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An Unchanged Mind -- The Problem of Immaturity in Adolescence
by John A. McKinnon, MD
© 2008
(Lantern Books, New York, NY)
All rights reserved.
[Answer 21 of 30 questions correctly to receive
14 hours of Continuing Education credit.]



Chapter 1: Point of Departure (p. 3-20)

1. Why was the author, a seasoned psychiatrist who had helped teenagers for 20 years, upset with the “managed care” company that handled Pauline’s case?
a. It was impersonal. Decisions were made from hundred of miles away by people who had never met Pauline.
b. It was motivated primarily by money. To maximize profits and minimize costs, the managed care company decided to discharge Pauline two days after she had attempted suicide.
c. It was ineffective. The author needed more time to insure that Pauline was no longer a danger to herself and to restore Pauline’s mother to full participation in her parenting.
d. All of the above.

Chapter 2: Global Disarray (p. 21-43)
2. What did the author and his colleagues discover that all the teenagers had in common who came to Montana Academy?
a. They all came from very dysfunctional homes where there was alcohol or drug addiction, divorce, prolonged unemployment, violence, abuse, etc.
b. They all associated with the “wrong crowd”, peers who helped to get them into trouble.
c. They all were failing in every typical adolescent setting -- Skipping
school, defying parental rules and authority at home, unable to make or keep good friends, and not even happy when alone. Likewise, when teens improved, they improved in every area, not just one.
d. They all were severely misunderstood by parents, teachers, friends, and ministers.

3. What is the author’s main objection to the widespread practice of the psychiatric community relieving symptoms in teenagers with pills?
a. Because treating the symptoms does not necessarily treat the cause of the problems.
b. Because of the dangers of becoming dependent upon medication.
c. Because of the danger of unstable teens having access to an overdose of pills.
d. Because of the additional behavioral problems that are often generated by being on too many medications.

Chapter 3: A Flawed Approach (p. 44-56)
4. Which is NOT true about a teenager’s psychological approach?
a. A psychological approach is a general mind-set that shapes a person’s motives, strategy, and tactics.
b. Instruction and example do not quickly alter a teenager’s flawed approach, so troubled teenagers fail to learn promptly from unhappy experiences.
c. All troubled teenagers have the same flawed approach with these five characteristics: gross narcissism; lack of true empathy; “puppet” relationships; magical thinking about the future; and selfish and concrete morals.
d. None of the above.

In the Notes for this chapter, the author highly recommends that therapists read
Robert Kegan’s
The Evolving Self: Problem and Process in Human Development and
In Over Our Heads: The Mental Demands of Modern Life

5. The one word that the author uses to describe the source of all troubled teenager’s flawed approach is
a. unskilled.
b. immaturity.
c. illogical.
d. unintelligent.


Chapter 4: Thought and Time (p. 59-88)

6. A teacher asks the students in her class what these three historical events have in common: 1) Galileo’s recantation, 2) the martyrdom of Jordano Bruno, and 3) the arrival of the first Pilgrims at Plymouth, Massachusetts. A student raises her hand and says, “Religious oppression.” The age of this student was most likely
a. 7
b. 9
c. 11
d. 15

7. How does abstract thinking benefit a teenager?
a. It helps in school, where teens can solve for an unknown mathematical variable after being given a logical relationship between x and y. And they can determine whether experimental data confirms or fails to confirm a scientific hypothesis.
b. It helps at home, where a teen knows which of his behaviors will honor or injure the trust of his parents.
c. It helps develop friendships, enabling a teen to talk about anything his peers consider important: ethics, politics, literature, music, religion, economics, current events, romance, etc.
d. All of the above.

8. Which is NOT true about teenagers?
a. They can consider alternative futures, and pick one as a goal.
b. They can alter their present behavior so as to move closer to the goal in “a”.
c. They primarily have a concrete view of time that they measure by clocks and calendars.
d. They can begin to sort out jumbled memories from their past, and to start making sense of them with their present and future.
e. They can imagine that adults once were children.

Chapter 5: Me, Myself, …and You (p. 72-88)
9. The cure for narcissism is when a teenager
a. recognizes another person as separate from himself and respects that person’s rights.
b. assumes personal responsibility for his actions.
c. learns to do things for others.
d. achieves recognition for his accomplishments.

10. For a teenager, concrete moral reason means doing what ____ think(s) is right.
a. his parents
b. God
c. he
d. his friends

11. For a teenager, abstract moral reason means for a teen to make decisions based upon
a. what works and what doesn’t work.
b. what brings others the greatest happiness.
c. larger issues such as justice and morality that go beyond what his friends think.
d. the largest number of people who would benefit.

Chapter 6: Gear Shift and Guitar (p. 89-115)
12. When Jane got in trouble as an adolescent by drinking, lying, and going to secret parties, what did her parents say it was that finally put a stop to her “attempts to fool us and evade our rules?”
a. All of Jane’s friends had parents who also took swift and immediate action when their teens misbehaved. Thus, their entire clique learned a collective lesson that their bad choices came with stiff consequences.
b. Jane’s parents took away privileges such as suspending Jane’s use of the car and not going out with friends on the weekend. They also gave her additional chores to do.
c. Jane’s parents had blunt, no-nonsense talks with her about her betrayal, her “rude” and “nasty” behavior, and how they wanted it to stop. They loved her, but they held her behavior in contempt and let her know they were very disappointed by it.
d. Jane’s parents made her change her circle of friends and associate only with teenagers who obeyed their parents.

13. In question #12, Jane came to view her parents as
a. authoritative over her, having been given the obligation to pass on their values to her.
b. separate from her, having the right to say “No” at times, and accepting their right to do so.
c. strong enough to not let her get away with serious misbehavior without incurring painful consequences afterward.
d. wise or clever enough to enforce changes that would help Jane avoid unacceptable behavior in the future, without Jane losing face with her friends.

14. According to the Gear Shift Model, a fully mature adolescent
a. will act mature in a mature setting and will fool around like a toddler in a playful setting, without ever forgetting he is a teenager.
b. will act mature all the time and not revert to child-like behavior.
c. reverts to child-like behavior only when tired or stressed.
d. is embarrassed when caught reverting to child-like behavior because he has failed to live up to adult expectations.


Chapter 7: Delay (p. 119-143)
15. Which of the following did the author NOT describe about a troubled, immature teenager?
a. He is failing in school, at home, and with friends.
b. Mature teenagers surpass him academically and shun his childishness. His parents grow weary with his inconsiderate behavior.
c. He knows how he could improve his behavior, but his refusal to do so is a conscious act of rebellion and defiance.
d. He cannot understand why he cannot make or keep friends. The remedy is to grow up, but he doesn’t know that he needs to. His immaturity keeps him from seeing what is blocking his progress.
e. Because he cannot do it by himself, his parents and other adults have to figure out how to help him grow up. They’re the ones that can anticipate the danger he is in and recognize the consequences of his actions, even if he cannot.

16. Helen’s home life was dominated by
a. a mother and father who argued all the time.
b. a mother and father who “had their moments” but nevertheless deeply loved one another.
c. a mother who was warm and affectionate and a father who was humorous and a good listener.
d. a mother who had a debilitating illness and a father who worked long hours.

17. When she was a freshman in high school, Helen responded to her home life by
a. not doing her homework and handing around with the wrong crowd.
b. taking care of her mother and staying up late to listen to her father talk about his work day.
c. excelling in sports in order to capture the attention of her parents.
d. spending lots of time with her mature friends.

Chapter 8: Obstacles (p. 144-175)

18. A mature adolescent will: 1) put others’ needs before his own (consideration), 2) put himself into another person’s shoes (empathy), 3) treat others as separate individuals who have rights that should be respected, 4) have goals and plans for his future, and 5) make ethical decisions on principles that go beyond what his friends think.
Under which conditions does this maturity take place in an adolescent?
a. Simply when the adolescent grows to a neurological readiness. Given enough time, most adolescents grow up.
b. When the adolescent is given appropriate experience by a parent at a time when the adolescent is neurologically ready for that experience.
c. When the adolescent is given appropriate experience by a parent even when the adolescent is not neurologically ready for that experience. In this respect, nurture is more important than nature.

19. Which is NOT true about intrinsic obstacles?
a. An intrinsic obstacle is an “equipment” problem, a faulty brain function that prevents readiness. It disrupts a teenager’s capacity to use experience, including parenting, to achieve a developmental milestone. Teenagers who cannot concentrate, focus, stay awake, sustain motivation, or think abstractly cannot be bullied into growing up.
b. Examples of intrinsic obstacles include congenital learning disability, attention deficit hyperactivity disorder (ADHD), fetal alcohol syndrome, autism, down syndrome, psychological trauma in a child, mood instability in a child, attachment disorder, obsessive-compulsive disorder (OCD) in a child, and eating disorder in a child.
c. A dyslexic girl cannot be taught to read.
d. Repetitive alcohol intoxication (and hangovers) interfere with focus and thinking, impair mood, and weaken motivation.
e. Chronic marijuana intoxication dissolved adolescent ambition and reduces the likelihood of sustained effort to learn or create.
f. A teenager cannot learn empathy, plan for her future, or write an abstract essay if she is delirious with encephalitis, sedated from seizure medication, or chronically stoned on marijuana.

20. What did the author NOT say about extrinsic obstacles?
a. Extrinsic obstacles disrupt the maturing of an adolescent by interfering with the two essential tasks of parenting: recognition and limit-setting.
b. Extrinsic obstacles include the death of a parent, a parent’s depression or anxiety, marital discord, separation and divorce, adoption, a parent’s alcoholism or substance abuse, parental immaturity, poverty, war, unemployment, a parent spending too much time at work, and parental ignorance.
c. Whether the problem is intrinsic or extrinsic, parenting must be part of the solution. Once an intrinsic obstacle has been removed, it takes effective parenting to address the remaining childishness. If the extrinsic problem is disrupted parenting, then the remedy is to restore effective parenting.
d. Mothers tend to give too much recognition to their children and fathers tend to be too strict in their limit-setting.
e. The power of parental recognition -- in their presence, watching, hearing, affection, and words of encouragement -- results in a child feeling important, sure of himself, and secure in a trusting relationship with his parents.
f. The purpose of setting limits for children is to help them grow out of their in-born selfishness by teaching them consideration for others, delayed gratification, to work for what they want to have, and to take responsibility for their actions. When parents fail to set limits, teenagers may become presumptuous, arrogant, and spoiled.

21. In the case of David and his parents, what is the real cause of why Susan became a withdrawn mother and why Paul became an overprotective father?
a. Susan succumbed to a deep depression over never fulfilling her dream of becoming a concert pianist.
b. Paul, assuming the role of both mother and father, didn’t have his wife’s input to balance or soften his perspective, so he became too restrictive.
c. Both Susan and Paul never recovered from the tragic loss of their first son, Isaac, whom Paul accidentally ran over with his vehicle. Susan attempted to crowd out her constant memories of Isaac by playing the piano for hours every day, afraid to bond with her new child, David. Paul’s over protectiveness seems to have been his determination to prevent another accident.
d. Paul was so resentful that he had to constantly watch David, due to Susan’s debilitating chronic fatigue syndrome and fibromyalgia that he took out his resentment on David.


Chapter 9: A Two-Step Treatment (p. 179-214)

22. The basic treatment for helping immature, troubled teenagers to grow up, and therefore catch up to their mature adolescent peers, is to
a. give them tasks to do, like chores, so they will learn responsibility.
b. put them in service positions, like helping the elderly, so they will learn empathy.
c. put them in a highly structured and disciplined program, so they will learn respect for authority.
d. give them accurate recognition for their efforts and set proper limits.

23. What type of troubled teenagers will the author NOT accept at Montana Ranch?
a. Teens who have parents who are unwilling to change their parenting, because the author believes that good parenting is absolutely necessary in order for the teen to grow up.
b. Teens who have attempted suicide and almost succeeded.
c. Teens who have been diagnosed with bi-polar disorder.
d. Teens who have been repeat offenders with the law.

24. Most adolescent attempts at suicide are
a. loud, unmistakable cries for help to parents who are not paying sufficient attention.
b. subtle, not so obvious cries for help to parents who are not paying sufficient attention.
c. loud, unmistakable cries for help to parents who are paying close attention.
d. subtle, not so obvious cries for help to parents who are paying close attention


25. When Helen was enrolled at Montana Ranch, she initially behaved like she did at home -- like an only child who wanted all the attention and as if the rules did not apply to her. How did the staff respond to her behavior?
a. With empathy, warmth, and understanding.
b. Avoiding her until she started acting responsibly.
c. A high tolerance supported by an understanding of her parents’ neglect.
d. Firm limit-setting and unpleasant consequences, having all privileges and fun put on hold.

26. At the height of her caustic contemptuousness, open rudeness, and presumptuous grandiosity, what was the quintessential question the adult staff asked Helen after they had established a caring relationship with her?
a. What trauma have you suffered to make you such a disagreeable person?
b. Why are you acting so immature?
c. Who the hell do you think you are?
d. Do you really want to behave this way?

27. In the last months of her stay at the ranch, Helen was growing up. She joined the cross-country team, wrote essays, poems, and short stories and became a favorite among her teachers. What was the one thing she could NOT accomplish?a. She couldn't stop drinking.
b. She couldn't get close to either parent.
c. She couldn't take the SAT exam for college.
d. She couldn't put her family back together again


28. The only effective way to confront and diminish David's childish narcissism, his angry demands, his tantrums when frustrated, his threats, and his pouting, was by

a. setting reasonable limits and sticking to them
b. ignoring him.
c. reassuring him that he was loved.
d. helping him to express his feelings in writing.

Chapter 10: Outcomes (p. 215-245)
29. The MAMA-p is a tool being developed at Montana Ranch that measures the progress made toward maturity by the teenagers. It consists of descriptive statements that are to be rated on a scale from “never” to “always”. These statements describe the five criterion for adolescent maturity:
1) Consideration for others
2) True empathy
3) Goals, plans, and self-discipline
4) Separate relationships and “acceptance of No”
5) Abstract, social moral ideas

This measurement tool is completed by:
a. the teenager's parents
b. the Montana Ranch staff.
c. the teenagers themselves.
d. the teenager's personal care physician, psychiatrist, and counselor prior to their enrollment at Montana Ranch.


30. Phil seemed to make significant progress at Montana Ranch after
a. he was shunned by his team members.
b. he went on a 6-week wilderness program
c. his parents stopped talking to him.
d. he had been deprived of privileges for several months.