effectively help Jacob understand how he was being triggered in school; providing psychoeducation about how these two events had become confused and aiding him in cognitively differentiating between the two; and, last, offering to provide further support to reduce future incidents.

Germane to the practice of school social work is the ability to work flexibly within a public health model to attend to trauma within the school setting. First, we suggest that a primary implication for school social workers is not to wait for explicit problems related to known traumatic experiences to emerge before addressing trauma in the school, but, rather, to follow a model of prevention-assessment-intervention. School social workers are in a unique position within the school system to disseminate trauma-informed material to both students and staff in a preventive capacity. Facilitating this implementation will help to establish a tone and sharpened focus within the school community, norming the process of articulating and engaging with traumatic material. In the aforementioned classroom case example, we have provided a sample of how school social workers might work with entire classrooms on a preventive basis regarding trauma, rather than waiting for individual referrals.

Second, in addition to functional behavior assessments and behavior intervention plans, school social workers maintain a keen eye for qualitative behavioral assessment ( National Association of Social Workers, 2012 ). Using this skill set within a trauma-informed model will help to identify those students in need who may be reluctant or resistant to explicitly ask for help. As called for by Walkley and Cox (2013) , we suggest that using the information presented in Table 1 will help school social workers understand, identify, and assess the impact of trauma on early adolescent developmental tasks. If school social workers engage on a classroom level in trauma psychoeducation and conversations, the information in Table 3 may assist with assessment of children and provide a basis for checking in individually with students as warranted.

Third, school social workers are well positioned to provide individual targeted, trauma-informed interventions based on previous knowledge of individual trauma and through widespread assessment ( Walkley & Cox, 2013 ). The individual case example provides one way of immediately engaging with students who are demonstrating trauma-based behaviors. In this model, school social workers engage in a brief inquiry addressing the current trauma to identify the trauma trigger, discuss the adverse experience in a calm but direct way, and help to differentiate between intrusive memories and the current situation at school. For this latter component, the focus is on cognitive discrimination and emotional regulation so that students can reengage in the classroom within a short time frame.

Fourth, given social work's roots in collaboration and community work, school social workers are encouraged to use a systems-based approach in partnering with allied practitioners and institutions ( D'Agostino, 2013 ), thus supporting the public health tenet of establishing and maintaining a link to the wider community. This may include referring students to regular clinical support in or out of the school. Although the implementation of a trauma-informed program will vary across schools, we suggest that school social workers have the capacity to use a public health school intervention model to ecologically address the psychosocial and behavioral issues stemming from trauma exposure.

As increasing attention is being given to adverse childhood experiences, a tiered approach that uses a public health framework in the schools is necessitated. Nevertheless, there are some limitations to this approach. First, although the interventions outlined here are rooted in prevention and early intervention, there are times when formal, intensive treatment outside of the school setting is warranted. Second, the ALIVE program has primarily been implemented by ALIVE practitioners; the results from piloting this public health framework in other school settings with existing school personnel, such as school social workers, will be necessary before widespread replication.

The public health framework of prevention-assessment-intervention promotes continual engagement with middle school students’ chronic exposure to traumatic stress. There is a need to provide both broad-based and individualized support that seeks to comprehensively ameliorate the social, emotional, and cognitive consequences on early adolescent developmental milestones associated with traumatic experiences. We contend that school social workers are well positioned to address this critical public health issue through proactive and widespread psychoeducation and assessment in the schools, and we have provided case examples to demonstrate one model of doing this work within the school day. We hope that this article inspires future writing about how school social workers individually and systemically address trauma in the school system. In alignment with Walkley and Cox (2013) , we encourage others to highlight their practice in incorporating trauma-informed, school-based programming in an effort to increase awareness of effective interventions.

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Module 7: Adolescence

Cognitive development during adolescence, learning outcomes.

• Explain Piaget’s theory on formal operational thought
• Describe cognitive abilities and changes during adolescence

Figure 1. Adolescents practice their developing abstract and hypothetical thinking skills, coming up with alternative interpretations of information.

Adolescence is a time of rapid cognitive development. Biological changes in brain structure and connectivity in the brain interact with increased experience, knowledge, and changing social demands to produce rapid cognitive growth. These changes generally begin at puberty or shortly thereafter, and some skills continue to develop as an adolescent ages. Development of executive functions, or cognitive skills that enable the control and coordination of thoughts and behavior, are generally associated with the prefrontal cortex area of the brain. The thoughts, ideas, and concepts developed at this period of life greatly influence one’s future life and play a major role in character and personality formation.

Perspectives and Advancements in Adolescent Thinking

There are two perspectives on adolescent thinking: constructivist and information-processing. The  constructivist perspective , based on the work of Piaget, takes a quantitative, stage-theory approach. This view hypothesizes that adolescents’ cognitive improvement is relatively sudden and drastic. The  information-processing perspective   derives from the study of artificial intelligence and explains cognitive development in terms of the growth of specific components of the overall process of thinking.

Improvements in basic thinking abilities generally occur in five areas during adolescence:

• Attention . Improvements are seen in selective attention (the process by which one focuses on one stimulus while tuning out another), as well as divided attention (the ability to pay attention to two or more stimuli at the same time).
• Memory . Improvements are seen in working memory and long-term memory.
• Processing Speed.  Adolescents think more quickly than children. Processing speed improves sharply between age five and middle adolescence, levels off around age 15, and does not appear to change between late adolescence and adulthood.
• Organization . Adolescents are more aware of their own thought processes and can use mnemonic devices and other strategies to think and remember information more efficiently.
• Metacognition . Adolescents can think about thinking itself. This often involves monitoring one’s own cognitive activity during the thinking process. Metacognition provides the ability to plan ahead, see the future consequences of an action, and provide alternative explanations of events.

Formal Operational Thought

In the last of the Piagetian stages, a child becomes able to reason not only about tangible objects and events, but also about hypothetical or abstract ones. Hence it has the name formal operational stage—the period when the individual can “operate” on “forms” or representations. This allows an individual to think and reason with a wider perspective. This stage of cognitive development, termed by Piaget as formal operational thought , marks a movement from an ability to think and reason from concrete visible events to an ability to think hypothetically and entertain what-if possibilities about the world. An individual can solve problems through abstract concepts and utilize hypothetical and deductive reasoning. Adolescents use trial and error to solve problems, and the ability to systematically solve a problem in a logical and methodical way emerges.

This video explains some of the cognitive development consistent with formal operational thought.

You can view the transcript for “Formal operational stage – Intro to Psychology” here (opens in new window) .

Formal Operational Thinking in the Classroom

School is a main contributor in guiding students towards formal operational thought. With students at this level, the teacher can pose hypothetical (or contrary-to-fact) problems: “What  if  the world had never discovered oil?” or “What  if  the first European explorers had settled first in California instead of on the East Coast of the United States?” To answer such questions, students must use hypothetical reasoning ,  meaning that they must manipulate ideas that vary in several ways at once, and do so entirely in their minds.

The hypothetical reasoning that concerned Piaget primarily involved scientific problems. His studies of formal operational thinking therefore often look like problems that middle or high school teachers pose in science classes. In one problem, for example, a young person is presented with a simple pendulum, to which different amounts of weight can be hung (Inhelder & Piaget, 1958). The experimenter asks: “What determines how fast the pendulum swings: the length of the string holding it, the weight attached to it, or the distance that it is pulled to the side?” The young person is not allowed to solve this problem by trial-and-error with the materials themselves, but must reason a way to the solution mentally. To do so systematically, they must imagine varying each factor separately, while also imagining the other factors that are held constant. This kind of thinking requires facility at manipulating mental representations of the relevant objects and actions—precisely the skill that defines formal operations.

As you might suspect, students with an ability to think hypothetically have an advantage in many kinds of school work: by definition, they require relatively few “props” to solve problems. In this sense they can in principle be more self-directed than students who rely only on concrete operations—certainly a desirable quality in the opinion of most teachers. Note, though, that formal operational thinking is desirable but not  sufficient  for school success, and that it is far from being the only way that students achieve educational success. Formal thinking skills do not insure that a student is motivated or well-behaved, for example, nor does it guarantee other desirable skills. The fourth stage in Piaget’s theory is really about a particular kind of formal thinking, the kind needed to solve scientific problems and devise scientific experiments. Since many people do not normally deal with such problems in the normal course of their lives, it should be no surprise that research finds that many people never achieve or use formal thinking fully or consistently, or that they use it only in selected areas with which they are very familiar (Case & Okomato, 1996). For teachers, the limitations of Piaget’s ideas suggest a need for additional theories about development—ones that focus more directly on the social and interpersonal issues of childhood and adolescence.

Hypothetical and abstract thinking 

One of the major premises of formal operational thought is the capacity to think of possibility, not just reality. Adolescents’ thinking is less bound to concrete events than that of children; they can contemplate possibilities outside the realm of what currently exists. One manifestation of the adolescent’s increased facility with thinking about possibilities is the improvement of skill in  deductive reasoning (also called top-down reasoning), which leads to the development of hypothetical thinking . This provides the ability to plan ahead, see the future consequences of an action and to provide alternative explanations of events. It also makes adolescents more skilled debaters, as they can reason against a friend’s or parent’s assumptions. Adolescents also develop a more sophisticated understanding of probability.

This appearance of more systematic, abstract thinking allows adolescents to comprehend the sorts of higher-order abstract logic inherent in puns, proverbs, metaphors, and analogies. Their increased facility permits them to appreciate the ways in which language can be used to convey multiple messages, such as satire, metaphor, and sarcasm. (Children younger than age nine often cannot comprehend sarcasm at all). This also permits the application of advanced reasoning and logical processes to social and ideological matters such as interpersonal relationships, politics, philosophy, religion, morality, friendship, faith, fairness, and honesty.

Metacognition

Metacognition refers to “thinking about thinking.” It is relevant in social cognition as it results in increased introspection, self-consciousness, and intellectualization. Adolescents are much better able to understand that people do not have complete control over their mental activity. Being able to introspect may lead to forms of egocentrism, or self-focus, in adolescence.  Adolescent egocentrism  is a term that David Elkind used to describe the phenomenon of adolescents’ inability to distinguish between their perception of what others think about them and what people actually think in reality. Elkind’s theory on adolescent egocentrism is drawn from Piaget’s theory on cognitive developmental stages, which argues that formal operations enable adolescents to construct imaginary situations and abstract thinking.

Accordingly, adolescents are able to conceptualize their own thoughts and conceive of other people’s thoughts.  However, Elkind pointed out that adolescents tend to focus mostly on their own perceptions, especially on their behaviors and appearance, because of the “physiological metamorphosis” they experience during this period. This leads to adolescents’ belief that other people are as attentive to their behaviors and appearance as they are of themselves.  According to Elkind, adolescent egocentrism results in two distinct problems in thinking: the imaginary audience and the personal fable .  These likely peak at age fifteen, along with self-consciousness in general.

Imaginary audience is a term that Elkind used to describe the phenomenon that an adolescent anticipates the reactions of other people to them in actual or impending social situations. Elkind argued that this kind of anticipation could be explained by the adolescent’s preoccupation that others are as admiring or as critical of them as they are of themselves.   As a result, an audience is created, as the adolescent believes that they will be the focus of attention.

However, more often than not the audience is imaginary because in actual social situations individuals are not usually the sole focus of public attention. Elkind believed that the construction of imaginary audiences would partially account for a wide variety of typical adolescent behaviors and experiences; and imaginary audiences played a role in the self-consciousness that emerges in early adolescence. However, since the audience is usually the adolescent’s own construction, it is privy to their own knowledge of themselves. According to Elkind, the notion of imaginary audience helps to explain why adolescents usually seek privacy and feel reluctant to reveal themselves–it is a reaction to the feeling that one is always on stage and constantly under the critical scrutiny of others.

Elkind also addressed that adolescents have a complex set of beliefs that their own feelings are unique and they are special and immortal.  Personal fable  is the term Elkind created to describe this notion, which is the complement of the construction of imaginary audience. Since an adolescent usually fails to differentiate their own perceptions and those of others, they tend to believe that they are of importance to so many people (the imaginary audiences) that they come to regard their feelings as something special and unique. They may feel that only they have experienced strong and diverse emotions, and therefore others could never understand how they feel. This uniqueness in one’s emotional experiences reinforces the adolescent’s belief of invincibility, especially to death.

This adolescent belief in personal uniqueness and invincibility becomes an illusion that they can be above some of the rules, disciplines and laws that apply to other people; even consequences such as death (called the invincibility fable ) .  This belief that one is invincible removes any impulse to control one’s behavior (Lin, 2016). [1] Therefore, adolescents will engage in risky behaviors, such as drinking and driving or unprotected sex, and feel they will not suffer any negative consequences.

Intuitive and Analytic Thinking

Piaget emphasized the sequence of thought throughout four stages. Others suggest that thinking does not develop in sequence, but instead, that advanced logic in adolescence may be influenced by intuition. Cognitive psychologists often refer to intuitive and analytic thought as the dual-process model ; the notion that humans have two distinct networks for processing information (Kuhn, 2013.) [2] Intuitive thought is automatic, unconscious, and fast, and it is more experiential and emotional.

In contrast, a nalytic thought is deliberate, conscious, and rational (logical). While these systems interact, they are distinct (Kuhn, 2013). Intuitive thought is easier, quicker, and more commonly used in everyday life. As discussed in the adolescent brain development section earlier in this module, the discrepancy between the maturation of the limbic system and the prefrontal cortex, may make teens more prone to emotional intuitive thinking than adults. As adolescents develop, they gain in logic/analytic thinking ability and sometimes regress, with social context, education, and experiences becoming major influences. Simply put, being “smarter” as measured by an intelligence test does not advance cognition as much as having more experience, in school and in life (Klaczynski & Felmban, 2014). [3]

Risk-taking

Because most injuries sustained by adolescents are related to risky behavior (alcohol consumption and drug use, reckless or distracted driving, and unprotected sex), a great deal of research has been done on the cognitive and emotional processes underlying adolescent risk-taking. In addressing this question, it is important to distinguish whether adolescents are more likely to engage in risky behaviors (prevalence), whether they make risk-related decisions similarly or differently than adults (cognitive processing perspective), or whether they use the same processes but value different things and thus arrive at different conclusions. The behavioral decision-making theory proposes that adolescents and adults both weigh the potential rewards and consequences of an action. However, research has shown that adolescents seem to give more weight to rewards, particularly social rewards, than do adults. Adolescents value social warmth and friendship, and their hormones and brains are more attuned to those values than to long-term consequences (Crone & Dahl, 2012). [4]

Figure 2 . Teenage thinking is characterized by the ability to reason logically and solve hypothetical problems such as how to design, plan, and build a structure. (credit: U.S. Army RDECOM)

Some have argued that there may be evolutionary benefits to an increased propensity for risk-taking in adolescence. For example, without a willingness to take risks, teenagers would not have the motivation or confidence necessary to leave their family of origin. In addition, from a population perspective, there is an advantage to having a group of individuals willing to take more risks and try new methods, counterbalancing the more conservative elements more typical of the received knowledge held by older adults.

Relativistic Thinking

Adolescents are more likely to engage in relativistic thinking —in other words, they are more likely to question others’ assertions and less likely to accept information as absolute truth. Through experience outside the family circle, they learn that rules they were taught as absolute are actually relativistic. They begin to differentiate between rules crafted from common sense (don’t touch a hot stove) and those that are based on culturally relative standards (codes of etiquette). This can lead to a period of questioning authority in all domains.

As we continue through this module, we will discuss how this influences moral reasoning, as well as psychosocial and emotional development. These more abstract developmental dimensions (cognitive, moral, emotional, and social dimensions) are not only more subtle and difficult to measure, but these developmental areas are also difficult to tease apart from one another due to the inter-relationships among them. For instance, our cognitive maturity will influence the way we understand a particular event or circumstance, which will in turn influence our moral judgments about it, and our emotional responses to it. Similarly, our moral code and emotional maturity influence the quality of our social relationships with others.

• Linn, P. (2016). Risky behaviors: Integrating adolescent egocentrism with the theory of planned behavior. Review of General Psychology, 20 (4), 392-398. ↵
• Kuhn, D. (2013). Reasoning. In Philip D. Zelazo (Ed.), The Oxford handbook of developmental psychology (Vol. 1, pp. 744-764). New York: NY: Oxford University Press. ↵
• Klaczynski, P.A. & Felmban, W.S. (2014). Heuristics and biases during adolescence: Developmental reversals and individual differences. In Henry Markovitz (Ed.), The developmental psychology of reasoning and decision making (pp. 84-111). New York, NY: Psychology Press. ↵
• Crone, E.A., & Dahl, R.E. (2012). Understanding adolescence as a period of social-affective engagement and goal flexibility. Nature Reviews Neuroscience, 13 (9), 636-650. ↵
• Adolescent development; cognitive development. Authored by : Jennifer Lansford. Provided by : Duke University. Located at : http://nobaproject.com/modules/adolescent-development?r=LDE2MjU3 . Project : The Noba Project. License : CC BY-NC-SA: Attribution-NonCommercial-ShareAlike
• Stages of Development. Authored by : OpenStax College. Located at : http://cnx.org/contents/[email protected]:1/Psychology . License : CC BY: Attribution . License Terms : Download for free at http://cnx.org/content/col11629/latest/.
• Adolescence. Provided by : Boundless. Located at : https://courses.lumenlearning.com/boundless-psychology/chapter/adolescence/ . License : CC BY-SA: Attribution-ShareAlike
• Adolescent egocentrism. Located at : https://en.wikipedia.org/wiki/Adolescent_egocentrism#cite_note-Elkindeia-1 . License : CC BY-SA: Attribution-ShareAlike
• adolescent boys. Authored by : An Min. Provided by : Pxhere. Located at : https://pxhere.com/en/photo/1515959 . License : CC0: No Rights Reserved
• Adolescence. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Adolescence . License : CC BY-SA: Attribution-ShareAlike
• Educational Psychology. Authored by : Kelvin Seifert. Provided by : OpenStax. Located at : https://cnx.org/contents/[email protected]:9u2dcFad@2/Cognitive-development-the-theory-of-Jean-Piaget . License : CC BY: Attribution . License Terms : Download for free at http://cnx.org/contents/[email protected].
• Formal operational stage - Intro to Psychology. Provided by : Udacity. Located at : https://www.youtube.com/watch?v=hvq7tq2fx1Y . License : Other . License Terms : Standard YouTube License

• Second Opinion

Cognitive Development in the Teen Years

What is cognitive development.

Cognitive development means the growth of a child’s ability to think and reason. This growth happens differently from ages 6 to 12, and from ages 12 to 18.

Children ages 6 to 12 years old develop the ability to think in concrete ways. These are called concrete operations. These things are called concrete because they’re done around objects and events. This includes knowing how to:

Combine (add)

Separate (subtract or divide)

Order (alphabetize and sort)

Transform objects and actions (change things, such as 5 pennies = 1 nickel)

Ages 12 to 18 is called adolescence. Kids and teens in this age group do more complex thinking. This type of thinking is also known as formal logical operations. This includes the ability to:

Do abstract thinking. This means thinking about possibilities.

Reason from known principles. This means forming own new ideas or questions.

Consider many points of view. This means to compare or debate ideas or opinions.

Think about the process of thinking. This means being aware of the act of thought processes.

How cognitive growth happens during the teen years

From ages 12 to 18, children grow in the way they think. They move from concrete thinking to formal logical operations. It’s important to note that:

Each child moves ahead at their own rate in their ability to think in more complex ways.

Each child develops their own view of the world.

Some children may be able to use logical operations in schoolwork long before they can use them for personal problems.

When emotional issues come up, they can cause problems with a child’s ability to think in complex ways.

The ability to consider possibilities and facts may affect decision-making. This can happen in either positive or negative ways.

Types of cognitive growth through the years

A child in early adolescence:

Uses more complex thinking focused on personal decision-making in school and at home

Begins to show use of formal logical operations in schoolwork

Begins to question authority and society's standards

Begins to form and speak his or her own thoughts and views on many topics. You may hear your child talk about which sports or groups he or she prefers, what kinds of personal appearance is attractive, and what parental rules should be changed.

A child in middle adolescence:

Has some experience in using more complex thinking processes

Expands thinking to include more philosophical and futuristic concerns

Often questions more extensively

Often analyzes more extensively

Thinks about and begins to form his or her own code of ethics (for example, What do I think is right?)

Thinks about different possibilities and begins to develop own identity (for example, Who am I? )

Thinks about and begins to systematically consider possible future goals (for example, What do I want? )

Thinks about and begins to make his or her own plans

Begins to think long-term

Uses systematic thinking and begins to influence relationships with others

A child in late adolescence:

Uses complex thinking to focus on less self-centered concepts and personal decision-making

Has increased thoughts about more global concepts, such as justice, history, politics, and patriotism

Often develops idealistic views on specific topics or concerns

May debate and develop intolerance of opposing views

Begins to focus thinking on making career decisions

Begins to focus thinking on their emerging role in adult society

How you can encourage healthy cognitive growth

To help encourage positive and healthy cognitive growth in your teen, you can:

Include him or her in discussions about a variety of topics, issues, and current events.

Encourage your child to share ideas and thoughts with you.

Encourage your teen to think independently and develop his or her own ideas.

Help your child in setting goals.

Challenge him or her to think about possibilities for the future.

Compliment and praise your teen for well-thought-out decisions.

Help him or her in re-evaluating poorly made decisions.

If you have concerns about your child's cognitive development, talk with your child's healthcare provider. 

Related Links

• Brain and Behavior
• Child and Adolescent Mental Health
• The Growing Child: School-Age (6 to 12 Years)
• Understanding the Teen Brain
• Topic Index

Related Topics

Adolescent Growth and Development

Cognitive Development in Adolescence

Growth and Development in Children with Congenital Heart Disease

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Adolescent Brain Cognitive Development Study (ABCD Study®)

Landmark study of adolescent brain development renews for additional seven years

With nearly $290M of new funding for seven years to research institutions around the country, the National Institutes of Health renewed its commitment to the  Adolescent Brain Cognitive Development SM Study (ABCD Study ® ) the largest long-term study of brain development and child health ever conducted in the United States.

“The next phase of the ABCD study will help us understand the effects of substance use, as well as environmental, social, genetic, and other biological factors on the developing adolescent brain,” said NIDA Director Nora D. Volkow, M.D. “Since the participants are now in their vulnerable middle school years or are beginning high school, this is a critical time to learn more about what enhances or disrupts a young person’s life trajectory.”  Read the Press Release .

2023 ABCD Annual Curated Data Release 5.0

ABCD Data Release 5.0 has been shared. The ABCD Study® and NDA have changed the way tabulated data are downloaded for the 5.0 release. The imaging and non-imaging tabulated data are packaged as a single .zip file containing all of the relevant tables for the domain. To obtain the data you must be logged into NDA (authenticated). Visit https://nda.nih.gov/study.html?id=2147 and select the “ABCD 5.0 Tabulated Release Data” file in the Results section to download all tabulated imaging and non-imaging 5.0 data. As in past releases, neuroimaging and other file-based data (e.g., genomics; raw behavioral data) are accessible via the NDA download manager tool.

All data access information is documented on the NDA ABCD Featured Dataset page and includes pointers to an external ABCD Study wiki  where data release notes and general information about the data resource are provided. All users should review the release notes for detailed information on the released data. Note that with the change to how release notes are made available, they will be updated regularly and thus users are advised to check https://wiki.abcdstudy.org/release-notes/start-page.html for the most up-to-date information. Release notes for qualified users only (i.e., non-public) are available at https://nda.nih.gov/study.html?id=2147 . The 5.0 data ontology and dictionary can be viewed at https://data-dict.abcdstudy.org/ .

The table below highlights key differences between the 4.0 and 5.0 data releases. Note that the Data Exploration and Analysis Portal (DEAP) has been decommissioned as of June 1, 2023. In addition, study creation no longer works with how the data are shared this year. We anticipate reinstating it with the 6.0 data release.

Data Release 5.0 contains early longitudinal data on the full participant cohort, including 2-year follow-up neuroimaging data (second imaging timepoint), as well as phenotypic data through the 3-year follow-up visits. Interim data are available for the 4-year follow-up visit, including some of the neuroimaging data. Also available are ABCD derived scores from linked external school performance and environmental data, including the Stanford Education Data Archive, EPA Smart Location Database, American Community Survey Area Deprivation Index, FBI’s Uniform Crime Report, lead exposure risk and air pollution indices, among others. Smokescreen genotyping array data with TOPMed imputations are available as well. These include common variations, as well as variations associated with addiction, smoking behavior, and nicotine metabolism.

ChildArt  ABCD Issue

This special issue of  ChildArt  introduces the intersection of the arts and neuroscience through an overview of the ABCD Study ® . It presents some of the data from the study, as well as other research looking at the impact of the arts on child development. The issue combines the work of experts in neuroscience, world renowned artists, specialists in child development, and others. Topics covered include the juncture between the arts and human culture, the developing adolescent brain, the interaction between cultural and biological processes and artistic creation, the interface of the arts and science as a multisensory experience, insights from the neuroscience of dance and music, and more.  We hope that this special issue will stimulate creativity and innovation in research on the impact of the arts on child development as well as encourage researchers to leverage the ABCD Study data to advance research on a wide range of other topics.

Podcast: With Neuroimaging, Large NIH Study Could Shine a Light on the Adolescent Brain

JAMA, August 14, 2019: Audio 25 min 18 sec

In this Medical News podcast , Jennifer Abbasi interviews the director of the ABCD study, Gaya Dowling, PhD, about this long-term study of brain development and child health in the United States.

Science Magazine, January 3, 2018 Huge study of teen brains could reveal roots of mental illness, impacts of drug abuse

CBS - 60 Minutes, December 9th, 2018

Please note: The ABCD study is assessing brain development in children throughout adolescence, while tracking social, behavioral, physical and environmental factors that may affect brain development and other health outcomes. Screen time is only one of many measures evaluated as part of the study protocol.

• Watch video (12:55)
• For additional articles about the ABCD study, visit  https://abcdstudy.org/news/
• View all NIDA press releases related to the ABCD Study

Study Enrollment Completed

ABCD Study Enrollment has completed as of 10/21/18 - The total enrollment stands at 11,880

• See announcement - ABCD study completes enrollment, announces opportunities for scientific engagement (12/3/18)

What Is the Adolescent Brain Cognitive Development Study SM (ABCD Study ® )?

ABCD is a landmark study on brain development and child health supported by the National Institutes of Health (NIH). This project will increase our understanding of environmental, social, genetic, and other biological factors that affect brain and cognitive development and that can enhance or disrupt a young person’s life trajectory.

For an overview of how the ABCD study got started, see article co-authored by NIDA Director Dr. Nora Volkow, NIAAA Director Dr. George Koob, NINDS Director Dr. Walter Koroshetz, and other NIH scientists: The conception of the ABCD study: From substance use to a broad NIH collaboration , published in Developmental Cognitive Neuroscience. 

How Will the ABCD Study ® Be Implemented?

Unique in its scope and duration, the ABCD study will:

• Recruit 11,900 healthy children, ages 9 to 10 across the United States, with the goal of retaining 10,000 into early adulthood.
• Use advanced brain imaging to observe brain growth with unprecedented precision.
• Examine how biology and environment interact and relate to developmental outcomes such as physical health, mental health, and life achievements including academic success.

Why Do We Need the ABCD Study ® ?

Adolescence is a period of dramatic brain development in which children are exposed to all sorts of experiences. Yet, our understanding of precisely how these experiences interact with each other and a child’s biology to affect brain development and, ultimately, social, behavioral, health, and other outcomes, is still incomplete. As the only study of its kind, the ABCD study will yield critical insights into the foundational aspects of adolescence that shape a person’s future.

What Will We Learn from the ABCD Study ® ?

The size and scope of the study will allow scientists to:

• Identify individual developmental trajectories (e.g., brain, cognitive, emotional, academic) and the factors that can affect them.
• Understand the role of genetic vs. environmental factors on development.
• Examine the effects of physical activity, screen time, and sleep, as well as sports and other injuries, on brain development and other outcomes.
• Study the onset and progression of mental disorders.
• Determine how exposure to substances (e.g., alcohol, marijuana, nicotine, caffeine) and new ways of taking them (e.g., vaping, dabbing) affect developmental outcomes and vice versa.
• Understand the impact of changing state and local policies and laws (e.g., marijuana, tobacco, alcohol) on youth drug use and related health and development.

Scientific publications authored by ABCD Study investigators, collaborators, and other researchers can be found at  https://abcdstudy.org/scientists-publications.html . 

Who Is Leading the ABCD Study ® ?

The ABCD study is led by the Collaborative Research on Addiction at NIH (CRAN):

• National Institute on Drug Abuse (NIDA)
• National Institute on Alcohol Abuse and Alcoholism (NIAAA)
• National Cancer Institute (NCI)

In partnership with:

• Centers for Disease Control and Prevention (CDC)
• Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)
• National Institute of Mental Health (NIMH)
• National Institute of Minority Health and Health Disparities (NIMHD)
• National Institute of Neurological Disorders and Stroke (NINDS)
• NIH Office of Behavioral and Social Sciences Research (OBSSR)
• NIH Office of Research on Women’s Health (ORWH)

For additional information on ABCD, please contact: Dr. Gaya Dowling, Director, ABCD Project at 301-443-4877 or at [email protected] or visit abcdstudy.org

For more information for researchers, visit: https://www.addictionresearch.nih.gov/abcd-study

Download : Flyer on the ABCD Study (PDF, 2.7MB)

A deep dive into adolescent development

Spearheaded by psychologists, a new long-term study will produce mountains of open-access data on adolescents

By Kirsten Weir

June 2019, Vol 50, No. 6

Print version: page 20

• Open Science

In January, the National Institutes of Health (NIH) released the first complete baseline data set from the largest-ever study of adolescent health and development. The Adolescent Brain Cognitive Development (ABCD) Study will follow 11,874 children, starting at ages 9 and 10, for the next decade.

The ABCD Study will collect mountains of data: on neurological development, sociocultural and psychological factors, mental and physical health, environmental exposures, substance use, academic achievement and more. It's a huge undertaking, with huge implications for understanding children's development as they move through adolescence and into early adulthood.

"This is a massive effort, notable for both its scope and its depth," says Sandra Brown, PhD, vice chancellor for research and professor of psychology and psychiatry at the University of California, San Diego, and co-director of the ABCD Coordinating Center.

Because the project looks at so many different aspects of development, researchers will be able to mine the data to understand problems such as substance use and the emergence of mental illness, as well as the normal course of healthy adolescent development, adds Sara Jo Nixon, PhD, a professor of psychology at the University of Florida and a principal investigator of the study. "Often, we're interested in what went wrong, and indeed we'll have data to speak to those problems. But we'll also have data to look at resiliency and the kinds of factors—whether biological, psychological, social or cultural—that really nurture healthy development," she says. "This study is the epitome of what any psychological scientist would love to do."

ABCD basics

Launched in 2016, the ABCD Study is coordinated by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, with support from numerous other NIH institutes and offices as well as the Centers for Disease Control and Prevention. To assist in recruitment, APA provided NIH with a statement encouraging families to consider participating, and an APA staff member serves on the ABCD national liaison board.

The study encompasses 21 research sites across the country and will follow participants for 10 years. It's an interdisciplinary effort, but psychologists Brown and Terry Jernigan, PhD, also at the University of California, San Diego, sit at the helm of the Coordinating Center, and 26 of the 40 principal investigators are psychologists. The study was carefully planned from the start to include a diverse group of adolescents, Brown says.

"We worked with high-quality epidemiologists, so the sample we're bringing to the table is a good reflection of the socio­demographics of the United States," she says.

To manage such a large project, the study's designers included funding for a co­­ordinating center and a data management center. There's also a retention committee that works to ensure that as many of the participants as possible stick it out over the next decade—no small feat, considering the time investment. The project involves neuroimaging, genetic testing and behavioral testing as well as numerous questionnaires for the children, their parents and teachers. Participants will wear sensors 'round-the-clock for several weeks, most likely once a year, to collect data about activity levels, heart rate and sleep patterns. Investigators will even collect hair samples and baby teeth to study exposures to environmental toxins. The study includes more than 2,000 twins and triplets, allowing researchers to begin to tease apart genetic susceptibility from environmental influences.

As the children move into their teenage years, researchers will be able to explore questions about substance use, physical activity, sports injuries, sleep, learning and the emergence of mental health problems—and that's just for starters, says psychologist Susan Tapert, PhD, a professor at the University of California, San Diego, and an associate director of the ABCD Coordinating Center. "There's really an infinite number of questions that can be addressed here."

Principal investigators aren't the only scientists who will be able to answer them. The study was developed with an open-access model, and the data collected are freely available to any qualified researcher who wants to tap into them via the National Institute of Mental Health Data Archive .

The open-science philosophy will drive the science forward faster, while the large sample size and methodologically rigorous study design will ensure that the data are trustworthy, says Raul Gonzalez, PhD, an ABCD principal investigator and professor of psychology at Florida International University. "There is a replication crisis in the sciences, and a lot of that crisis is partially due to small sample sizes and a bias to publish significant results," he says. "With this study, there is an opportunity to assess a lot of questions that are controversial in our field."

Another unique element of the open-access model: Lead investigators won't have preferential access to data before they've been made available to the general public. Whether you're a principal investigator at one of the study sites or a grad student far from the action, you will have the same opportunity to access the same information at the same time through planned data releases. "That says a lot about the commitment of the leadership team to make sure transparency and reproducibility are addressed head-on," says Nixon.

Early findings

Investigators finished recruiting participants only last year, yet they have already begun drawing insights from the study. In one analysis of the baseline data, Aaron Blashill, PhD, and Jerel Calzo, PhD, of San Diego State University, explored differences in mood disorders and suicidality between 9- and 10-year-olds who identified as gay, lesbian or bisexual and those who identified as heterosexual. The rate of mood disorders was 22.5 percent for sexual minority children, compared with 6.9 percent for heterosexual children. Similarly, 19.1 percent of sexual minority children experienced suicidal thoughts, while just 4.6 percent of heterosexual children did ( Journal of Affective Disorders , Vol. 246, No. 1, 2019).

Other groups have pulled from ABCD data to explore a pressing 21st-century problem: the effects of screen time. Jeremy Walsh, PhD, now at the University of British Columbia Okanagan, and colleagues explored physical activity, screen-time behavior and sleep among more than 4,500 of the participants. They found that children who met recommended guidelines for these activities—at least 60 minutes of physical activity, no more than two hours of recreational screen time and 9 to 11 hours of sleep daily—had better cognition than those who did not, as measured by tests of attention, language abilities, episodic memory, working memory, executive function and processing speed. Unfortunately, though, only half of the children in the sample got the recommended amount of sleep, just 36 percent had fewer than two hours of screen time and a mere 17 percent engaged in the recommended amount of daily exercise, the researchers found ( The Lancet Child & Adolescent Health , Vol. 2, No. 11, 2018).

Meanwhile, Tapert and colleagues found a link between screen time and a variety of complex structural brain changes, including cortical thickness, sulcal depth and gray matter volume. Different patterns of structural changes were related to downstream outcomes such as externalizing psycho­pathology and fluid and crystallized intelligence. But the changes differed depending on the type of screen media—and they weren't all bad (or all good) ( Neuroimage , Vol. 185, No. 1, 2019). "Kids who frequently played video games tended to have poorer mental health profiles and more family conflict, for example, while kids who were engaged in social media tended to have slightly better social and mental health functioning," she says. "It's not just how much screen time a child gets, but what they're doing."

With a single time point of data, it's too soon to make conclusions about the pros and cons of different screen media activities, Tapert notes. But as researchers follow the children in the years to come, they hope to be able to paint a more detailed picture of the effects of screen time on the brain.

A study that evolves

A lot can change in a decade. New social media platforms pop up almost overnight. Drug laws change, and the popularity of certain substances of abuse can wax and wane. New genetic tests and biomarkers may be discovered, new sensor technology could become available and neuroimaging techniques will be refined. The ABCD investigators have designed the study to accommodate such changes, so that new survey questions can be added and new technologies can be incorporated in future waves of data collection. "We have structures within ABCD that allow us to maintain enough continuity, so we can look at change in a systematic way and also augment the study using new methodologies," Brown says.

With its breadth, depth and flexible experimental design, the ABCD Study will serve as a model for other large-scale, long-term projects, investigators say. It also serves to showcase just how much psychology can do. "This is truly team science, led in large part by psychologists," Nixon says. "It speaks to the strength of our science, and the opportunity for psychologists to play a leading role in inter­disciplinary research." 

The Structure of Cognition in 9 and 10 Year-Old Children and Associations With Problem Behaviors:Findings From the ABCD Study's Baseline Neurocognitive Battery Thompson, W.K., et al. Developmental Cognitive Neuroscience , 2018

A Description of the ABCD Organizational Structure and Communication Framework Auchter, A.M., et al. Developmental Cognitive Neuroscience , 2018

Adolescent Neurocognitive Development and Impacts of Substance Use:Overview of the Adolescent Brain Cognitive Development (ABCD) Baseline Neurocognition Battery Luciana, M., et al. Developmental Cognitive Neuroscience , 2018

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