As with adolescence in general, the cognitive transformations are psychosomatic in a literal sense: changes in the brain (including synaptogenesis, electroencephalographic patterns, and metabolic function) at the start of puberty closely match the emergence of major discontinuation in behavior and cognition (9). As regards the cognitive transformations, Piaget's model of cognitive stages has received utmost attention (10). It implies that the child processes information from the environment in very different ways, depending on the respective developmental stage. Piaget differentiated the pre-logic stage (first years of life), the concrete logic stage (elementary school age), and the logical thinking stage, the latter usually beginning in early adolescence and characterized by cognitive abilities that increasingly correspond to the adult's way of information processing. Although not without critiques (8,10) there is general agreement that development proceeds "from simple to complex, from concrete to abstract, and from egocentric to decentered" (8). "Egocentric" in cognitive terminology is quite different from being selfish. It means that the reasoning is still fixed to the subject's perspective, that the child is not yet able to imagine the world from another person's point of view. Unlike the child, the young adolescent is increasingly able to perceive the world from different perspectives and becomes even able to abstract from the world as it is and to imagine how it could be (Table 1). This ability of hypothetical reasoning brings about profound irritation as for the credibility and reliability of the adult world which now may be questioned. Hypothetical reasoning together with an enhanced concept of time also provides a more thorough understanding of terms like chronic illness or long-term impact of disease activity. And as youngsters are increasingly able to refer to their own cognitive processing (introspection), a discrepancy between real and ideal self emerges which constitutes their typical psychological vulnerability and irritability during adolescence.
Table 1 Developmental Gains in Cognitive Functioning During Adolescence
■ Ability to reflect on hypothetical problems
■ Ability to systematically explore solutions
■ Abstract thinking
■ Ability to reflect on one's own thinking
■ Advanced concept of future
Source: Adapted from Ref. 10.
Other characteristic modes of perception, although not purely cognitive in nature, are the strong desire to compare oneself with peers and to be alike. This is heavily influenced by the divergence in physical growth and development, especially at the start of puberty. Not surprisingly, then, "the worst fear of young adolescents is to be excluded by the crowd"(8). As a consequence of being able to reflect on oneself (discover the self), adolescents also tend to overestimate their uniqueness ("personal fable") and to disregard that statistical rules (like risk ratios) may also apply to themselves, leaving the characteristic feeling of invulnerability (6,11). This may trigger risk taking behavior, although the latter is often determined by motives belonging to the developmental process of identity formation, rather than merely resulting from cognitive misinterpretations (6). However, these may at least exaggerate respective tendencies.
Finally, adolescents are often said to be erratic, including their convictions and preferences, at least that they "typically struggle with some uncertainty while they are deciding on their future commitments" (12,13). Although several studies have reported that turmoil is the exception rather than the rule, adolescents are perceived to be somewhat more changeable and unpredictable at least by adult standards (8). However, we should keep in mind that this "lack" of stability and accountability is functional with respect to the ongoing process of identity formation (12).
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