Bio-psycho-social assessment
Title: Bio-psycho-social assessment
Bio-psycho-social assessment; To learn more about a patient's physical, emotional, and social health, mental health specialists, medical professionals, and social workers frequently employ a bio-psycho-social assessment, a thorough examination technique. It entails evaluating the biological, psychological, and social elements that affect a patient's mental health. Information on the patient's physical health, including medical history, medication use, and any underlying health conditions, is gathered as part of the assessment's "Bio" section. This information can shed light on the potential relationship between the patient's physical and mental health problems. The "Psycho" component entails examining the patient's psychological state, including their feelings, behaviors, and past experiences with mental illness. An evaluation of mental health symptoms including anxiety, depression, or trauma is part of this process. This component's data collection can aid in making a precise diagnosis and choosing the best course of action. The patient's social and environmental elements that may be affecting their mental health are the subject of the assessment's "Social" section. This could entail investigating their connections, housing arrangements, employment, financial condition, and access to amenities like healthcare and social support systems. The social component also sheds light on potential societal and cultural influences on the patient's mental health. A Bio-Psycho-Social Assessment is a useful tool for medical and mental health professionals to gain a thorough understanding of a patient's mental health status and to create a suitable treatment plan.
- biopsychosocial assessment,
- critical thinking,
- risk and resilience,
- psychological and social theoretical perspectives
- the stages of development in early life.
- Reflections:
- Describe a systems perspective and its relevance to developing knowledge of human behavior in the social environment.
- Describe and apply the biopsychosocial approach to assessment.
- Describe the major developmental changes that occur during infancy, early and middle childhood.
- Explain and apply Erikson’s psychosocial stages of development, particularly those pertaining to infants and children.
- Explain and apply attachment and psychoanalytic theories and ego psychology.
- Readings:
- philosophical, socio-political and theoretical perspectives.
- These include social systems, person-in-environment, ecological perspective, the goodness of fit, biopsychosocial assessment, strengths, social justice, and globalization.
- the impact of communities and agencies on individuals, children, and families
- Describe community risk factors and protective factors that may affect child and youth development and well-being.
- Identify ways in which agencies may increase the likelihood of engaging children and families with complex social and emotional needs.
- psychodynamic theories.
- macro perspective to explore the ‘social’ part of the biopsychosocial by looking at bi-psycho-social assessment communities and organizations/agencies and their fit with the needs of children and families.
- Most people are deeply impacted by the communities in which they live, i.e., by community strengths, resources, composition, location, environment, gaps in service, risk factors,
- focus on pathological outcomes to one of resilience.
- Compare and contrast risk and protective factors at the individual, family and
- Identify adaptive systems that support resilience.
- exposed to traumatic social or family experiences during their childhood.
- families function as systems.
- family factors associated with resilience.
- Understand genograms and apply them to family relational patterns.
- family life cycle,Emotion regulation
- Reflections :
- Some people believe, “If all families just had a stronger set of values, children would grow up with fewer problems and would be more resilient.”
- Would you agree with this statement in whole or even in part? Consider why or why not?
- Think about your own family’s belief systems, communication patterns, and organizational patterns. How might they have shaped your approach to dealing with adversity?
- Readings:
- the strength and flexibility of its internal resources.
- Describe several social and economic stressors and their impact on families.
- Analyze the possible impact of policy decisions on the family.
- possible consequences of substance abuse on families and children.
- ways a family may respond to a child with a disability.
- Readings:
- challenges are considered normative and transitional as members move from one phase of development to the next. Some are situational but do not rise to the level of crisis/trauma which usually implies a serious threat to life of oneself or someone close.
- Often, the difference between whether a challenge becomes a crisis/trauma or not has to do with the internal resources of the family as well as the social and economic support available and the political environment within which the family lives. To understand families we must see them as systems which are embedded within and interact with their cultural, socio-economic, and policy/political environments.
- Some families will also be affected by positive, progressive changes in society, even when certain social factions are not supportive. For example, it is interesting to note the unfolding changes in attitudes toward LGBT families since the Supreme Court has banned discrimination against same sex marriage.
- Children of substance-abusing parents experience many adverse effects. Children rely on their parents for protection, nurture, support, guidance, role modeling, moral development, and other necessities of life. However, to a greater or lesser extent, substance-abusing parents are frequently inconsistent, erratic, and unavailable. They may also be emotionally neglectful and/or physically/sexually abusive. ‘There is clear evidence that children of parents who abuse alcohol or other drugs are at measurable risk for developing emotional behavioral and/or social problems’ (Gruber & Taylor, 2006, p.12). Due to the multiple problems the non-substance-using parent is contending with, he/she may be unavailable as a parent too.
- A family’s culture, values, beliefs, and personal experiences will all affect its functioning, attitudes, and adaptation to a differently abled member. The availability of financial and supportive resources will also have a great influence on adaptation.
- meaning of “trauma informed care.”
- Families experience profound loss for any number of reasons including migration, foster care and adoption, military deployment, illness and death, murder, separation, divorce and abandonment, etc.
- the dynamic relationship between human behavior, research, policy, practice and field.
- Loss and related shifts within a family system are usually accompanied by significant stress and, at times, trauma.
- Two profoundly important social issues which many families have experienced are migration and foster care.
- Consider the factors : pre-existing family problems and peri-migration traumas, reasons for migrating, who was left behind, differences between the socio-political-economic conditions in the home and host countries, the developmental stage of the family and individual members, the family’s strengths and ways it has coped in the past, members’ expectations and dreams, , supports (resources), and challenges experienced since entering the host country.
- how and why the addition of a spiritual dimension to a biopsychosocial assessment would be of value.
- Recently, it has been suggested that the biopsychosocial perspective should be extended to become a biopsychosocial spiritual assessment. This recommendation has emerged from social work educators, theoreticians and practitioners’ growing awareness of the role of spirituality and religion in many clients’ lives. Integration of these ideas is crucial to a strengths based and holistic assessment. Adding this dimension to our assessment processes may well promote greater understanding of clients’ values and worldviews and help us tune into their ways of making meaning of significant life events. We also need to understand the role of religion/spirituality in the lives of trauma survivors, immigrants, and recovering substance abusers, amongst others, who consider this aspect of themselves and of their family lives, community and culture extremely important
- spiritual assessment to the biopsychosocial, we’re able to determine (with the client, of course) if and how their presenting problems are affected by their views of what is unknowabl
- relationship between stress (acute and chronic) and mental and physical health, and examine some of the social forces associated with physical/mental health inequities.
- lack of access to resources and negative health and mental health outcomes
- Distinguish between progressive permanent disability, constant or permanent disabilities, and relapsing or episodic syndromes.
- issues surrounding invisible disabilities.
- concept of social determinants of health.
- invisible/hidden disabilities experience
- Chronic Illness and Disability : historical, medical, economic and the sociopolitical
- progressive and permanent conditions (diabetes, cancer, rheumatoid arthritis, and HIV/AIDS), constant and permanent disabilities (deafness, blindness and visual impairment), and relapsing or episodic conditions (MS, lupus).
- physical, emotional and social implications of each illness, the course of the disease presents unique challenges. A family with a child who has a first psychotic break during adolescence, for example, will certainly face a somewhat different experience than a young mother who discovers she has breast cancer or an elderly person who loses their hearing.
- Medosch has conditions that cause intense fatigue and chronic pain. She took part in a 2014 Stanford Medicine X conference that included discussion of "invisible" illnesses.
- considere anyone’s complaints re: exhaustion, pain, etc., to be hypochondriacal or thought they were unnecessarily whining and maybe even dismissed their concerns? Happens all the time. Could it happen with clients? Could their complaints be a physical expression of trauma they’ve experienced? A symptom of a disease which is difficult to diagnose? An indication of substance abuse?
- underlying social conditions : association between health and socioeconomic status, e.g., in life expectancy, overall mortality rates and higher rates of infant and perinatal mortality.
- Thoits (2010) identifies five major findings from more than forty decades of sociological research on stress:
- Stress has a substantial and damaging effect on physical and mental health.
- It is primarily through differential exposure to stress that inequalities in physical and mental health are produced in members of targeted groups (people of color, women, people with disability, the poor, etc.).
- Discrimination stress is an additional way in which people of color are regularly harmed.
- Stressors increase over the lifespan and are passed on from one generation to the next creating an ever-widening equity gap.
- High levels of mastery, self-esteem and social support may ameliorate the negative impact of stress on physical and mental health.
- Readings:
- neurobiology is relevant to a biopsychosocial perspective.
- injuries and disabilities related to brain functioning.
- key periods of sensitivity in brain development.
- neuroplasticity and early life abuse and neglect and other forms of trauma.
- neurobiological perspective to a vignette.
- Preventive Interventions
- Readings:
- critical periods of brain development, neural plasticity, memory, cognition and the impact of stress and trauma on the brain and behavior are obviously important for social workers to be cognizant of.
- brain disruption and psychiatric disorders; neurons responsible for alcoholism identified; memory loss in people with psychosis; borderline personality traits being associated (through studies of the brain) with lower empathy; the potential for prevention and treatment of PTSD through blocking memory pathways; and increases in our understanding of the social brain.
- neuroanatomy
- nurture (experience) and nature (gene expression).
- neurobehavioral disorders such as Autism, Attention Deficit Hyperactivity Disorder, Asperger’s Disorder, Dyslexia, and Mood Disorders. The central theme of this chapter is the effects of neurobiology on human behavior.
- Nelson, Kendall, and Shields (2014)
- Gunnar and Fisher (2006)
- developmental theories.
- Erikson’s theory of psychosocial development
- principles of Critical Race Theory (CRT)
- Standpoint Theory
- Anti-Oppressive practice
- Globalization and child development
- psychosocial theory ( strengths and limitations)
- Readings:
- important to recognize their inherent limitations. For example, they are unavoidably developed within a specific social, cultural, and historical context.
- believing people follow a sequence of predetermined stages of development.
- biological forces and age-related social or cultural expectations.
- physical, emotional, and cognitive and demands of the social environment
- Ego strength eg, balance of trust vs. mistrust.
- Toddlerhood (anal stage)
- self-confidence ,mastery
- motor skills
- ashamed and doubt their ability to develop control.
- ‘stand on one’s own two feet.’
- Early Childhood (oedipal/phallic stage)
- Young children must develop a growing capacity to plan and initiate actions or they may feel guilt about ever taking initiative.
- Middle Childhood (latency)
- sense of competence
- complete tasks
- feel inferior or incompetent.
- socially decisive stage – there is danger when the school-aged child begins to feel that the color of his/her skin, parents’ backgrounds, or his clothes – rather than his wishes or his will – decide his worth and, thus, his/her sense of identity.
- Adolescence (puberty)
- Childhood comes to an end.
- Physiological revolution
- develop /confusion sense of identity.
- Adolescents and peers.
- Young Adulthood (genitality)
- capacity to commit to deep connections
- sense of isolation.
- choosing a career,
- Interpersonal intimacy
- socializing with the same or opposite sex,
- capacity to love or mutuality of devotion.
- Middle Adulthood
- develop self-interest/ feel stagnated.
- ‘Mature genitality’
- Stagnation or self-absorption reflects interpersonal impoverishment.
- Late Adulthood
- Critical Race Theory and Cultural Sensitivity Dilemma:
- Readings:
- been subjected to scientific scrutiny?
- be harmful to specific groups?
- assess this theory using a standpoint or critical race perspective?
- aspects of infant development from a biopsychosocial perspective.
- the core resources an infant needs to build a lifelong foundation of health.
- infant brain develops in the context of the environment and relationships.
- risks to healthy development in infants.
- Erikson’s psychosocial stage of trust versus mistrust.
- the purposes of the attachment bond, different styles of attachment and the way they may manifest at various stages and cultures.
- ecosystems perspective in which behavior and growth are viewed as the outcomes of transactions between innate biological endowments and the family, social and physical environments.
- biological and social levels . brain development and how ‘volley and return’ builds brain architecture.
- impact of trauma on infancy and early childhood development.
- the meso and macro level forces which have a significant bearing on the interaction between innate biological endowments and the social and physical environment.
- The study of attachment theory gives us the opportunity to zero-in on the interaction between the genetic/biological, social/relational/parenting and the psychological -- as the baby’s development occurs within the context of interactions with the most important people in its life.
- Overview of Infancy Rogers (2019) )
- infancy stage of human development from an ecosystems perspective in which behavior and growth are viewed as the outcomes of transactions between innate biological endowments and the social and physical environment.
- biological, cognitive, and psychological development within a sociocultural context. They also discuss the infant’s capabilities at birth, innate motivational and behavioral systems, temperament, culture, and attachment.
- Impact of Trauma on Infancy and Early Childhood
- exposed to traumatic events including physical and/or psychological stressors that overwhelm their capacity to cope.
- risk for negative outcomes now and in the future.
- All children experience what is considered to be normative stressors. Being fully insulated from such experiences can actually have a deleterious effect on development as such protection may inhibit the development of self-soothing techniques and interfere with the long range objectives of doing well in work and in love. On the other hand, in the absence of sensitive and responsive support, normative fears may persist and lead the way to future mental health problems.
- recognize that experiencing violence and trauma disrupts normal developmental processes in infants and young children.
- Sidebars 2 and 3 on page 214 provide important information on the Signs and Symptoms from a Traumatic Event and Behaviors Resulting from Traumatic Events respectively.
- Readings:
- Reflection:
- Infancy (oral stage) basic trust vs. mistrust (birth to about one year)
- Attachment Theory Shilkret and Shilkret (2011
- attachment theory was not developed specifically for the practice of psychotherapy.
- theory of development.
- the belief in an unconscious (Freudian topographical theory) and the creation of internal working models of relationships.
- The notion of internal working models is important in Object Relations Theory (which you may study in another course).
- Attachment theory is highly influential in many realms of social work practice including trauma and psychopathology, affect regulation, and understanding the process of psychotherapy.
- Types: secure and insecure attachment styles (including case examples), trauma and attachment, attachment over the lifespan, attachment theory and temperament, and attachment and psychopathology.,culture and attachment
- major developmental changes that occur during early childhood.
- the child’s emerging sense of self evolves according to Erikson.
- importance of school readiness, peer relationships and play in early childhood.
- contextual variables that shape development in early childhood.
- Analyze the strengths and limitations of central concepts of psychoanalytic theory.
- advances in biological and behavioral sciences may be integrated into
- Readings:
- Early Childhood: The Toddler and Early School Years
- neurological, motor, cognitive, language, and moral development, and the emerging sense of self. Sociocultural development including peer relationships and play, individual differences, culture and the impact of disabilities are discussed.
- disabilities discussed in this chapter includes Attention Deficit Hyperactivity Disorder and Autism. Contextual variables that shape development such as the childrearing environment, culture, class and parental discipline strategies are summarized as well as a variety of factors that impact on school readiness and later school achievement.
- early experiences affect the quality of brain architecture via the interactive influences of genes and experiences. Human brain development evolves from the development of sensory pathways to language and on to higher cognitive functions.
- Psychosocial Ego Development
- Toddlerhood (anal stage) Autonomy vs. shame, doubt (about 1-3 years)
- Early Childhood (oedipal/phallic stage) Initiative vs. guilt (3-5 years)
- Freud’s Psychoanalytic Concepts
- A Bio-developmental Framework
- Shonkoff (2010) provides an enhanced model for considering the origins of disparities in learning, behavior, and health. The author asserts that current transactional and ecological models and concepts of risk and protective factors (at multiple levels) have stood the test of time. However, there is a growing body of evidence that “foundations of healthy development and the origins of many impairments can be found among biological ‘memories’ that are created through gene-environment interactions in the early years of life, in some cases beginning as early as the prenatal period” (Shonkoff, p. 359).
- The Foundations of Healthy Development and Sources of Early Adversity as well as Adult Outcomes in Learning, Behavior and Health , the interaction between genes and environment (whether cumulative or during sensitive periods, how these are expressed through important (e.g., metabolic) biological systems, and their proposed outcomes in adult learning, behavior, and health.
- biopsychosocial perspective and to be inclusive of the many important systems which influence middle childhood development including family, school, peers, and community.
- ego psychological theory (ego/executive functions.)
- assessment of ego functioning is often part of a biopsychosocial assessment
- the main components of a comprehensive biopsychosocial assessment of a child between the ages of 6 and 11/12.
- Synthesize some of the major changes in biological, physical, psychological, cognitive, moral, gender, and racial development in middle
- Discuss the social, cultural, and economic factors and various contexts that impact development in middle childhood.
- key concepts associated with ego psychological theory and ego functions.
- Assess aspects of ego functioning of an individual.
- Analyze the strengths and limitations of ego psychological theory.
- the effects of oppressive school environments on child development.
- Readings:
- Reflection:
- Ego Psychology
- Readings:
- Effective ego functioning is crucial to perceiving and adapting to reality, to executing sound judgment and to effective decision-making.
- Ego functions are also strongly related to the development of interpersonal relationships, to regulating impulses, to distinguishing the internal from the external, to delaying gratification, to utilizing a range of defenses and coping mechanisms, and to learning in all its forms.
- Readings
- Adolescence
- Biological Development
- Physiology sets the wheels in motion for adolescence.
- Puberty (pyscho-sexual development).
- Physiological changes begin about two years earlier for girls than for boys.
- Adolescence begins with pubescence and ends with significant physical growth and a shift away from family toward the peer group.
- Development is quite variable at this stage. Girls are most dramatically affected by where they fall on the developmental spectrum.
- Inherent dangers include eating disorders, precocious sex, substance abuse, and lowered self-esteem.
- Bodily and emotional changes are rarely synchronized.
- Cognitive growth and development of systematic logic involves grasping abstract concepts, but this process is not completed during early adolescence.
- Moodiness due to physiological (hormonal) changes.
- Psychosexual Changes & Development
- The goal of genital phase of psychosexual development is the integration of sexual maturation into the sense of self and the development of the capacity for intimacy in object relations.
- Object libido is withdrawn from parent and invested in themselves and peers with a narcissistic libido.
- Psychosocial Developmental Stage: Identity versus Role Confusion.
- Ethnic and racial identity issues arise.
- Gender identity confirmation and re-identification.
- Sexual identity formation.
- Social Environmental Factors and Influences
- Consolidation of separation process begun in early adolescence.
- Teens tend to perceive themselves as adults and are far more focused on the adult world and where to place themselves within that world.
- Early relationships with parents are left behind to make room for their own present and future.
- Peer interactions as seen through school and neighborhood channels.
- Risks of bullying, drug use, gang affiliation, and violence increases but are also dependent on individual, familial and environmental (protective) factors.
- Early Adulthood
- Traditional markers in Western middle class society are noted below.
- Leaving home and becoming responsible for housing.
- Taking on work and/or educational tasks.
- Developing significant relationships and one’s own social networks.
- Becoming a parent, caring for others.
- Individuation continues and young adults prepare to differentiate emotionally, geographically, and financially from their family of origin.
- Biological and Psychological Development
- Physical functioning is typically at its height during early adulthood.
- Health risks include unprotected sex, STDs or HIV, unplanned pregnancy, substance abuse including alcohol, accidents, and diabetes.
- Greatest fertility rates during early adulthood.
- Cognitively, there is an expansion of abstract thinking which enhances problem solving and reflective thought processes. Early adults are able to entertain multiple viewpoints from various perspectives. Cognitive capacities become more flexible.
- Morally, there is more complex contemplation given to ethical principles and there is a recognition of larger systems and appreciation for community.
- Psychosocial developmental stage: Intimacy versus Isolation.
- Intimacy is focused on the ability to form deep interpersonal attachments which require sacrifice and commitment.
- Intimate relationships require the ability to take care of as well as being taken care of, meeting each other’s needs and accepting each other’s limitations.
- These intimate relationships include sexual relationships and meaningful relationships with friends, teachers, family members and fellow workers.
- Without successfully reaching “intimacy,” isolation may result.
- Attachment Styles in Adulthood
- Secure
- Anxious Preoccupied
- Dismissive-Avoidant
- Fearful-Avoidant
- Social Environmental Factors and Influences
- Mental health issues may surface due to biological and social factors.
- Suicidality
- Inequality in mental health
- Family systems are established and young adults may take on the role of parenting.
- Risk and protective factors may insulate some adults.
- Middle Adulthood
- Biological and Psychological Development
- Biological changes may occur in sensory and motor functioning.
- Male and female climacteric occur.
- Cognitive strengths continue but some decline may be noted in perceptual speed and numerical abilities.
- Psychosocial developmental stage: Generativity versus Stagnation.
- A significant way in which creative capacities are applied is in the pursuit of occupational success and economic security.
- Generativity involves cognitive, emotional and social development and requires the ability to take action and make life decisions based on the needs and interests of others as well as one’s own.
- Midlife crisis: The awareness of paths that have not been taken may generate regret or pressure to make changes.
- “Narcissistic” vulnerability is a common feature and it is important to be aware of such threats to one’s sense of self and self-worth.
- Identity issues may also surface as middle adults grapple with questions of selfhood.
- Social Environmental Factors and Influences
- Family systems continue to evolve.
- Developing adult-to-adult relationships with children.
- Adjustment to grandchildren and in-laws.
- Taking care of unfinished business in relation to aging parents and perhaps caring for them.
- Divorce is common or a restructuring of family.
- Work-life balance
- Managing the rigors of work and family responsibilities.
- Late Adulthood
- late adulthood has three sub-phases, young (65-74), middle (74-84) and oldest (85+).
- Biological and Psychological Development
- There are progressively larger populations of older adults.
- There are many physiological changes that accompany late adulthood, particularly because it spans such a large time frame.
- Cognitive issues at various gradations may be experienced by some elders. This is dependent on genetics, and on psychological and social factors.
- Ageism continues to be experienced by many in different areas of society.
- Psychosocial developmental stage: Ego integrity versus Despair.
- The challenge here is to come to terms with the realities of life circumstances and its limitations.
- False beliefs and ego attachments are loosened.
- Mental health issues, such as depression and anxiety will continue to challenge some older populations.
- Suicidality is not uncommon among the elderly and there are increasing issues with the overuse of drugs and alcohol.
- Social Environmental Factors and Influences
- Late adulthood continues to be filled with transitional points.
- Retirement
- Family Changes
- Death of spouse/partner
- Divorce
- Grandchildren
- Facilitated Living
- Death
- Socioeconomic factors continue to pose issues for some older adults.
- LGBT older adults face certain challenges that are particular to that population.
- Re-identify the biopsychosocial perspective and describe why it’s important to the evaluative frame.
- Human Behavior in the Social Environment II is centered on the biopsychosocial approach, which presents a multidimensional view of human development and behavior. This perspective views the person in the context of the environment, and takes into consideration the challenges, stressors and life tasks that occur throughout the life cycle. The course stresses the centrality of culture, race, ethnicity, gender and the socioeconomic environment.
- Using systems theory as a critical theoretical underpinning, HBII takes a non-linear view to development in which there is a continuous reciprocal interchange and mutual impact among different systems (individual, family, group, community).
- A major focus of the course is on the development of the human biological, psychological and social structures as they occur throughout the lifespan. HBII draws upon the approaches studied in HBI, and continues with the study of adolescence through late adulthood, and it also reviews the processes of grief and loss. The social realities of the urban environment and immigration are emphasized.
- Adolescence
- Emerging Adulthood
- Early Adulthood
- Middle Adulthood
- Late Adulthood
- Chronic Illness and Disability
- Grief, Loss and Bereavement
- Biopsychosocial Perspective
- let's review the stage of development that precede adolescence.
- Children continue to grow in height –usually two to three inches per year– and they will often gain 3 to 5 pounds of weight per year. We need to be on the lookout for some eating related issues here but I will speak more about this during adolescence. Gross motor skills such as climbing, running, and throwing, and fine motor skills such as hand-eye coordination and writing continue to improve during the middle childhood years.
- Cognitively, according to Piaget, middle childhood is when concrete operations develop wherein children become able to reverse or undo an action in their mind (Ginsburg & Opper, 1979). They are also able to focus on
- on more than one aspect of something at a time, and they have the ability to understand that the properties of an object do not change when their appearances alter. Middle childhood is also when children are developing more of their executive functioning skills (i.e., keep track of belongings, complete more homework assignments, complete longer term projects, raise hands before speaking), although complete development does not occur until late adolescence (Kagan, 1984).
- Adolescence: Biological Development
- key features of adolescent development.
- biological changes that accompany puberty.
- sexual development may impact and/or challenge an adolescent's sense of self.
- neurological developments that occur during adolescence.
- issues related to the development of eating disorders in adolescence.
- Adolescence is characterized by significant physical changes, sexual maturation, increased cognitive functioning, formative identity development, increased independence, and the possible experimentation with sex and substance use. It is also a time for peer group connections, including the development of close friendships, social circles and various clubs. Generally, the ages that commence and end adolescence vary and are dependent on the individual, biology, and culture. it is noted to start as early as 10 years of age and to end as one approaches their 20th year, marked by college commencement or entry into the workforce.Adolescence is usually separated into three overlapping sub-phases: early, middle, and late. Each phase has its own dominant themes, and we will explore the characteristics that are often found in each.
- Readings
- The experience of adolescence is contingent on gender, culture, ethnicity, socioeconomic class, and one’s physical and mental health. There is a great deal of variability in each of these areas that will directly affect the way an individual will process the dynamic interplay of adolescence.
- the biological changes that occur during adolescence. The physical changes observed during adolescence are attributable to puberty, which sets off complex hormonal surges that bring about physical maturation and the development of secondary sexual characteristics. These physical changes often occur rather quickly, which can make teens feel very self-conscious of their bodies. This factor, along with other biological and environmental precursors and circumstances, may lead some adolescents to have some form of body image dissatisfaction. Due to changes in their physical bodies, adolescents also start seeing themselves as sexual beings, which motivates their exploration of their own bodies and the bodies of others.
- During adolescence, neurological changes in the frontal regions (neocortex) of the brain are enhancing the teen’s ability to think logically and to understand abstract concepts and theories. As noted by Piaget (Ginsburg & Opper, 1979), adolescents are within the formal operational stage of their cognitive development and, as such, are quickly learning how to manipulate ideas with
- This particular section, focuses on the biological changes ushered in by puberty.
- The biological information provided within Chapter 9 of Rogers (2019). Note the physiological changes that adolescents are experiencing in puberty, as this will provide some context to the behaviors and emotions being relayed and observed within the social environment. Also, pay particular attention to how the physiological changes of adolescence are influenced –both negatively and positively– by the adolescent's social environment (i.e., nutrition, poverty, trauma, etc.).
- Reflection:
- What are some of the pubertal similarities experienced by both males and females?
- How may dieting and poor nutrition negatively impact the biological processes that take place during adolescence?
- Does the sexual maturation process of one person’s one sex (male/female) seem more complex than the others?
- Where have we historically discussed transgender or intersex during adolescence? How has that changed over time?
- According to Freudian theory, with sexual maturation, Oedipal tensions resurface and must be dealt with and resolved. Within the genital, and final stage of psychosexual development, teens must redirect their sexual interests away from the parent and toward opposite sex partners in the outside world. Thus, according to Freudian theory (and society’s acceptance of its notions),normal psychosexual development includes internalizing the norms and traditions of society, identifying with the same-sex parent and fulfilling sexual gratification through genital-to-genital contact with a member of the opposite sex. Research and society have arguably been slow to include those who don’t fit within a male or female description and as a result, those that may define themselves in other ways, may be left out, invisible, or worse. For the adolescent, trying to understand who they are and how their bodies are changing, not having additional terminology that better explains their bodies is important. Today, there is more research to suggest that sex is a spectrum and that there are other terms, such as transgender or intersex, that prompt the inclusion of those that may not be characterized within the definition of “male” or “female”. While our society continues to move away from this binary characterization of sexual development, it does provide the foundation by which sexuality is historically examined. In order to expand the discussion and offer additional information, you are encouraged to look at GLAAD's Media Reference Guide that provides a glossary of terms.
- The hormonal surges that accompany puberty bring forth physiological changes that incite a sexual maturation effect that has psychological implications. Teens may start to acknowledge themselves as sexual beings and, as such, become progressively interested in experiencing sexual activity with others.
- With the advent of sexual activity comes the concern of contracting sexually transmitted diseases and infections, and of becoming pregnant. STDs often have no obvious sign or physical symptoms, so regular screenings are critical.
- Reflection: Discuss how a trans-identified teen may be emotionally/psychologically affected by the biological changes brought on by puberty that may not necessarily affect a teen who is cisgender (or cis)?
- Reflection:
- Case: A 15-year-old student tells you that they are feeling ugly and overweight compared to their peers.
- Using Markey (2010) and your own knowledge about body image dissatisfaction, how would you describe and attribute the student’s her present feelings to your clinical supervisor? As you consider the student’s situation, keep in mind their present stage of biological development and sociocultural context.
- Understanding the developmental processes that occur within different substructures of the brain can have bearing on the way that teens are treated in different areas of the social environment.
- The Steinberg (2012) article will provide a general overview of some changes that occur in the adolescent brain, while also noting how the knowledge of such scientific developments are informing public policy and other initiatives.
- Jean Piaget (1986-1980). According to Piaget, by the time individuals reach adolescence, they should have passed three stages of cognitive development: the sensorimotor, preoperational, and concrete operational. Arriving at the formal operational stage, most adolescents, depending on their genetics, environment and interests, would progressively develop the ability to reason and verbally state a hypothesis, as well as deduce the consequences that hypotheses imply (Austrian, 2008).
- As they continue to mature, adolescents start to draw logical conclusions, become more flexible with their thinking, exchange information in broad circumstances, and allow their thinking to become adaptive to various issues that arise (Austrian, 2008).
- Theories applied :
- Piaget stages of cognitive development.
- Kohlberg’s stages of moral development
- Piaget was a strong influence to the work of Lawrence Kohlberg (1927-1986), a psychologist whose research included the stages of moral development. Kohlberg’s formulations of moral development were based on the analysis of 72 boys who were upper-middle to lower socioeconomically, and ranging in ages, 10 through 16 (Cincotta, 2008). From childhood, the stages are separated into three main phases: pre-conventional morality, conventional morality and post-conventional morality. View the stages of moral development below and note the parameters set for adolescents (conventional morality).
- Reflections:
- What are your thoughts about these theories? In particular, what may be some of the limitations of stage-based theories of development? For example, consider their limitations in regard to age/time, race, gender, sexual identity, socioeconomic status, etc. Theories can also lead to assumptions and they may reinforce ideas about certain populations. How might these theories lead to “otherness” categorizations?
- Steinberg (2012) It also will help in concretizing the understanding that the biological changes accompanying adolescence don't occur in isolation, but rather have an interactive effect with the environment. From an ecological perspective, when we examine any biological factor, we must also consider the effects it may have on the meso and macro levels.
- how might you explain to concerned parents and board members the risk-taking behaviors that teens engage in?
- Readings:
- An adolescent’s psychological development encompasses a multitude of variables. One that is of particular importance is identity.
- cohesive identity will provide the internalized structure for understanding the self in relation to the world and to remaining true to one’s own beliefs and value systems.
- dimensions that comprise identity formation. We will concentrate our time on exploring the constructs of race, ethnicity, gender and sexuality.
- key features of adolescent psychological development.
- the factors that comprise an adolescent's identity construction.
- Name and describe
- social elements that challenge an adolescent’s identity
- Chapter 3, Rogers (2019) notes the contributions of Erik Erikson to the importance we place onidentity development. In his eight psychosocial stages of development, Erikson named the crisis that pertains to adolescence as that of Identity versus Role Confusion. Here, the challenge of the adolescent is to construct a sense of self within the social group, as opposed to becoming very confused about themselves and their purpose.
- Theory:
- Ethnic and Racial Identity
- signficant stress and confusion for the individual. Others who are more racially ambiguous may have have more of a choice to construct their own ethnic/racial identity, within limits. Regardless, the social pressure to "choose only one race" remains a feature of American society and presents unique challenges for the development of racial identity for this heterogeneous group.
- Rogers (2019) provided you with the basic tenets of various identity constructs. Most were based on traditional stage conceptualizations. However, as we have learned, issues as complex as identity development don't neatly conform to a set formula. Yi and Shorter-Gooden expand our understanding of ethnic identity formation by proposing a constructivist narrative approach. Ethnic identity is observed as being more fluid and multidimensional in context, influenced by the interactions one has with friends, family and social institutions and parties. This isn't as uniform and linear as stage models have often depicted.
- Yi and Shorter-Gooden (1999) use the term ethnic identity broadly enough to encompass racial identity too. As such, according to an internal quotation that Yi and Shorter-Gooden (1999) utilize, ethnic identity is “an enduring fundamental aspect of the self that includes a sense of membership in an ethnic group and the attitudes and feelings associated with that membership” (Phinney, 1996, p. 22).
- Reading:
- IMMIGRANT IDENTITY
- Gender Identity
- In her book The Second Sex (1973), Simone de Beauvoir, suggests that gender is in fact constructed and evolves due to appropriations made by the individual within the context of cultural compulsions. Developing one's own gender identity or subscribing to the gender prescriptions encoded by culture and society can be challenging, particularly for those who are gender variant. There are many adolescents who struggle with gender identity issues and who must navigate very tough situations in order to gain individual and public acceptance.
- The articles for this section were selected because they discuss important issues that we must keep in mind since we are a profession that works with a wide and diverse population. As noted within the Social Worker's Code of Ethics (National Association of Social Workers, 2008):
- Value: Dignity and Worth of the Person
- Ethical Principle: Social workers respect the inherent dignity and worth of the person.
- challenges confronted by trans-identified adolescents and how those experiences affect their quality of life. According to the NY Times (Hartocollis, 2014), due to the wider acceptance of transgender identity, the number of teens obtaining reassignment surgery has steadily increased. Yet, even with growing acceptance, there continue to be appalling acts of violence perpetrated against trans people, most especially against Black and Latinx individuals (Hartocollis, 2014). The Human Rights Campaign (Baum et al., n.d.) noted that at least 29 transgender-identified individuals were murdered in 2017, the highest number recorded.
- What are some of the challenges that the teens depicted and experience in their daily lives that are a direct result of their gender identity? What are their coping mechanisms?
- Sexual Identity
- Homelessness: impacts a disproportionate number of lesbian, gay, bisexual, transgender, and queer/questioning youth in the United States1. In a recent national report, those youth and young adults who identify as LGBTQ are over 100% more likely to experience homelessness than their straight and cisgender peers.2
- Some youth (minors) who identify as LGBT may be forced by their parents or caregivers to attend reparative (conversion) therapy, a pseudoscientific treatment modality whose main objective is to change the homosexual orientation of a person to heterosexual. Both medical and mental health communities have condemned the practice of conversion therapy due to the serious effects it has on the patient.
- Consider the influences that family has on LGB identity and how rejection may affect identity formation. Consider how symbolic interaction theory and the role that family may play in administering social support to teens who are expressing their sexual identity. Also interesting to note are the various theoretical models of sexual identity development that are discussed.
- Reflection: How will the trajectories of sexual identity development differ between those teens that identify as heterosexual and those that identify as LGB?
- the important mezzo and macro systems that interact with adolescents and distinguish the similarities and differences.
- the risks and protective factors that adolescents may encounter within family systems.
- the risks and protective factors that adolescents may encounter within peer groups.
- As adolescents continue to develop and start taking steps toward understanding their own sense of self, they begin the separation process from their families of origin. This separation is not so much physical as it is emotional. The redefinition of self is not based on parental identities, as it was in childhood. Rather, the definition encompasses the social world. Teens begin to more fully engage with peers and also expand their affiliation with school and community channels. As they interact, integrate and assimilate into different spheres of the environment, they may experience certain challenges. When examining eachsome of these situations, consider the effect it may have on the adolescent as well asbut also on the other entities within the social environment. For example, when discussing teen drug use, think of its implications from the societal perspective, but also critically examine the consequences that behavior may have on family units, on school and medical systems, and on communities.
- The ecological model is yet another way to understand the multi-textual frames by which social workers can assess the relationship between the individual and the environment.
- Family, especially parents, parental figures, and caregivers have a particularly strong reaction to adolescent development. Some may fear it due to the challenges it ushers into the family unit. They may experience vulnerability due to the infiltration of other social systems (peers, gangs, etc). Parents and caregivers will observe their adolescent undergo a series of social milestones where they will explore sex, independence, drinking and maybe even drug use. There is also the inevitable process of letting go that parents must manage. Families must tackle the challenging aspect of developing the ability to provide control and order, while also relinquishing some power to the adolescent. The change in the status quo may even instigate a mourning process for the parent in the loss of the child they once knew. Additionally, there will definitely be disequilibrium due to the challenges confronted, but homeostasis should be reestablished in time.
- Due to the amazing changes in their physical bodies, adolescents start seeing themselves as sexual beings and they take initial steps to separate themselves from parents and caregivers. According to Blos (1967), there is a second individuation whereby the adolescent separates from the primary love objects in order to become a participating member of society. Consequently, there is a greater tendency toward self-absorption and, paradoxically, toward having more peer interactions. Lyons-Ruth (1991) appropriately noted that good and healthy development requires a degree of individuation but it also must constitute attachment, rather than full separation. The push toward greater independence is in keeping with the adolescent's need for establishing a self-identity. The loosening of their dependence on parents helps the early teen to step out of childhood. Some teens may move from total reliance on parents to more of a reliance on peers and environmental supports external to the family, including community centers, schools, sports leagues, and religious organizations.
- the important role that families play in fostering resilience in teens that navigate some very challenging social circumstances, including racism, poverty, poor school performance, and stigmas related to physical and personal characteristics. Resilience is a term that you encountered earlier in the Human Behavior sequence. It refers to a strengths component that plays an important part in explaining how many people get through challenging times. According to Masten (2001), resilience can be described as a "good outcomes in spite of serious threats to adaptation or development" (p. 228).
- Constructionists state that resilience is the result of "negotiations between individuals and their environments to maintain a self-definition as healthy” (Ungar, 2004, p. 24). Teens want to develop more independence and are looking to create their own self-identity. Often they will negotiate terms with their parents as it pertains to supervision, and they will be the gatekeepers to the amount of interactions that are done in conjunction with adults (Ungar, 2004). That being said, studies have noted that teens continue to need family support. If there is poor parenting, there is a greater likelihood of having a child that has poor mental health and behavior (Gerard & Buehler, 1999). Consequently, familial resources in the form of contact and control, unconditional acceptance, consistent emotional support, and attention and hope are often necessary and expected (Lefkowitz, 1986; Werner & Smith, 1992). The diagram below( Eastman k corona demonstrates the importance that family interactions have on adolescent behavioral outcomes.
- Reflection:
- Peer relationships are of paramount importance in adolescence, as identity constructs are influenced by the exploration and experimentation that adolescents partake in with others. Teens will increase their interactions with peers and with other groups and organizations in an attempt to find similarities and commonalities. Peer support has been correlated with successful academic outcomes, increased motivation, and better mental wellbeing (Brittian & Gray, 2014; Maurizi et al., 2013).
- In attempting to expand their external support system, some adolescents may turn to gangs. St. Cyr and Decker (2003) have noted that there were some overlapping factors that may lead a teen to become a gang member: (1) family troubles, (2) gang presence within the neighborhood or community, and (3) a family member’s connection to a gang. Research has noted that gang members have delinquency and drug use rates at a much higher level than teens not involved in gangs (Thornberry et al., 1993).
- Within adolescence, comparisons are made between the self and others in terms of appearance, bodily changes, athletic and intellectual abilities, popularity, social influence, and a multitude of other variables. As comparisons are made, inevitably vulnerabilities are noted and very often expose the individual to marginalization or bullying. Bullying has been defined as "negative actions, physical or verbal, that have hostile intent, are repeated over time, and involve a power differential between the bully and the victim" (Pepler et al, 2006, p. 376; Olweus, 1993).
- Emotional distress
- Family conflict
- History of depression or other mental illness
- Alcohol or drug abuse
- Stressful life event or loss
- Easy access to lethal methods
- Lack of access to resources/support
- Relationship problems
- the adolescent:
- social environment,
- family and peer interactions.
- the risk and protective factors to adolescents related to school systems, communities and neighborhoods.
- issues of engagement/participation, violence, alcohol and drug use, college enrollment and employment.
- the risks and protective factors that adolescents may encounter within school systems, neighborhoods, and communities.
- issues related to adolescent college enrollment and employment.
- Readings:
- Schools, neighborhoods and communities can be great resources to adolescents in a variety of ways. They can provide teens with protective factors, including positive peer interactions, mentors, and in improving skills and learning, all of which can build pride, esteem and cultural capital. However, schools and neighborhoods can also bring negative consequences, increasing risks to teens when those environments are poorly managed, constructed and when they contain negative elements.
- Adolescents spend a large portion of their day in school engaged in learning based activities. Schools are also the environment that may affect adolescents’ development on many other levels (i.e., physical, psychological, social, and in terms of safety) (Marin & Brown, 2008). Schools can affect a student’s mental health through academic and social stressors; they are also the environment where mental health issues may first be diagnosed and treated (Marin & Brown, 2008). Students may receive direct physical care through a school’s healthcare services but their safety may be compromised if the school’s security is vulnerable to violence and gang related activities.
- Neighborhoods and communities will also deeply affect adolescent development but the extent of the interaction and effect has not been studied as much as within school systems. Despite this limitation, however, research has noted that involvement in neighborhood organizations and activities will motivate adolescents to achieve greater academic success, particularly those that live in poor areas (Quane & Rankin, 2006). Teens who engage in civic activities are also less likely to become pregnant and to use and abuse drugs (Zaff & Michelsen, 2002). Additionally, when they engage in community activities, including the YMCA, Boys or Girl Scouts, religious youth groups, and organized sports teams, they are more likely to have better grades, an increased esteem and be more likely to be civic minded regarding volunteerism and work.
- Social ecological model > Bronfenberrer
- the risk and protective factors associated with both schools and neighborhoods. The risk and resilience factors discussed within the articles provide a very good foundation for the next few sections. Themes continue to reverberate throughout the complex layers of the social environment. Within Maurizi et al. (2013), read the introduction and the discussion sections carefully and note how neighborhood and school belonging have a particular effect on Latino youth. When reading Brittian and Gray, (2014), note the importance that a connection to ethnic identity plays on educational outcomes, most especially in situations where racism continues to be a pervasive challenge. Recall the points made about race and ethnic identity within Lesson 3 as you review the introduction of the article and the discussion sections.
- Youth who experience a trauma related to abuse, rape, sexual assault, violence and the urban environment (e.g., gang activity, poverty, drug use, etc.), are at a greater risk to experience mental health difficulties (McKay, Lynn & Bannon, 2005), due to the effects that such experiences have on brain activity.
- Victims of trauma are more likely to suffer from depression, post-traumatic stress disorder, alcohol and drug abuse, and be prone to suicidal ideations (RAINN, Cniro et al, 2005; D’Augelli, Grossman, et al., 2006. McKay et al., 2005).
- Note each section of the brain to obtain an understanding of its functionality and the role it plays in PTSD.
- Due to the biological, cognitive and social changes that occur, it is almost expected that adolescence be a time for experimentation and exploration.
- Peer pressures and just the nature of increased socialization exposes teens to various situations where the opportunities to drink alcohol and use drugs present themselves.
- teens are at a significantly higher risk of developing an addiction compared to adults. The National Institute on Drug Use (Robertson, David, & Rao, 2003) provides a list of risk and protective factors that pertain to drug abuse.
- Readings:
- Note how these risks and protective points are similar to those that were discussed when reviewing violence and victimization. Also, notice how the domains relate directly to the social environment that you have been studying.
- A number of adolescents are participating in the work force before and after school, during school vacations and on weekends. As teens continue to construct and progressively develop their identities, they should become more aware of the interests, which may subsequently lead them to pursuing a particular vocation or career. Career readiness, the skills and knowledge to achieve an understanding of one’s future work plans (Johnson et al., 2014), is hinged on some of the social environmental factors we have reviewed. Parental guidance and monitoring, school academic resources, and community channels all play a significant role in getting an adolescent ready to move on to the next step of development, emerging adulthood.
- Factors of risk and resilience stemming from various sectors of the social environment will impact a teen’s ability to engage in the notion of work and the idea of having a future, possibly pursuing a post-secondary education or in a skills/vocational training program.
- the characteristics of emerging adulthood.
- the differences between emerging adulthood and late adolescence.
- factors that have led to the disenfranchisement of youth in the US.
- the differences in identity formation in emerging adulthood.
- Emerging adulthood is a transitional point between adolescence and early adulthood. As such, it absolves the individual from having to fully participate in normative operations and expectations that usually accompany adult development.
- This time of development is characterized as a period for exploration and experimentation with different roles, occupational intents, educational pursuits, religious beliefs and relationships. Individuals place more focus on these aspects of their lives than they did in adolescence but there is still no full commitment undertaken. Emerging adulthood theory recognizes that the socialization experienced within family, peer groups, school and community,
- Experts have noted that socioeconomic factors, delayed marriage plans and the pursuit of education have led more youth to make the decision to live at home. There are some mutual benefits that parents and their kids get from living together. Besides the economic and emotional perks grown kids get from living at home longer, parents also benefit by having fewer depressive symptoms since they feel a part of their grown children's lives (Byers et al., 2008; LeMoyne & Buchanan, 2011). According to a poll conducted by Clark University in 2013, 61% of parents said that they received little to no social support from their grown children (Arnett, 2015).
- Sociocultural assessments and articles centered on education have noted that parental involvement is crossing serious lines for youth within the emerging adulthood stage of development, very much to their detriment. Helicopter parenting, the term given to caregivers who are crossing boundaries by becoming too involved in their grown children's lives, is limiting the opportunities for youth to become self-reliant adults. The behaviors associated with being a helicopter parent are being especially noted within colleges and universities. Parents are waking their grown children up, transporting them, speaking to professors for them, reminding them of deadlines, completing application forms, and speaking with college administrators. A 2014 study from the University of Colorado (Barker et al., 2014) has determined that when parents provided children with a highly structured childhood, they developed less executive functioning skills (Barker et al., 2014). It was also noted that these students were more anxious, prone to depression and more rigid in their thinking (LeMoyne & Buchanan, 2011).
- Reflection:
- Within the interactive play of dependence and independence that unfolds between parents/caregivers and their kids, many young people between the ages of 18 and 25 are taking steps to explore work and other relationships.
- youth will explore different paths of employment in order to better understand which course is the one to settle on for the future. Consequently, unlike previous generations, the intention is not just to find a steady job to add to their stability. Rather, the task is centered on finding a job that will be the basis for their professional identity (Mayseless & Keren, 2013). Additionally, they will seek to explore the career that will be guiding them into adulthood and providing them with a meaningful life. Mayseless and Keren (2013) delve into the construction of a meaningful life and why it’s thought to be a major developmental task for youth.
- using work venues as a way of tapping into their identities and quest for a meaningful life, youth are also engaging in various relationships in an attempt to understand more of what they like, physically and emotionally (Mayseless & Keren, 2014). Emphasis is placed on the casual, although this period may be interspersed with committed relationships or no relationships at all. There isn’t one linear approach, as relational situations are often complex and dependent on a few variables. As was noted in Munson et al. (2013), not all youth follow this progression of romantic exploration. For some, depending on their personality, environmental circumstances and culture, this period can be one in which they participate in a milestone of adulthood by getting married or having a child.
- Maysless and Keren (2014) will also discuss romance in emerging adulthood, and the way it may add and, at times, subtract from the quest to construct a life that one is happy in pursuing. (Please note that romantic love and the forms it takes will be discussed in greater detail in the next lesson on Early Adulthood.)
- Due to the relational experiments that emerging adults often participate in, they are at higher risk of contracting sexually transmitted diseases, including HIV, and of having an unwanted pregnancy.
- time to experiment with work interests in order to gain a better perspective on one’s self and professional identities.
- Lewis and Burd-Sharps (2015), youth disconnection continues to be both insidious and pervasive. The report assesses the current situation and presents the various socio-demographic variables as pertain to respective regions of the United States.
- Readings:
- biological changes that accompany early adulthood development.
- the Eriksonian psychosocial stage that pertains to early adulthood development.
- attachment theory as it pertains to adulthood.
- biological and psychological issues that may present challenges in early adulthood.
- Readings:
- Traditional markers in Western industrialized, middle class societies may include:
- Financial independence and authority in decision making. Although, as we noted in emerging adulthood, a certain level of financial independence may not always signify adulthood.
- Taking on work and graduate-related educational endeavors. Here, too, as was reviewed in emerging adulthood, there may still be a reliance on parental/caregiver’s care.
- Developing a significant relationship and subsequently getting married (or formalizing the relationship).
- Piaget : cognitive development, adulthood is a continuation of the intellectual progression that was started during adolescence (Austrian, 2008; Ginsburg & Opper, 1979). In the Formal Operational stage, individuals expand, refine and challenge existing belief systems. There is an expansion of abstract thinking which enhances problem solving and reflective thought processes.
- Early adulthood is also marked with an increase in the person’s executive functions, which include coping, adaptation, self-assurance, and self-control.
- Morally, early adulthood brings greater independence in decision making. There is an ability to contemplate more complex ethical principles. This is also a time when individuals start to develop a moral conscience. They move from seeking social approval through conformity to redefining and revising values and selecting behaviors that match those values. They start to give more to larger systems and they have more appreciation for community. Young adults also gain more understanding that social roles are relativistic, instead of rigid and prescribed.
- increased socialization and physical intimacy, health risks include STDs and HIV. Since the greatest fertility rates occur during early adulthood, there are also risks of unplanned pregnancies. Using early adulthood as the entryway into adulthood generally, there are some interesting statistics that should be noted regarding physiology and mental health.
- Other common types of adult disabilities included those related to vision and self care, independent living, and memory. Interestingly, but not terribly surprising if you recall our discussion of risk factors within the social environment, individuals with lower levels of education and income, and unemployment tended to report more disabilities (Geggel, 2015). When examining ethnic and racial lines, it was shown that non-Hispanic black adults and Hispanics report more disabilities.
- Of course, health issues are not always the result of an individual’s investment in certain behaviors. It may also be directly related to the factors endemic to society or the family of origin. For example, stress can place an incredible amount of demand on the body. There are many types of stress, for example,stress may be rooted to the environment, socioeconomic class, family life, and acculturation, to name just a few.
- Acute stress, the most common form of stress, is short-term and stems from the demands and pressures of the recent past and anticipated demands and pressures of the near future (APA, 2011).
- Chronic stress, a long term form of stress, derives from unending feelings of despair/hopelessness, as a result of factors such as poverty, family dysfunction, feelings of helplessness and/or traumatic early childhood experience (APA, 2011). Chronic stressors associated with health disparities include perceived discrimination, neighborhood stress, daily stress, family stress, acculturative stress, environmental stress and maternal stress (Djuric et al, 2010; NIH, 2011).
- Long-term activation of the stress-response system can disrupt almost all of the body’s processes and increase the risk for numerous health problems (Mayo Clinic Organization, 2011; NIH, 2011).
- attachment theory, originated by the seminal work of John Bowlby and Mary Ainsworth, is no longer connected solely to infancy. Rather, the theoretical constructs of attachment are being applied throughout the life developmental process. Bowlby believed that human beings must maintain some form of bond with others in order to create stability and security in their own lives (Bowlby, 1980; Sable 2008). The attachments that we form early in life become the working models by which we create parts of our adult personality and adult relationships (Bowlby 1969, Sable 2008). The forming of a bond or attachment is the means by which to create health and wellbeing.
- Attachments in adult relationships are quite complex and multidimensional and consequently, it may be difficult to correlate them directly to attachment concepts (Sable, 2008). The convoy model has been used to account for various degrees of relationships in adulthood, with a perspective given to the individual in relation to the other within the environment (Antonucci et al., 2004).
- Hazan and Shaver (1987), configurations of adult attachment styles within the context of intimate relationships have been formulated. Research on attachment has also attempted to create a linear progression of attachment styles from childhood through adulthood. Although the descriptors of the attachment styles are quite standard, the names of each may change depending on the author. The chart below presents two ways in which the descriptors may vary so that you may gain familiarity with the differences.
- Readings:
- the social environmental issues that impact early adulthood.
- significant events/milestones that occur during early adulthood.
- the changes that may take place in the family system.
- Adults within the early stage of development continue to experience many of the social and cultural conditions discussed in emerging adulthood. That is, much of their attention is spent developing relationships on the various plains of intimacy. There is an increase in socialization through work and other channels, but young adults also start to engage in more committed long-term relationships. As was noted in the previous section on young adulthood, attachment is formed in terms of intimate or romantic relationships. Some may choose to marry and cohabitate, while others may opt for another pathway to intimacy.
- Rogers (2019) notes that early adulthood is also marked by the testing out independence, completing educational goals, acquisition of employment that can support themselves, and perhaps moving into a space of their own or with similar phases roommates.
- Rogers (2019) acknowledges that tasks or roles traditionally thought to be done in young adulthood have been taking place slightly later. As a result, a new life stage, emerging adulthood, has been conceptualized (Arnett, 2000). This life period is categorized as the development phase between adolescence and mid-twenties although this distinction is only made for those living in industrialized countries. The emerging adulthood phase was meant to help explain the time shift in the adult roles previously accomplished in younger adults. Other tenets of this newly defined age category include delayed childbearing and marriage, more frequent job changes, and an increase in risky behaviors.
- Meyer (1990) noted that a unit is considered a family when two or more people are joined together by bonds of sharing and intimacy. The family is an intimate environment, a constellation in which people live, and hopefully, thrive. According to Carter and McGoldrick (2005), a family unit may include extended kin, the community and cultural groups. Their definition of family certainly broadens the scope of the familial construction and it speaks to the diversity within the United States. Currently, American families are more “ethnically, racially, religiously and stylistically diverse than half a generation ago” (Angier, 2013).
- The definition of family should be kept flexible and broad for the sake of our clients, so that we may better comprehend their narratives and accommodate the work needed in reaching their goalss. Families differ from other systems in an important manner – in other systems members may leave and be replaced at one time or another, but in families – the main component is the value of the relationship. Therefore, when one person leaves, they cannot be replaced (Carter & McGoldrick, 2005).
- Along with establishing a family, many individuals in early adulthood also endeavor to have children. They may be single parents or share the responsibility with one or more people. Adapting to new roles as parents means a certain loss of freedom and the acquisition of new responsibilities. The new parents’ childhood experiences, as well as structural and socioeconomic variables, will strongly influence the family’s structure and the dynamic interplay between parent and child. Cultural values significantly affect how children are socialized, the values they acquire, and the behaviors they learn. For example, parents from ethnic minority groups expound goals that are more directed toward interdependence and family cohesion, instead of the individualism that is the preferential mode of behavior expounded by the European American parents (Suizzo, 2007).
- Today’s families are also diverse in their constitution. Thirty-four percent of children today are living with an unmarried parent, which is a huge shift in the family structural unit considering that the same number for 1960 and 1980 were 9 percent and 19 percent, respectively (Livingston, 2014).
- Mental illness is defined here as
- Individuals with a serious mental illness (SMI), have a mental disorder that seriously impairs their functional abilities and it interferes with or limits one or more major life activities. Although the statistics being cited are rendered for all adults, it is pertinent that the information be reviewed here in early adulthood since that is the developmental time frame when many mental illnesses manifest.
- Long term socioeconomic disadvantages, economic stress, and lack of net worth (wealth) have been attributed to increases in mental health issues and stability (Mossakowski, 2008). poverty and mental health problems in children and subsequent health issues in adulthood (McDonough & Berglund, 2003; Mossokowski, 2008).
- the link between childhood issues that have followed into adulthood has been all the more validated. Research has noted that adverse childhood experiences are directly correlated to poor health and life satisfaction in adulthood, including an increase of symptoms related to depression and anxiety. Additionally, Grollman (2014) explains the effects that societal discrimination has on mental and physical health.
- the physiological changes that accompany middle adulthood.
- the emotional issues that may arise due to the physiological changes that take place during middle adulthood.
- explain the Eriksonian psychosocial stage that pertains to middle adulthood development.
- Reflect on the meaning of midlife crisis.
- Readings:
- people show a period of industriousness in their 30s, followed by a series of adjustments and readjustments between their late 30s and 40s, and responsibility and stability in their 50s and 60s (Lesser & Pope, 2011).
- During midlife there is a general trend toward increased competence which is very much affected by the availability of resources. Individuals’ experiences are dependent on social and structural opportunities, as well as cultural and familial influences.
- Many factors drive outcomes in midlife including: personality, health, family, as well as other social, economic, situational, cultural, and biological variables. Additionally, an individual’s own ego strengths will determine whether midlife is a time of real and perceived deterioration, or of increasing confidence and adjustment.
- Rogers (2019), life events during middle age may stress an individual’s sense of self and self-esteem. Identities as a spouse or parent shift as partner relationships change and divorce occurs, or offspring leave the home thereby ending the period of everyday parenting responsibilities. “Narcissistic” injury may be particularly experienced when bodily changes lessen feelings of cisgender women or cisgender men, health, and physical strength.
- Depression may be the result of shame, self-consciousness, a loss of confidence, and feelings of rejection (Goldstein, 2005). Similarly, cisgender men may experience climacteric, described as a change in life, where they are in a stage of reevaluation whether it be in their careers, familial relationships, and other areas of life (Rogers, 2019).
- Cognitively, middle adulthood continues to be a time when there is peak strength in postformal thought, and overall development seems to be multidirectional.
- the stage of Erikson’s psychosocial theory pertinent to middle adults.
- the midlife crisis that can very much be related to Erikson's discourse on stagnation.
- the re-evaluatory process accompanying midlife may in fact bring forth changes in identity, particularly as it relates to sexuality.
- generativity has been defined differently for male identified than for female identified. Males were thought to be generative in matters of work and females in matters related to the household. These limited perspectives have changed considerably in the last few decades, as exemplified by the manner in which creative capacities are applied in the pursuit of generativity in occupational success and economic security.
- Generativity involves cognitive, emotional and social development and requires the ability to take action and make life decisions based on the needs and interests of others as well as oneself. In family matters, to be generative with raising children must include providing guidance based on one’s maturity and desire to nurture. Not having children does not preclude being generative, and having children in and of itself does not mean being generative. On the other hand, “stagnation” is often evident in people who have difficulties in the roles of parent or worker. Torges et al. (2008) describe how the generativity one has at midlife is helpful to achieving the ego integrity sought in later adulthood.
- psychological tasks include accepting the end period of one's life,
- reviewing and evaluating the past,
- deciding what to keep of the past and what to reject
- considering possibilities for the future
- Losses may significantly challenge important values, self-esteem, security and safety.
- There have been various theoretical perspectives offering diverging views on the “midlife crisis”. At the same time, Levinson’s Theory of Adult Development would suggest that a midlife crisis is more a reflection of the “normal tasks” of adult development rather than negative responses to aging (Rogers, 2019).
- the illness and death of parents necessitate changes in their own self-concept, a reworking of relationships and a possible revisit of earlier developmental issues.
- The awareness of paths that have not been taken may generate regret or pressure to make changes.
- Opportunities for career development and satisfaction may diminish.
- Latent conflicts may come to the fore as challenges and other stressors present themselves.
- Depending on the individual’s particular situation, illness and even death may loom, which exposes one to certain vulnerabilities and threatens any sense of immortality.
- Abraham Maslow’s (1908-1970)
- Midlife is not necessarily a time of crisis, nor is it only a time of loss and decline. It may also be a time of achieving goals, sustaining satisfying relationships, finding a sense of safety, security and well being, freedom, stability and personal power. All of this depends upon the larger sociocultural context and values system, the individual’s particular circumstance leading up to midlife, and the current situation that one is attempting to grapple with in order to gain a better understanding of self.
- One of the most fundamental tasks of adult life involves maintaining self-esteem and identity in the face of biological, psychological, and social stressors and losses that occur as we grow older. There is an existential quality to identity re-evaluation, as has been noted in Erikson and all the midlife undercurrents of “crisis.”
- There is also something quite real and concrete in the identity redesign
- When faced with imbalance –like disruptions or crises– systems tend to regulate cohesion in response to the stressors. As with other systems, families attempt to maintain or preserve balance. For example, a reevaluation of one's life at midlife, or the death of a close family member will cause a disruption in the family system. Homeostasis is maintained in the family unit by some kind of intervention. When there is a death in the family, another family member stepping in to take over the role of the deceased can restore equilibrium.
- Ahrons (2016) outlines the five transitional stages that constitutes the divorce developmental process. Though the stages are presented sequentially, some may happen simultaneously. Working with divorce requires a complex multilevel approach. We often need to be aware of our own biases and stereotypes and correct them by gaining knowledge of the emotional, legal and economic factors that characterize a divorce process.
- Divorce presents dual tasks of managing physical and emotional separateness while maintaining ongoing familial connections. These processes of separateness and connectedness are particularly significant to family life and to the parent-child relationship. Lives need to be restructured so children can continue their relationships with both parents. There are many factors that contribute to the healthy adjustment of children, including meeting their basic economic and psychological needs and continuing to foster warm and loving relationships via the divorcing parents and other family members (Ahron, 2016).
- One of the primary tasks of clinicians who work with divorced or divorcing parents is to facilitate the interpersonal and intrapsychic reconstruction and redefinition of the parent-to-child relationship and parent-to-parent relationship. The modified and redefined family system will present itself in the context of the social environment and will therefore interact with other family systems, peers, schools, community and society at large.
- As was previously noted, families work on a system of checks and balances. Rules and common operatives help to maintain equilibrium and allow the family unit to prosper and grow. Some of the consequences of disruptions in the family system are the result of external and structural forces such as a gender-based division of labor, an oppressive labor market that perpetuates gender and racial economic inequities, a dual welfare system, and insidious and systemic sexism in society (Bianchi & Milkie, 2010; Jang & Zippany, 2011).
- These factors that infiltrate our lives both inside and outside the home, make finding equanimity and balance all the more important, while continuing to advocate for policies that reduce workforce equities.
- Work-life balance is defined broadly as the satisfaction obtained with the “integration of personal time, family care and work with a minimum of role conflict” (Jang & Zippay, 2011, p. 84). Work-life balance issues affect many people from different strata of the social and economic spheres. However, the factors of work-life balance remain particularly important for single parents, individuals with disabilities and chronic health problems, low income families, racial minorities, and those individuals that care for multiple children and elders (Jung & Zippay, 2011).
- Overall, the roles of parents/caregivers within families have really seen a change over the last few decades. Identified males are spending more time at home and engaging in home related activities and identified females are working more outside of the household.
- the physiological changes that accompany late adulthood.
- factors that contribute to HIV infections in older adults.
- explain the Eriksonian psychosocial stage that pertains to late adulthood development.
- the mental health issues that are prevalent in late adulthood.
- Readings:
- There is also an increasing feminization of older adults throughout the world as women live longer than men, especially within the older than 80 age group (Murray et al., 2006).. Current life expectancy is 81.1 years for women and 76.1 years for men. The CDC and the Prevention’s National Center for Health Statistics reported that the US life expectancy age has decreased somewhat in the last few years due to increased deaths caused by opioid use and suicide.
- Ageism, like racism and sexism, is a form of prejudice, which oppresses and limits those that are the object of oppression. The very act of holding ageist views shapes the perceptions of people, both young and old (Laws, 1995, p. 113). Ageism is manifested in a wide range of phenomena, on both individual and institutional levels stereotypes and myths, outright disdain and dislike, simple subtle avoidance of contact, and discriminatory practices in housing, employment, and services of all kinds (Butler, 1989). By the time younger individuals become elderly they have spent upwards of 50 years expressing and internalizing negative stereotypes of aging. Therefore, it isn’t surprising that older adults and younger age groups may have the same notion or hold the same stereotype of the aged.
- Biological myths address the physical changes associated with the aging process. These include illness, unattractiveness, exertion, sleep, and sexuality. There is a belief that all older people are alike and will go through the same process.
- Psychological myths include rigidity, tranquility, unresponsiveness, senility, diminished intelligence, memory issues, lack of problem solving, diminished sexual interest, and dependency.
- Social functioning myths include withdrawal, isolation, alienation, stress, retirement, and the increase in leisure time.
- Ageism is communicated through verbal and behavioral actions in many areas of society. Ageism is also structurally insidious on the macro level and it works its way to the mezzo and micro levels:
- Policies
- Services
- Workplace
- Organizations
- Print and Electronic Media (representation/under-representation)
- Schools
- Neighborhoods
- Families
- Older adults grow to believe that they are not physically functional and may become more sedentary.The lack of thought-provoking activities given to late adults may produce cognitive stagnation.Chronic exposure to stereotypes related to limitations in physical activity may cause some older individuals to lose motivation to engage in forms of exercise. Physical activity (i.e., 30 to 60 minutes of moderate exercise) is very important for older adults. Older adults who have more positive outlook on the aging process will take better care of their health and may engage in more physical activity.
- Vivian Clayton, a neuropsychologist in California defined wisdom as containing three components: cognition, reflection and compassion. Unfortunately processing speed and the ability to recall information declines as one ages. Yet, quality of life in older adulthood is more strongly linked to clarity in thinking than it is to the speed at which information is processed. Additionally, older people have more information stored than young people, so it may in fact take longer to process (Korkki, 2014). Professor Ursula Staudinger of Columbia University discusses that true personal wisdom involves five elements: personal insight, demonstrating your personal growth, being self aware of your own life experiences, being aware of and understanding of priorities and values, and having a knowledge of life’s ambiguities (Korkki, 2014).
- The initial stage of cognitive dysfunction is called age-associated memory impairment (AAMI). It is followed by even greater memory loss which is diagnosed as mild cognitive impairment (MCI) which may progress to dementia (e.g., increasing forgetfulness and disorientation). AAMI and MCI are limited to memory loss alone, whereas dementia results in the disruption of daily living and an inability to function normally.
- Risks for cognitive decline and dementia include genetic factors such as being female, medical conditions including heart disease and diabetes, lifestyle choices such as smoking, or substance abuse. However, as noted within Erickson et al. (2013) cognitive strengths may be maintained by taking steps toward physical activity. Additionally, older adults should do as much as possible to work with modifiable risk factors such as (a better) diet, smoking (cessation), (increased) education, obesity and hypertension.
- cognitive impairment, it is important to not overlook the fact that older adults with cognitive dysfunctions are often the target of abuse. Elder abuse has seen a spike in several parts of the world in recent years. Learn more about the factors associated with this form of behavior that targets a vulnerable population.
- that the physical and cognitive changes described in most studies are not necessarily inevitable but are profoundly influenced by extrinsic factors such as socioeconomic status, trauma, nutrition, access to quality health care, exercise, medications, and the presence or absence of satisfying relationships. Sexual potency begins to decline early in the developmental process (approximately in the 20s through early 30s), but without disease and certain mental health diagnoses, sexual desire and capacity continue into late adulthood.
- chronic illness and death can be delayed through lifestyle changes including improvements in one's diet, social activities, smoking, alcohol and drug cessation, and regular health screenings. Successful aging has been defined as “minimal debility past the age of 65 or so, with little or no serious chronic diagnoses, depression, cognitive decline or physical infirmities that would prevent someone from living independently” (Reynolds, 2014). Various forms of exercise are consistently noted as being beneficial to providing successful aging, particularly when activities were started earlier in adulthood (Reynolds, 2015).
- One obtains integrity by identifying with all humanity and coming to learn that everyone is interconnected. Additionally, psychosocial development in late adulthood asks that individuals make peace with the temporal existence of life. They are challenged to come to terms with the realities of life’s circumstances and its limitations. In so reflecting, they will come to develop feelings of wholeness and meaningfulness about their life. False beliefs and ego attachments are loosened. Self-integration may also lead to despair when one is dominated by feelings of regret and notions that they’ve wasted their lives (Marcia, 2014). The older adult is unable to let go of the feeling that they would do it all again if they had a chance.
- A number of longitudinal studies have indicated that happiness in later adulthood is marked by diminished trauma and of loving connections in early life (Stossel, 2013).
- For some older adults, depression and suicidal thoughts may be triggered by external events, including a disabling illness, a death of a spouse or loved one, retirement, and moving out of one’s home to a living assisted community (NAMI, 2009). Some of the suicides committed by older adults could have been prevented since many of them reached out for help before taking steps toward more tragic consequences: 20% see a doctor the day they die, 40% the week they die, and 70% the month they die (NAMI, 2009).
- The increased use by this population may be attributed to the fact that Baby Boomers, the cohort born between 1946 and 1964, have a more relaxed viewpoint of drug use and may in fact have experimented with different drugs in their youth (McGarvey, 2015). Additionally, nursing home and long-term health care facilities are also prescribing, many times unnecessarily, medications that patients may become addicted to.
- Readings:
- the social environmental issues that impact late adulthood.
- the factors that are challenging to LGBTolder adults.
- issues that affect family systems in late adulthood.
- Readings:
- Late adulthood is certainly a time for social role transitions and of experiencing multiple life events. Some significant transitional life events that cause the most stress cluster in late adulthood and include retirement, death of a spouse or partner, institutionalization, and coming to terms with one’s own health and eventual death.
- The retirement age has increased only slightly in the last 10 years to the age of 64 for male identified and 62 for female identified (Center for Retirement Research, March 2015). There are those seniors who continue to work out of choice and those who must for financial reasons. In early 2014, the Bureau of Labor Statistics projected that by 2022, 31.9% of people ages 65 to 74 will continue to be working.
- Robert Atchley (2000) developed six descriptive phases of retirement that provide some understanding of the transitional process experienced by the individual. The stages are classified as remote, near honeymoon, disenchantment, reorientation, stability and termination.
- Emotional and social intimacy may occur at any age if the opportunity to form new relationships is present. Our abilities to relate to and bond with one another are the most fundamental attributes of human beings. Valued friendships provide people with self-affirmation, feedback and shared meaning. Dependable and somewhat predictable friendships help produce a sense of security. Connections and interactions with close others will likely promote health and shape daily behavior choices (Martire & Franks, 2014).
- what constitutes chronic illness and disability.
- how chronic illness affects individuals along the stages of development.
- the challenges that family systems face when addressing chronic illness.
- the issues that surround chronic illness in the current medical/political climate.
- Readings:
- Increase Risk Factors - Excess body weight, tobacco use, high risk activities or behaviors, chronic conditions such as, diabetes, high blood pressure, back pain, anxiety or depression, frequent alcohol consumption or substance abuse.
- Decreased and Protective Factors - Maintaining a healthy body weight, no tobacco use, healthy diet and sleep habits, regular exercise, moderate to no alcohol consumption, avoidance of high risk behaviors including substance abuse, maintaining a healthy stress level, and effective treatment of chronic health conditions.
- According to the American Association of Intellectual and Developmental Disabilities and ARC, intellectual disability is characterized as having below average cognitive ability and three other distinctive features:
- Children with learning disabilities must be given special attention. Social workers must do their best to protect children with learning disabilities from being sexually exploited. Smeaton (2015) outlines a few steps that social workers can follow in addressing such situations. Emphasis is placed on knowing that children with learning disabilities are just as or more than vulnerable as other young people, which makes it all the more imperative that safety measures be a part of every child’s care plan. Social workers must build a strong relationship with children to facilitate disclosure and then respond to each child’s communication and learning abilities. They must also be aware of how the child’s behavior can in fact reflect the nature of the sexual exploitation.
- Grief, loss, and bereavement will be examined through various theoretical lenses, particularly assessing the effect it has on individuals at different stages of life's developmental process. Additionally, focus will be placed on the way that death and mourning are explained and attended to through faith, spirituality, and social network systems.
- factors related to grief, loss, and bereavement.
- how society and culture (macro/mezzo levels) play a role in the ways that loss and grief are experienced and processed.
- Readings:
- As individuals progress through the life cycle, they tend to experience substantial losses. Loss can be associated with both negative (e.g., death of a loved one, declining physical health, financial insecurity), and positive (e.g., graduation, marriage) life events and circumstances. Losses can also usher in a variety of emotions, which may be directly related to the experienced change (e.g., retirement, relocation). Every loss causes a degree of disruption; the intensity is very much connected to the type and the meaning associated with the loss. Each kind of loss requires the individual to adapt to the new situation. It will challenge one's ability to cope and it will also test one's resilience.
- Death and discussions of it often cause individuals in our society to experience anxiety. Death anxiety is a term used to describe the fear one has when thinking of one's own death and the death of others. However, in not speaking about it, individuals are denied ways to develop coping skills about this particular phase of life. In the video clip featuring Dr. BJ Miller (below), he addresses the ways in which he’s faced his own death, while still taking valiant steps in living. His presentation is significant, particularly because he discusses death from both an individualistic and systems perspective.
- Different stage-related models were developed to explain the emotional states and the notable sequences and patterns experienced by individuals when undergoing the mourning process. Elisabeth Kübler-Ross developed a five stage model to indicate the emotional responses that individuals experience when dealing with the death of a loved one. Her stages are identified in the diagram below.
- Damianakis and Marziali (2012) explore how grief is manifested in older adults who have experienced the loss of a spouse. They note and examine how spirituality plays a part in helping individuals readjust following the death of a loved one. Since social work and other clinical practices are progressively recognizing spirituality as an important resource for many of our clients, Damianakis and Marziali’s study is particularly noteworthy.
- It is important to understand the consequences of loss and its accompanying bereavement for individuals. In particular, note how death is managed by the very young. Longitudinal and qualitative studies conducted with children experiencing loss note that it was very important for children to maintain some connection and attachment to the deceased person. Often it was done through dreams, waking dreams, by maintaining a personal object that had belonged to the deceased, by maintaining a personal interaction with the deceased in communicating thoughts and feelings, and by internalizing some of the goals of the deceased and working toward them (Silverman & Worden, 1992; Klass, Silverman, & Nickman, 1996).
- Quinn-Lee (2014) explores some of these factors when examining the grieving process of children within the school setting. The age of the child will often dictate how death is confronted and in the manner in which grief is manifested. Since social workers may work with children, the article provides some important information on how to effectively recognize and help children who are experiencing loss. Social workers may also utilize the information to assist parents and caretakers who are tending to a grieving child.
- During times of crisis, particularly when there is loss and grief, people often turn to organized religion or other assemblies of faith to obtain support and guidance. They also use faith and religion as a means to celebrate the life of the person who died.
- According to a 2015 Pew Research Center report, the number of US adults who do not identify with a particular religious group has increased. As the charts below indicate, those who identify as Christian still hold a majority in America but other religious identities and affliations are gaining traction.
Place your order
