The teen with positive
self-esteem
Expresses opinions
Mixes with other teens (e.g., interacts socially with groups of teens) Initiates friendly interactions with others
Makes eye contact easily when speaking Faces others when speaking to them
Observes comfortable, socially determined space between self and others Speaks fluently in first language without pauses or visible discomfort Participates in group activities
Assumes leadership role among peers Works collaboratively with others Gives directions or instructions to others Volunteers for tasks and activities The teen with negative
self-esteem
Avoids eye contact
Appears overly confident (e.g., brags about achievements or skills to mask a lack of self-efficacy in performance skills)
Expresses self-criticism, makes self-deprecating comments; makes fun of self as a form of humor Speaks loudly or dogmatically to avoid others responding
Is submissive and overly agreeable to others’ requests or demands, even if he or she does not wish to do them
Gives opinions or views reluctantly, especially if it will draw attention to himself or herself Monitors behaviors (e.g., hypervigilant of surroundings and other people)
Makes excuses for performance, seldom evaluates personal performance as satisfactory or good Engages in putting others down, name calling, gossiping, and, at worst, bullying
Reports a lack of emotional support from parents and friends Modified from Santrock, J. W. (2003).Adolescence.New York: McGraw-Hill.
throughout adolescence. Persistent low self-esteem is asso- ciated with serious psychological difficulties (e.g., depression; anxiety disorders such as social phobia, bulimia, and self- abuse). Self-abuse may take the form of cutting or harming one’s self, excessive use of alcohol and drugs, or engaging in risky behaviors such as promiscuity and unprotected sex. Beha- viors such as frequently making negative self-critical state- ments, fears of anticipated failure, and difficulty coping with perceived failure also indicate poor self-esteem. Teens with poor self-esteem are hypersensitive to negative comments from peers and adults alike, and to lack of responsiveness or over- reaction from others, and can be defensive to constructive crit- icism. In a desire to belong or “fit in” by seeking social approval, they are more susceptible to peer-group influence.
Factors contributing to self-esteem of adolescents with disabilities are similar to those of nondisabled teens, espe- cially the value-laden self-assessment of one’s own attributes and limitations. A stereotypical view of adolescents with dis- abilities infers that self-esteem is low. However, the research data on this topic do not support this view. A meta-analysis of studies examining self-esteem in teens with minor physical disabilities reported that, compared with their nondisabled peers, they had lower self-esteem about physical competen- cies, but the effect on their general, social, and physical appearance self-esteem was only moderate.76 This analysis did find a relationship between the severity of physical disabil- ity and level of general self-esteem. However, Miyahara and Register found that this low self-esteem was related to
misunderstanding by peers and adults and poor performance that reflected lack of effort rather than disability.77A study of self-esteem and self-consciousness among adolescents with spina bifida found that their perception of being treated by parents in an age-appropriate manner and parents’ tolerance of social participation contributed positively to self-esteem, whereas school problems and the perceptions of disability by others contributed negatively.113 Occupational therapy practitioners who work with students who are “clumsy” or have poor motor planning or learning disabilities need to rec- ognize these potential obstacles to positive self-esteem and incorporate strategies and experiences that validate and facili- tate self-recognition of one’s strengths and abilities as part of the therapeutic process.
Adolescence and Mental Health
Mental health is defined as the “successful performance of mental functions, resulting in productive activities, fulfilling relationships with others, and the ability to change and cope with adversity.”107Adolescents who have good mental health generally have better physical health than peers who have poor mental health; they demonstrate positive social behaviors and are less likely to participate in risky behaviors (Box 4-3).63 However, adolescents are vulnerable to mental health disor- ders. Most diagnosable disorders associated with altered think- ing, mood, or changes in behavior causing distress and/or impaired cognitive functioning begin in adolescence, many before the age of 14. Adolescents who have mental health
BOX 4-3 Critical Health Behaviors of American Adolescents
ALCOHOL & DRUG USE
Alcohol is the most widely used substance by adolescents (more than tobacco or illicit drugs). Typical initial drug use for boys is alcohol. Among teens surveyed (Monitoring the Future Study 2000 [MFS]), 22% of 8th graders and 41% of 10th to 12th graders drank alcohol in the previous month. Rural teens have equal access to drugs as urban teens. Alcohol is a factor in approximately 41% of all deaths from
motor vehicle accidents.
TOBACCO USE
Every day, approximately 4,000 adolescents aged 12-17 try their first cigarette. Typically, initial drug use for girls is cigarettes. 4.5 % of 8th graders, 8.9 % of 10th graders and 15.8% of 12th graders report daily cigarette use in the past 30 days. This is a decrease compared with levels reported in surveys.
INJURY & VIOLENCE (INCLUDING SUICIDE)
Injury and violence is the leading cause of death among youth aged 10-24 years: motor vehicle crashes (30% of all deaths), all other unintentional injuries (15%), homicide (15%), and suicide (12%).
NUTRITION
Healthy eating is associated with reduced risk for many diseases, including the three leading causes of death: heart
disease, cancer, and stroke. In 2007, only 21.4% of high school students reported eating fruits and vegetables five or more times daily (excluding fried potatoes and potato chips) during the past 7 days.
PHYSICAL ACTIVITY
Between 16% and 22% of adolescents are obese or overweight.
Overall, in 2007, 35% of 9th to 12th graders had participated in at least 60 minutes per day of physical activity.
Approximately half of American adolescents (aged 12-21 years) are vigorously active on a regular basis. Inactivity is more common among females (14%) than males (7%) and among black females (21%) than white females (12%).
SEXUAL BEHAVIORS
Approximately 50% of high school students are sexually active; by graduation, 2/3 will have had sexual intercourse. Approximately half of the 19 million new STD infections
in the United States are among adolescents aged 15 to 24. In 2007, 39% of sexually active high school students did not use a condom during last sexual intercourse.
Teenage pregnancy rate is dropping. Between 1991 and 1998 birth age for teens 15-19 declined by 18%.
Data from Monitoring the Future Study (2001-2003). http://www.nida.nih.gov/Infofax/HSYouthtrends.html; National Center for Chronic Disease Prevention and Health Promotion Healthy Youth, YRBSS Youth Online: Comprehensive Results. Available at: http://apps.nccd.cdc.gov/yrbss/QuestYearTable.asp?path=byHT&ByVar=CI&cat=5&quest=508&year=2007&loc=XX and Neinstein, L. S. (2002).Adolescent healthcare: A practical guide, (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
disorders (e.g., depression, substance abuse) are likely to have difficulties learning and developing social and life skills, and are likely to engage in risky health behaviors.
The Mental Health of Adolescents: A National Profile Report estimates that 1 in 5 adolescents experience symptoms of emotional distress and that 1 in 10 are emotionally impaired.63The most common disorders are depression, anxi- ety disorders, substance use/abuse, and attention deficit disor- der (with and without hyperactivity). The Youth Risk Behavior Surveillance study reported that 37% of female and 20% of male high school students answered “yes” to the question “Have you ever felt so sad or hopeless every day for two weeks in a row that you couldn’t do some of your usual activities?”17
This depression in young people (15 to 20 years of age) is often comorbid with other mental health disorders, such as addictions, anxiety disorders, and conduct disorder. Further- more, suicide, the third leading cause of death in adolescents, is significantly associated with depression. In 2005, 8.4% of high school students attempted suicide. Although suicide attempts were more frequent among female students, espe- cially in the ninth grade, the number of deaths from suicide among males between the ages of 10 and 14 was 2.5% higher than females and 3.5% higher in the 15- to 19-year-old age range.30
Other mental health disorders include eating disorders (e.g., anorexia nervosa or bulimia), learning disorders, and behavioral disorders (e.g., conduct disorder and oppositional defiance disorder). Schizophrenia and bipolar disorder are seri- ous, but less common disorders. The onset of schizophrenia (excluding paranoid schizophrenia) in males is typically in late adolescence. Both schizophrenia and bipolar disorder have sig- nificant implications for teens because they disrupt participa- tion in typical developmental activities, and these lost opportunities can contribute to lifelong disability.
Occupational therapy practitioners can assist with early identification of children and adolescents with mental health disorders because initially (e.g., in early adolescence) they may receive services for related difficulties such as learning and behavioral problems. Occupational therapy practitioners also are among the professionals involved in interdisciplinary teams providing early detection and intervention for teens with mental health disorders such as schizophrenia and bipolar disorder.