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In early adolescence, children begin to develop the capacity for abstract, logical thought. This increased sophistication leads to an enhanced awareness of self and the ability to reflect on one’s own being. Because of the many noticeable physical changes of adolescence, this self-awareness often turns into self-consciousness, with an accompanying feeling of awkwardness. The adolescent also has a preoccupation with physical appearance and attractiveness and a heightened sensitivity to differences from peers.

Adolescents also apply their new reflective capabilities to moral issues. Preadolescents understand right and wrong as fixed and absolute. Older adolescents often question standards of behavior and may reject traditions—to the consternation of parents. Ideally, this reflection culminates in the development and internalization of the adolescent’s own moral code.

As adolescents encounter schoolwork that is more complex, they begin to identify areas of interest as well as relative strengths and weaknesses. Adolescence is a period during which young people may begin to consider career options, although most do not have a clearly defined goal. Parents and clinicians must be aware of the adolescent’s capabilities, help the adolescent formulate realistic expectations, and be prepared to identify impediments to learning that need remediation, such as learning disabilities, attention problems, behavior problems, or inappropriate learning environments.

Many adolescents begin to engage in risky behaviors, such as fast driving. Many adolescents begin to experiment sexually, and some may engage in risky sexual practices. Some adolescents may engage in illegal activities, such as theft and illicit drug use. Experts speculate that these behaviors occur in part because adolescents tend to overestimate their own abilities in preparation for leaving their home. Studies of the nervous system also have shown that the parts of the brain that suppress impulses are not fully mature until early adulthood.

During adolescence, the regions of the brain that control emotions develop and mature. This phase is characterized by seemingly spontaneous outbursts that can be challenging for parents and teachers who often receive the brunt. Adolescents gradually learn to suppress inappropriate thoughts and actions and replace them with goal-oriented behaviors.

The emotional aspect of growth is most trying, often taxing the patience of parents, teachers, and clinicians. Emotional lability is a direct result of neurologic development during this period, as the parts of the brain that control emotions mature. Frustration may also arise from growth in multiple domains.

A major area of conflict arises from the adolescent’s desire for more freedom, which clashes with the parents’ strong instincts to protect their children from harm. Parents may need help in renegotiating their role and slowly allowing their adolescents more privileges as well as expecting them to accept greater responsibility for themselves and within the family.

Communication within even stable families can be difficult and is worsened when families are divided or parents have emotional problems of their own. Clinicians can be of great help by offering adolescents and parents sensible, practical, concrete, supportive help while facilitating communication within the family.

The family is the center of social life for children. During adolescence, the peer group begins to replace the family as the child’s primary social focus. Peer groups are often established because of distinctions in dress, appearance, attitudes, hobbies, interests, and other characteristics that may seem profound or trivial to outsiders. Initially, peer groups are usually same-sex but typically become mixed later in adolescence. These groups assume an importance to adolescents because they provide validation for the adolescent’s tentative choices and support in stressful situations.

Adolescents who find themselves without a peer group may develop intense feelings of being different and alienated. Although these feelings usually do not have permanent effects, they may worsen the potential for dysfunctional or antisocial behavior. At the other extreme, the peer group can assume too much importance, also resulting in antisocial behavior. Gang membership is more common when the home and social environments are unable to counterbalance the dysfunctional demands of a peer group.

Clinicians should screen all adolescents for mental health disorders, such as depression, bipolar disorder, and anxiety. Mental health disorders increase in incidence during this stage of life and may result in suicidal thinking or behavior. Psychotic disorders, such as schizophrenia, although rare, most often come to attention during late adolescence. Eating disorders, such as anorexia nervosa and bulimia nervosa, are relatively common among girls, but may also occur in boys, and may be difficult to detect because adolescents go to great lengths to hide the behaviors and weight changes.

Illicit drug use typically begins during adolescence.

Alcohol use is common and is the substance most often used by adolescents. The Monitoring the Future Survey on Drug Use reported that in 2021 by 12th grade, 54% of adolescents have tried alcohol, and nearly 26% are considered current drinkers (having consumed alcohol within the past month) (1). Binge drinking is common and leads to both acute and chronic health risks. Research has shown that adolescents who start drinking alcohol at a young age are more likely to develop an alcohol use disorder as an adult. For example, adolescents who start drinking at age 13 are 5 times more likely to develop an alcohol use disorder than those who start drinking at age 21.

Rates of combustible tobacco use among adolescents fell dramatically in the 1990s and 2000s and continue to decline. In 2021, about 4.1% of 12th graders reported current cigarette use (smoked in the previous 30 days), down from 28.3% in 1991 and from 5.7% in 2019; only about 2% report smoking every day (1).

Current e-cigarette use (nicotine vaping, not counting other substances) among 12th graders increased markedly from 11% in 2017 to 25.5% in 2019. In 2021, e-cigarette use decreased to 19.6%, and about 40.5% of 12th graders tried e-cigarettes (nicotine and other substances), which is a decrease from 45.6% in 2019 (1).

In 2021, the prevalence of current cannabis (marijuana) use among high school seniors was 19.5%, which is a decrease from 22.3% in 2019. About 38.6% of high school seniors reported having used cannabis one or more times in their life (1).

Use of other illicit drugs is much less common, although misuse of prescription drugs, including drugs for pain and stimulants, is on the rise.

Parents can have a strong positive influence on their children by setting a good example (eg, using alcohol in moderation, avoiding use of illicit drugs), sharing their values, and setting high expectations regarding staying away from drugs. Parents also should teach children that prescription medications should be used only as directed by a health care professional. All adolescents should be confidentially screened for substance use. Appropriate advice should be given as part of routine health care because even very brief interventions by physicians and health care professional have been shown to decrease substance use by adolescents.

In addition to adapting to bodily changes, the adolescent must become comfortable with the role of adult and must put sexual urges into perspective; sexual urges can be very strong and sometimes frightening to adolescents.

As adolescents navigate their sexuality, they may also begin to question their gender identity.

• Sex refers to a person's biologic status: male, female, or intersex.

• Sexual orientation or identity refers to the gender to which a person is sexually attracted (if any).

• Gender identity is the subjective sense of knowing to which gender one belongs; ie, whether people regard themselves as male, female, transgender, or another identifying term (eg, genderqueer, nonbinary, agender).

• Gender expression is the objective, public expression of gender identity and includes everything that people say and do to indicate to themselves and to others the degree to which they are the gender that they identify with.

Gender identity starts to develop early on, but may evolve over time. In a subset of children and adolescents, the sex they were assigned at birth does not match their gender identity. This mismatch can cause considerable psychologic distress known as gender dysphoria. Dysphoria is often worsened by lack of acceptance from family members and peers or by threats of violence. Evidence shows that gender-affirming care is integral to reducing the distress caused by gender dysphoria. In certain situations, medical intervention may be warranted to help align physical characteristics with gender identity.

Some adolescents struggle with the issue of sexual identity and may be afraid to reveal their sexual orientation or gender identity to friends or family members. Adolescents may fear that their sexual orientation or gender identity will not be accepted by family or peers. Such pressure (especially during a time when social acceptance is critically important) can cause severe stress. Fear of abandonment by parents, sometimes real, may lead to dishonest or at least incomplete communication between adolescents and their parents. These adolescents also can be taunted and bullied by their peers. Threats of physical violence should be taken seriously and reported to school officials or other authorities. The emotional development of adolescents is best helped by supportive clinicians, friends, and family members.

Few elements of the human experience combine physical, intellectual, and emotional aspects as thoroughly as sexuality and all the feelings that go along with it. Helping adolescents put sexuality and gender identity into a healthy context through honest answers regarding reproduction and sexually transmitted infections is extremely important. Adolescents and their parents should be encouraged to speak openly regarding their attitudes toward sexuality and gender identity; parents’ opinions remain an important determinant of adolescent behavior.