Commentary

Defining adolescence: A call for consistency in the chronic pain literature

Abigail Jones, Line Caes, Jeremy Gauntlett-Gilbert and Abbie Jordan

printable version (PDF)

Adolescence is the distinct developmental period of transition from childhood to adulthood, involving changes in physical, psychological and biological functioning (Tanti et al., 2011; Berenbaum et al., 2015; Tilton-Weaver & Marshall, 2017; Nahman-Averbuch et al., 2023). Whilst adolescence itself is a well-recognized term, there is a lack of consensus regarding the temporal boundaries of adolescence, leading to confusion across the developmental literature.

When considering a definition of adolescence, a common approach is to align with puberty, such that adolescence spans from the start of puberty to physical maturation. Adopting this position, the World Health Organization (WHO) defines adolescence as spanning ages 10 to 19 years (WHO, 2014). However, this purely physical definition overlooks the significant psychological and social development quintessential to this adolescent period (Lesko, 2012). Indeed, literature has shown adolescence to be a time of increased risk taking, autonomy development, focus on identity formation and increased importance of peer relationships compared with other developmental timepoints (e.g. Lam et al., 2014; Smith et al., 2015; Soenens et al., 2017; Schwartz & Petrova, 2018). Neuropsychological research over the last 20 years has shown that such psychosocial development occurs alongside neurological maturation, which continues into the mid-20s (Foulkes & Blakemore, 2018).

Adding complexity, these developmental processes appear to be elongating over time. Universally, adolescence is assumed to end when adulthood begins, often identified by life events such as moving out of the familial home and assuming financial responsibility for oneself. Over time, such normative signs of entering adulthood are occurring later. For example, across the Western World, the average ages associated with entering full-time employment, moving out from the parental home, getting married, and having children have increased over time (Office for National Statistics, 2019; Population Reference Bureau, 2019; Eurostat, 2022). Despite greater variation, such trends towards signs of adulthood appearing later in life are seen globally (e.g. Raymo et al., 2015). Considering these trends alongside increased life expectancy (GBD 2017 Mortality Collaborators, 2018) suggests that developmental trajectories across the lifespan have elongated. In the normative developmental literature, such changes have led to calls for the creation of a new life stage referred to as emerging adulthood (Arnett et al., 2014). This new life stage of emerging adulthood encapsulates those individuals who are legally adults, but who are yet to achieve adult developmental milestones. However, although the idea of emerging adulthood has been adopted by some, it has also been met with criticism and debate regarding its evidence base and conceptual usefulness (Côté, 2014). It is also important to note that there is a distinction between developmental concepts such as childhood, adolescence, and adulthood, and legal or societal concepts of child and adult. For example, a 22-year-old may be legally and societally considered an adult, and yet may not be developmentally an adult.

The challenges of clearly defining the age boundaries of adolescence means a plethora of terms and age ranges exist to describe and define this developmental period. In an attempt to overcome this, Sawyer and colleagues (2018) present a valuable overview of the variable terms which are often used interchangeably across the literature (see Table 1). Sawyer et al. (2018) also propose an extended definition of adolescence, spanning an age range of 10 to 24 years old. We agree with this extended definition of adolescence and that its adoption would help to create consistency across the literature.

Table 1
Variations in ages and terminology used in the pediatric pain literature
 

Whilst it is important to consider the developmental context of adolescence in the normative literature, it has arguably greater importance in the pediatric pain literature. There is a growing body of literature providing evidence that adolescent developmental trajectories are altered in the context of chronic pain. For example, adolescents who experience chronic pain may struggle with their peer relationships and identity development (Jordan et al., 2018; Jones et al., 2021). Alternatively, some adolescents with chronic pain report enhanced autonomy as a result of having to manage the many challenges associated with living with chronic pain (Jones et al., 2022). Such evidence points to the extended age definition of adolescence as the most appropriate term to use within the pain literature, over alternatives such as emerging adulthood, as the developmental tasks are fundamentally adolescent in nature and occur on an elongated timescale. These altered developmental trajectories require pain researchers to ensure greater clarity and transparency regarding conceptual definitions and language around adolescence. Consequently, we strongly encourage members of the pain community to be mindful of their language choices, and to consider the developmental stages and influences on their participants.

Currently in the pediatric pain literature, terminology used to refer to adolescents is loosely defined and used inconsistently, creating confusion and lack of clarity. By way of illustration, the examples in Table 1 show that the same group of 10- to 17-year-olds could be described in multiple ways including as children, youth, young people, or adolescents, dependent on the term adopted by the authors.

Without clarity and developmentally appropriate language, it is impossible to fully contextualize, understand, compare, and draw robust conclusions from research findings. Additionally, further clarity would also provide substantial methodological benefits, for example facilitating sub-group analysis in meta-analytic research. We believe that the extended definition of adolescence proposed by Sawyer et al. (2018) provides the most appropriate and inclusive definition for use within a pediatric pain context. However, we acknowledge that there are challenges raised by this extended definition of adolescence and that inconsistencies in terminology occur due to no single definition being perfect. For example, the 10 to 24 years of age definition of adolescence runs the risk of suggesting that a 12-year-old and a 22-year-old are developmentally equal. Such a problem can be overcome by researchers disaggregating adolescence into early-, mid-, and late-adolescence where needed. A more difficult challenge of the extended definition of adolescence is the inclusion of some individuals who are pre-pubescent, and some who are developmentally established adults. However, no age-bound definition of adolescence would be able to include all, but solely only those who are developmentally adolescents. Additionally, this extended definition of adolescence could be argued to suggest a reduction in the span of childhood if adolescence is considered to begin earlier. Such issues highlight the complexity of defining adolescence and the need to make a decision concerning whether to have an overly inclusive definition of adolescence (such as the proposed extended age range), an overly exclusive definition, or one that will include some individuals yet exclude others. We feel that the best of these imperfect options is to adopt an overly inclusive definition of adolescence as doing so ensures that all aspects of adolescent development are included, adopting a view of adolescence as a broad transition from childhood to adulthood.

We feel that whilst it is important to acknowledge these imperfections, they do not outweigh the benefits gained by ensuring greater clarity and consistency across the literature. Such consistency would allow for easier review and knowledge synthesis of the literature regarding chronic pain and adolescence. Additionally, consistent use of this extended age definition of adolescence would help to ensure that all aspects of chronic pain and adolescent development are explored.

Conclusions

Going forward, we propose two strategies. Firstly, in the context of chronic pain and associated altered developmental trajectories, we argue that researchers use the extended age range of adolescence (10 to 24 years of age). Depending on the research question under investigation, this large age range may be disaggregated into early (10 to 14 years), mid (15 to 19 years), and late (20 to 24 years) to reflect more developmentally distinct periods of adolescence. Researchers may decide that only one or two of these subdivisions of adolescence are appropriate for a study, and in those instances, we urge researchers to clearly state which they are using and why. When the entire adolescent age range is used, we recommend that researchers include descriptive statistics outlining the distribution of their sample across the three adolescent subdivisions.

Secondly, although we feel the literature would benefit from consistent use of the extended definition of adolescence, we acknowledge that researchers may disagree and consider alternative terminology more appropriate. For example, terminology choices may be determined by patient and public involvement or how their participants self-define, as seen in the autism literature (Kenny et al., 2016). Regardless of such disagreements, we emphasize the importance of researchers carefully considering terminology and the developmental context of their participants. We urge researchers to be transparent around the rationale for their language choices, and how it aligns with the research question and the participants’ developmental stage. Connected to this, we urge reviewers and editors not to impose their own language preferences, and if language choices are well-defined and well-justified, we recommend allowing authors to use the terminology they feel most appropriate. This approach would ensure authors consider and justify their language choices and create greater clarity across the literature as terminology would represent the preferences of the authors and their rationale for their use.

Cite as: Jones A, Caes L, Gauntlett-Gilbert J, Jordan A. Defining adolescence: A call for consistency in the chronic pain literature Pediatric Pain Letter 2023;24(2):9-13. ppl.childpain.org

References

Arnett JJ, Žukauskienė R, Sugimur, K. The new life stage of emerging adulthood at ages 18-29 years: implications for mental health. Lancet Psychiatry 2014;1:569-576. PubMed Abstract

Berenbaum SA, Beltz AM, Corley R. The importance of puberty for adolescent development: conceptualization and measurement. Adv Child Dev Behav 2015;48:53-92. PubMed Abstract

Bonvanie IJ, Oldehinkel AJ, Rosmalen JGM, Janssens KAM. Sleep problems and pain: a longitudinal cohort study in emerging adults. Pain 2016;157:957-963. PubMed Abstract

Côté JE. The dangerous myth of emerging adulthood: an evidence-based critique of a flawed developmental theory. Appl Dev Sci 2014;18,177-188. Link

Donovan E, Mehringer S, Zeltzer LK. A qualitative analysis of adolescent, caregiver, and clinician perceptions of the impact of migraines on adolescents’ social functioning. Pain Manag Nurs 2013;14:e135-e141. PubMed Abstract

Eurostat. Marriage indicators, 2022. Link

Forgeron P, McGrath P. Self-identified needs of youth with chronic pain. J Pain Manag 2008;1:163-172.

Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nat Neurosci 2018;21:315-323. PubMed Abstract

GBD 2017 Mortality Collaborators. Global, regional, and national age-sex-specific mortality and life expectancy, 1950-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018;392:1684-1735. PubMed Abstract

Heathcote LC, Timmers I, Kronman CA, Mahmud F, Hernandez JM, Bentley J, et al. Brain signatures of threat-safety discrimination in adolescent chronic pain. Pain 2020;161:630-640. PubMed Abstract

Huguet A, Eccleston C, Miró J, Gauntlett-Gilbert J. Young people making sense of pain: cognitive appraisal, function, and pain in 8-16 year old children. Eur J Pain 2009;13:751-759. PubMed Abstract

Jones A, Caes L, Eccleston C, Noel M, Gauntlett‐Gilbert J, Jordan A. The sands of time: adolescents’ temporal perceptions of peer relationships and autonomy in the context of living with chronic pain. Paediatr Neonatal Pain 2022;4:110-124. PubMed Abstract

Jones A, Caes L, McMurtry CM, Eccleston C, Jordan A. Sociodevelopmental challenges faced by young people with chronic pain: a scoping review. J Pediatr Psychol 2021;46:219-230. PubMed Abstract

Jordan A, Noel M, Caes L, Connell H, Gauntlett-Gilbert J. A developmental arrest? Interruption and identity in adolescent chronic pain. Pain Rep 2018;3(Suppl 1):e678. PubMed Abstract

Kenny L, Hattersley C, Molins B, Buckley C, Povey C, Pellicano E. Which terms should be used to describe autism? Perspectives from the UK autism community. Autism 2016;20:442-462. PubMed Abstract

Lam CB, Mchale SM, Crouter AC. Time with peers from middle childhood to late adolescence: developmental course and adjustment correlates. Child Dev 2014;85:1677-1693. PubMed Abstract

Lesko N. Act your age!: a cultural construction of adolescence (2nd ed.). New York: Routledge, 2012. Link

Meldrum ML, Tsao JCI, Zeltzer LK. “I can’t be what I want to be”: children’s narratives of chronic pain experiences and treatment outcomes. Pain Med 2009;10:1018-1034. PubMed Abstract

Nahman-Averbuch H, Li R, Boerner KE, Lewis C, Garwood S, Palermo TM, Jordan A. Alterations in pain during adolescence and puberty. Trends Neurosci 2023;46:307-317. PubMed Abstract

Office for National Statistics. Milestones: journeying into adulthood, 2019. Link

Pas R, Ickmans K, Van Oosterwijck S, Van Der Cruyssen K, Foubert A, Leysen L, et al. Hyperexcitability of the central nervous system in children with chronic pain: a systematic review. Pain Med 2018;19:2504-2514. PubMed Abstract

Population Reference Bureau. Median Age at First Marriage (Men), 2019. Link

Raymo JM, Park H, Xie Y, Yeung WJ. Marriage and family in East Asia: continuity and change. Annu Rev Sociol 2015;41:471-492. PubMed Abstract

Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health 2018;2:223-228. PubMed Abstract

Schwartz SJ, Petrova M. Fostering healthy identity development in adolescence. Nat Hum Behav 2018;2:110-111. Link

Smith AR, Steinberg L, Strang N, Chein J. Age differences in the impact of peers on adolescents’ and adults’ neural response to reward. Dev Cogn Neurosci 2015;11:75-82. PubMed Abstract

Soenens B, Vansteenkiste M, Van Petegem S, Beyers W, Ryan R. How to solve the conundrum of adolescent autonomy? On the importance of distinguishing between independence and volitional functioning. In: Soenens B, Vansteenkiste M, Van Petegem, S, editors. Autonomy in adolescent development: towards conceptual clarity. London: Taylor & Francis, 2017. pp. 1-32. Link

Soltani S, NevilleA., Hurtubise K, Hildenbrand A, Noel M. Finding silver linings: a preliminary examination of benefit finding in youth with chronic pain. J Pediatr Psychol 2018;43:285-293. PubMed Abstract

Tanti C, Stukas AA, Halloran MJ, Foddy M. Social identity change: shifts in social identity during adolescence. J Adolesc 2011;34:555-567. PubMed Abstract

Tilton-Weaver LC, Marshall SK. Governance transfer: a dynamic perspective on adolescent behavioral autonomy and parent regulation. In: Soenens B, Vansteenkiste M, Van Petegem, S, editors. Autonomy in adolescent development: towards conceptual clarity. London: Taylor & Francis, 2017. pp. 74-93. Link

Twiddy H, Hanna J, Haynes L. Growing pains: understanding the needs of emerging adults with chronic pain. Br J Pain 2017;11:108-118. PubMed Abstract

World Health Organization. Health for the world’s adolescents: a second chance in the second decade, 2014. Link