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Journal of Medicine and Philosophy, 35: 518–525, 2010 doi:10.1093/jmp/jhq044 Advance Access publication on September 24, 2010

Adolescent Psychological Development, Parenting Styles, and Pediatric Decision

Making

BRIAN C. PARTRIDGE* Kenai Peninsula College - Kachemak Bay Campus, Homer, Alaska, USA

*Address correspondence to: Brian C. Partridge, M.S., Kenai Peninsula College - Kachemak Bay Campus, 533 East Pioneer Ave, Homer, Alaska 99603. E-mail: [email protected]

The United Nations Convention on the Rights of the Child risks harm to adolescents insofar as it encourages not only poor deci- sion making by adolescents but also parenting styles that will have an adverse impact on the development of mature decision-making capacities in them. The empirical psychological and neurophysi- ological data weigh against augmenting and expression of the rights of children. Indeed, the data suggest grounds for expanding parental authority, not limiting its scope. At the very least, any adequate appreciation of the moral claims regarding the authority of parents with respect to the decision-making capacity of adoles- cents needs to be set within an understanding of the psychological and neurophysiological facts regarding the development of ado- lescent decision-making capacity.

Keywords: adolescent development, adolescent psychology, convention on the Rights of the Child, medical decision making

A core cluster of controversies in the bioethics of pediatric decision making concern the capacities of adolescents to be competent decision makers. In this article, the Convention on the Rights of the Child (United Nations, 1989/1990) is referenced, given its global influence. Special emphasis is given to the controversies associated with participation and expression rights mandated by the Convention on the Rights of the Child, which controversies involve both bioethical and psychological issues. The focus of this article is on the psychological issues that bear on what kind of decision makers ado- lescents are, as well as on what kinds of parenting can most likely aid them to develop into competent adult decision makers. Although some right- and wrong-making conditions may be independent of the psychological facts of

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the matter, the claims of the Convention regarding the proper expression rights and participation rights of children depend at least in part, if not in great part, on the capacity of adolescents effectively to participate in decisions re- garding their health care, as well as the effect of parental guidance on their achieving the ability to act in a fashion that merits adolescents’ being held blameworthy and praiseworthy as adults are. That is, the psychological data bear on their being recognized as fully competent moral agents. It is these psychological facts of the matter that are addressed in this article. The goal is to assess the psychological realities that frame the actual functioning of ado- lescents as decision makers and the roles of their parents as authorities guid- ing their development with special reference to pediatric decision making.

The data reviewed in this article go against the view that adolescents should be regarded as in many circumstances materially equivalent to adults. Instead, data argue in favor of recognizing a qualitative difference between adolescent versus adult decision making. It would appear that, even if ado- lescents can with proper coaching from their social environment make choices similar to those of competent adults, they do so with their decisional capacities overlaid by an impulsivity and inability to envisage the long-range consequences of their decisions that separate the decisional capacities of most adolescents from those of most adults. This brief article cannot com- pass the extensive literature that has developed regarding adolescent deci- sion making in health care (see, e.g., Bluestein, 1982, 1993; Ross, 1998; Hyun, 2000, 2003), save to note that this literature generally does not suffi- ciently reference or attend to recent behavioral and neuropsychological find- ings. The focus in this article is not on bioethical theorizing, but instead on some psychological findings that should inform bioethical analyses of pedi- atric decision making and that bring some of these theories into question.

The propriety of authoritative parental involvement in their children’s med- ical decision making depends, at least in part, on two clusters of empirical issues concerning the capacity of adolescents to make decisions with an ef- fective responsibility similar to most persons over the age of 18 years: (1) the impact of adolescent impulsivity as well as their limited capacity to envisage the long-term consequences on their decisional capacity and (2) the impact of parenting styles on the development of mature decisional capacity. The first set of issues bear on the ability of adolescents as mature or emancipated mi- nors to command a level of medical decision-making capacity that approaches that of persons over the age of 18 years. The question is when it is credible to hold that adolescents should be treated as autonomous decision makers. This concern is tied to the plausibility of holding that there are important de- velopmental milestones reached by most adolescents by the age of 18 years or older, but not much before they are 18 years of age, that make reasonable the threshold age as at least as early as 18 years for the recognition at law of the usual presence of the capacity of adult decision making. The position one embraces on these issues on the basis of the available data needs to address

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the case of those minors who actually emancipate themselves at the age of 16 years, as well as those who could be held to be mature minors. The question is whether such treatment of minors as effective autonomous decision makers as well as the threshold in general for mature decision making should be re- evaluated in light of the extent to which adolescents are likely to meet the conditions for effective decisional capacity. The capacity of adolescents to realize effective autonomy (the capacity to choose in ways that effectively support their long-range interests) appears to depend on their development of the ability, at least in part, to choose non-impulsively and to envisage ad- equately the future consequences of their decisions. The actual data regarding the facts of the matter indicate the implausibility of the expression and partici- pation rights advanced by the Convention on the Rights of the Child and even suggest grounds for substantively revising upwards the current understandings of the age for competent late adolescent decision making.

A second set of issues concern the differential impact on the development by adolescents of exposure to different styles of parenting. One might pre- sume that, for example, a permissive parenting style might better support the development of decisional capacity by giving to children a wider opportu- nity for their realizing effective decisional capacity. On the other hand, one might presume that an authoritative or directive parenting style might help the adolescent more effectively to focus on decisional acts. If it is the case that parental direction that limits and thereby focuses the growing autonomy of the child in the end augments the real autonomy of the adult the child will become, then there will be strong grounds for parents acting paternalisti- cally. Depending on the data bearing on the first question regarding the threshold for effective autonomy, one may wish to increase or lighten the burden of proof for treating minors as emancipated or mature minors, espe- cially in the area of medical decision making. Depending on the empirical data bearing on the impact of authoritative parenting on adolescents’ devel- oping mature decisional capacity, one may come to support greater or lesser authoritative or directive parental involvement, guidance, and limit setting in the decisions of their children, especially in areas bearing on their health care. In short, the question is when it is plausible, given the data regarding the development in adolescents of the capacities as moral agents, it is unrea- sonable to treat adolescents as having medical decisional capacity, as well as what the data indicate are the influences of different approaches to parental involvement on the child’s future decisional capacities as an adult. Answers to these questions will depend in great measure on the facts of the matter.

Adolescence, the period during which the Convention on the Rights of the Child seeks to augment the role of the mature minor in making medical deci- sions, is a precarious stage in life. During these years of development, the adolescent’s capacity to understand the consequences of choices increases dramatically both intellectually and affectively, thus augmenting the capacity of adolescents to choose in ways that support their own long-term interests.

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In this development, there is a delicate interplay of intellectual and affective capacities. What renders this development particularly complex is that there is a complex interaction between the child’s capacities intellectually to state a view about decisions to be made and the adolescent’s ability in fact effec- tively through an interplay of intellectual and affective capacities adequately to envisage the consequences of important decisions. In particular, the data indicate that, although intellectual capacities to appreciate aspects of mate- rial elements of important decisions can develop quite early in adolescence, these capacities are limited by (1) the affective turmoil of adolescence and (2) the adolescent’s incomplete capacity to envisage the consequences of choices that reach beyond the immediate future. In one study of risk-taking behaviors, Galvan et al. (2007) suggested “a developmental shift in reward- related accumbens activity and in how the perception of positive or negative consequences of risky behavior might influence actual engagement in risky behavior. Specifically, for children and adolescents, less risky behavior was associated with anticipated negative consequences . . . ” (Galvan et al., F13). Another study demonstrates that risk-taking behaviors, as defined by use of alcohol, tobacco, or marijuana, are inversely related to the adolescent’s abil- ity to delay gratification (Romer et al., 2010) The point is that an adolescent may be able to rehearse mathematical probabilities of the risks and benefits associated with particular choices, although still lacking a mature capacity for decision making that will reliably allow the adolescent sufficiently to ap- preciate the implications of the risks and benefits of different medical deci- sions for the adolescent’s future life as an adult. Intellectual capacities narrowly construed are not equivalent to effective decisional capacities.

The data suggest that there are significant differences between the adoles- cent and the adult brain that have implications for decisional capacity (Giedd, Blumenthal, and Jeffries, 1999; Sowell et al., 1999; Thompson, Giedd, and Woods, 2000; Dahl and Spear, 2004; Reyna, 2004; Reyna et al., 2005; Reyna and Farley, 2006 ). These structural and functional differences, the immature characteristics of the adolescent brain, appear correlated with adverse out- comes. “. . . a quarter of all fatal road injuries (27%) and hospitalizations (26%) are in the age group 7 to 25 years which is disproportionately high . . . this is because of the adolescent brain” (Bessant, 2008, 7). Both the anatomi- cal-physiological data and the outcomes data support the view that there is no clear positive correlation between an adolescent’s capacity intellectually or abstractly to assess risk, or even the adolescent’s experience with risk, and the adolescent’s capacity to make mature decisions regarding matters involv- ing risk. The neurophysiological data that would explain these behavioral findings remain complex and not fully clarified. For example, Berns, Moore, and Capra (2009) found that teens that engaged in dangerous activities have frontal white matter tracts that are more adult like showing that the neuro- logical picture will need further explanation. In her book, The Primal Teen: What the New Discoveries About the Teenage Brain Tell Us About Our Kids,

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Barbara Strauch quotes the former head of child and adolescent research at the National Institute of Mental Health (NIMH), Peter Jensen, as concluding that “learning may, in fact, not count for much until the appropriate underly- ing brain structures are in place” (Strauch, 34, 2003). The limited decisional capacity of adolescents with regard to adequate risk assessment appears in particular to be connected with the late full maturation of the frontal lobes that are necessary for effective executive functions. These areas of the brain necessary for the realization of responsible and reasonable choices are the last to achieve an adult development (Geidd, Blumenthal, and Jeffries, 1999; Spear, 2000). If effective decisional capacity requires appreciating the long- term consequences of one’s decisions, then adolescents generally do not have full possession of this capacity. These data if anything support not low- ering but raising the age for the legal recognition of mature decisional capac- ity to the traditional age of 21 years, rather than generally treating adolescents under the age of 18 years as possessing mature decisional capacity.

American law and public policy have come to be influenced and changed by data from such studies regarding psychological development and the neuroscience of the adolescent brain. Evidence for such influence includes the Supreme Court decision in Roper v. Simmons (2005), which abolished the juvenile death penalty. In these proceedings, Justice Anthony Kennedy, writing for the majority, specifically identified youthful impetuousness and susceptibility to outside pressures of adolescents as grounds for barring the imposition of capital punishment for crimes committed by individuals youn- ger than 18 (Roper v. Simmons, 2005). The same data also supported the decision of the Supreme Court to consider the argument to abolish life sen- tences without parole for juvenile offenders (Liptak, 2009). Such legal and public policy acknowledgement of the limited decision-making capacities of adolescents is at odds with the current movement to lower the age of med- ical decision making as seen in the Convention on the Rights of the Child (United Nations, 1989/1990). The data give a basis for revising current stan- dards upward but not for lowering the age at which adolescent decision making is generally considered to be decisive.

As to issues regarding the impact of authoritative parenting and limit set- ting, the data concerning parenting styles are from one perspective contrary to some expectations, especially those congenial with the Convention on the Rights of the Child that would further marginalize the roles of parents in medical decision making involving their adolescent children. It appears to be the case that adolescents are more likely to grow to be effective, autono- mous decision makers if their autonomy and freedom of decision making receive authoritative direction and limit setting by their parents. In particular, a considerable body of data concerning the general influence of permissive, neglectful, authoritative, and authoritarian parenting styles indicate that par- ents by setting limits to and providing direction for the decision making of adolescents in the end augment these decisional capacities. Authoritative

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parenting styles generally support and do not undermine the adolescent’s maturing to be a competent adult decision maker. Contrary to what many might intuitively assume, the well-considered setting of limits to the adoles- cent’s autonomy appears for most adolescents to enhance the adolescent’s growing autonomy rather than to undermine its development.

The data in particular show that there is strong positive correlation be- tween authoritative parenting styles and the adolescents’ positive academic performance (Dornbusch et al., 1987; Steinberg, Lamborn, and Dornbusch, 1992), increased competence, autonomy and self-esteem (Baumrind, 1989; Steinberg, Elmen, and Mounts, 1989; Steinberg et al., 1991), and an increased ability to resist potentially harmful involvements such as substance abuse (Weiss and Schwarz, 1996; Adalbjarnardottir and Hafsteinsson, 2001; Huver et al., 2007 ). The extensive literature bearing on the effect of authoritative parenting styles is, in general, very supportive of the direction giving and limit setting associated with much of traditional parenting. A review of the literature supports the conclusion that the traditional authoritative approach to parental oversight and direction of adolescent decision making is pos- itively correlated with adolescents’ developing a capacity for mature autonomous decision making. In particular, the data regarding the impact of parenting styles on the future capacities of adolescents sustain the view that authoritative direction giving and limit setting, which characterize the tradi- tional family, correlate positively with the child’s becoming an adult with effective decisional capacities. The achievement of mature decisional capac- ities is generally enhanced when the adolescent’s decisions are nurtured within the constraints of paternalistic parental guidance. These data bring into question the commitment of the Convention on the Rights of the Child to participation and expression rights.

Parental authority expressed in direction and limit setting would appear to offer two significant benefits, given the general character of the available em- pirical data. First, due to the general higher impulsivity of adolescents com- bined with their limited capacity adequately to envision the long-term consequences of their decisions, parents by setting limits and giving direction will generally protect adolescents from making poor choices at a period in their development during which their decisional capacity is limited, that is, during a developmental period when they are often unable effectively to make deci- sions with long-range consequences on their lives. Second, in this regard, for most adolescents, there are grounds to hold that parents in intact functioning traditional families who engage an authoritative, directive parenting style ef- fectively nurture the maturation of adolescents as mature decision makers. The giving of direction and the setting of limits in the end augment characteristics associated with adolescents becoming adults with mature decisional capacity.

The Convention on the Rights of the Child, insofar as it marginalizes and discounts such directive roles for parental authority through encouraging an amplification of participation and expression rights, risks harm to adolescents,

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not only in terms of encouraging the making of bad choices but also in terms of encouraging parenting styles that will have an adverse impact on the devel- opment of mature decision-making capacities. All of this justify a view of pa- rental authority that is not reducible simply to parents being trustees of their children’s best interests until the children can clearly assert their own author- ity. Parents are not just usually the best authorities regarding what direction and limits should be given to the choices of their adolescent children, but the current data indicate that the exercise of parental authority itself impacts favor- ably on the decisional capacity of the adults the adolescents will become.

In summary, the empirical psychological and neurophysiological data re- garding the decisional capacity of adolescents and the impact of authoritative parents run contrary to the claims advanced by the Convention on the Rights of the Child. They instead weigh against augmenting the participation and expression rights of the child. The data suggest grounds for augmenting pa- rental authority and paternalism, not limiting or marginalizing their presence. At the very least, any adequate appreciation of the moral claims regarding the authority of parents and adolescents, as well as any realistic bioethics of pe- diatric decision making, deserves to be set within a better understanding of the psychological and neurophysiological facts of the matter regarding ado- lescent decision-making capacity and the impact of authoritative parenting.

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