Chapter 3: The Challenges of Early and Middle Adulthood



Like childhood and adolescence, adulthood is characterized by transitional periods. In adults, these periods commonly involve the reappraisal of one’s desires, goals, and values and can therefore provide important opportunities for growth and development. If an individual does not negotiate these transitions successfully and instead becomes emotionally “stuck” at some developmental point, long-term consequences can result. The heterosexual 45-year-old man who has lived with a succession of different women over the years but has been unable to make a commitment to any of them may face isolation and loneliness in the future.

Some people not only stop developing during transitional periods but may actually retreat or regress to an earlier stage of development. The young adult who, after being diagnosed with a chronic illness, begins to show the volatility and acting-out characteristics of adolescence, must accept and adapt to a new image of herself if she is to progress in her life.

People may be particularly vulnerable to physical and emotional illness during periods of life change. An alert physician can identify such patients and help them successfully negotiate these milestones. Such intervention may also help reduce the likelihood of future medical as well as social problems for the patient.

Demographics and Current Trends


An old joke poses the question, “Do married people live longer?” The tongue-in-cheek punch line is, “Not really, it only seems longer.” In fact, not only do married people, particularly men, live longer, but research shows that they also are mentally and physically healthier than nonmarried people. When matched for age, race, and sex, married people have less cancer, heart disease, and other disorders than divorced people. It is not clear whether these health benefits result from being married or whether physically and emotionally well people are more likely to be married. In either case, in the United States, the average age of first marriage is about 25 years for women and 27 years for men. By age 30, most Americans are married.


With marriage, the birth of a child, or the adoption of a child, a new family is formed. Although there are many types of families in the United States, the most common type of family includes mother, father, and dependent children (i.e., under age 18 years) living together in one household—a configuration known as the nuclear family.

Approximately 60% of American children live with their married biological parents [Harden, 2001]. Other types of American families include cohabiting heterosexual and gay parent families and single-parent families. The extended family includes other family members such as grandparents who, in this country, usually live outside of the nuclear household.

In most two-parent American families, both parents work and, in 2007, median household money income was about $50,000. Both parents work outside the home in more than half of all married couples with at least one child of preschool age and almost 70% of couples with school-age children. Only about 25% of children live in a traditional family configuration, in which the father works outside of the home and the mother is a full-time homemaker. No matter what the family configuration, parenting children is expensive; the cost of raising a child to age 18 years in the United States is more than $200,000. And, as medical students and their families know too well, postsecondary education can effectively double this figure.


Currently, close to half of all marriages in the United States end in divorce. Unhappily, when at least one spouse is a physician, the divorce rate is up to 20% higher than when neither spouse is a physician. A study of graduates of The Johns Hopkins University School of Medicine from 1948 through 1964 showed that, among married physicians, gender, specialty choice, and time of marriage were related to rates of divorce. Female physicians, physicians choosing psychiatry, and medical students married before medical school graduation had the highest divorce rates [Rollman et al., 1997].

In the general American population, factors that have been associated with the high rate of divorce include short length of the courtship period, marriage during teenage years, and premarital pregnancy. Other factors relate to the couple’s family of origin and include absence of family support for the couple, prior divorce in the family, and differences in religion or socioeconomic background between the couple. Although it might be expected that life stress draws couples together, the unfortunate reverse seems to be true. Couples that experience the serious illness or death of a child are more likely than other couples to divorce.

Single-parent families

In 2010, approximately 27% of American children lived in single-parent families, a percentage that varied by ethnic group (Table 3-1). Most single-parent families are headed by women and, although many unmarried mothers belong to low socioeconomic groups, the fastest growing population of single mothers is actually made up of educated, professional women who choose to bear or adopt children on their own.

Table 3.1 Distribution by Ethnic Group of Percentage of Children Living in Different Family Types in the United States

Ethnic Group Married Parents (%) Unmarried Parents (%) Single Mother (%) Single Father (%) No Parent (%)
African American 34.7 4.6 49.7 3.6 7.5
Hispanic American 60.9 6.0 26.3 2.7 4.0
White American 71.5 3.4 18.3 3.5 3.4

Single-parent families face unique challenges. Studies have consistently demonstrated that all members of single-parent families are at increased risk for physical and mental illness. Although the issue is complex, it is believed that the lower incomes and less social support that characterize single-parent families are related to this increased risk. Another sobering finding of this research is that children whose parents divorce are at particularly high risk for failure in school, depression, drug abuse, suicide, criminal activity, and for divorce themselves in the future.

Child custody

When the parental unit is broken, it must be decided which of the involved adults will have custody, or primary responsibility for the children, and with whom the children will live. Until the last few decades, the most common type of custody arrangement after divorce was sole custody. In this scheme, the parent with whom the child lived, usually the mother, had legal responsibility for the child and made decisions about his or her care. The other parent, usually the father, contributed to the child’s financial support and had the right to visit the child on a regular schedule. In recent years, joint residential custody has become more popular than sole custody. In this arrangement, the child spends part of the time living with each parent; the parents share legal responsibility and jointly make decisions about the child’s care. If the parents live close to each other, the child may spend part of the week with each parent. A now familiar sight for grade-school teachers is a child—toting a bulging backpack filled with clothing, toys, and schoolwork—arriving at school from his father’s home and leaving school bound for his mother’s home. If parents with joint custody live some distance from each other, the child may spend the school year with one and summers and vacations with the other.

An alternative custody choice is split custody. In this option, usually reserved for teenagers, each parent has custody of at least one child in the family. That child may be asked to choose which parent to live with, or his living situation may be decided for him by parents or ordered by the court. In contrast to past years, fathers are increasingly asking for and being granted the custodial care of their children. No matter what the custody type determined after divorce, children who continue to have regular contact with the noncustodial parent have fewer emotional and behavioral problems than those who have no contact with that parent.

Assisted reproduction and adoption

Although most couples bear children within a few years of marriage, more Americans now than in the past are choosing to postpone having children. Because fertility tends to decrease with age, this choice increases the likelihood of infertility. Thus, more frequently than in the past, couples must enhance their chances for conception using new reproductive technologies such as in vitro fertilization with its resultant risks (see Chapter 1).

Another option for couples and single people who want children but are unable or unwilling to bear a child is adoption. Although the outcome of most adoptions is positive—the couple or single person has a child to love and care for and the child gains a family—adoptive parents can also face special challenges. In addition to dealing with the expected problems associated with the developmental stages of childhood (see Chapters 1 and 2), some adopted children, particularly those adopted after infancy, are at increased risk for behavioral problems in childhood and adolescence. Another unique issue faced by adoptive parents is when and how much to tell their child about the adoption. It is generally accepted that children should be told that they are adopted at the earliest age possible and that they should be told all that is known about their biological parents. This strategy has many benefits, including decreasing the chance that a person other than a parent will tell the child these facts and details before the parent is able to do so.

Early Adulthood: 20 to 40 Years

Daniel Levinson, who studied early adulthood, noted that at age 30, one’s role in society is defined, physical development has peaked, and the individual is independent. Not uncommonly, a critical period of reappraisal of one’s life, which has been called the age 30 transition or crisis, also occurs at about this time.

Love and work

Most people emerge from the turmoil of adolescence with a sense of who they are and where they belong in the world. This sense makes it possible for a person to establish intimacy with another individual without feeling a loss of his or her own sense of identity. When Erikson described early adulthood as the stage of intimacy versus isolation, he implied that an individual who does not develop a loving, emotional, and sexual relationship with another person at this time may be unable to do so in later years. Most individuals develop this intimate relationship through marriage or other type of committed relationship.

Sigmund Freud said that, in addition to love, gratifying work is an essential component of emotional health in adulthood. Such work can take place both inside and outside of the home. In the United States, most men work outside of the home and develop their careers throughout early adulthood. Women who initially choose one career path, like full-time homemaker or career person, often change paths in their middle 30s, either by returning to work or school after their children reach school age, or by becoming full or part-time homemakers after developing a professional career.

Middle Adulthood: 40 to 65 Years

Although young adults tend to look at middle adulthood with dread, age does have its advantages. The middle-aged person usually still possesses good health and has more money, power, and authority than at any other life stage. Despite its financial benefits, middle age is associated with unique social responsibilities. With their aging parents living longer but not necessarily in better health, and their adult children remaining financially dependent on them for longer, people now in middle age, who have responsibilities to both older and younger relatives, have been called the “sandwich generation.”

Generativity versus stagnation

Most middle-aged individuals are active and productive and have a sense of contributing to the world. However, if a person has not achieved his goals by middle age, the realization that there is more of life behind him than in front of him can result instead in a sense of emptiness—Erikson’s stage of generativity versus stagnation. In response to this sense, some people develop what has been called a midlife crisis. This phenomenon, which occurs primarily in men in their middle forties or early fifties, may be precipitated by severe or unexpected lifestyle changes, such as the death of a parent or spouse, loss of a job, or serious medical illness. It can lead to a change in profession, infidelity, divorce, or increased use of alcohol or drugs. Physicians need to be aware that their middle-aged patients, who are sandwiched between needy relatives in older and younger generations or who experience significant changes in lifestle, may be at increased risk for health problems.

The climacterium

The physiological changes that occur in men and women during midlife have been called the climacterium. In men, although hormone levels do not change significantly in middle age, a decrease in muscle strength, endurance, and sexual performance (see Chapter 18) occurs. In women, these changes are identified by menopause, a time when the ovaries stop functioning and menstruation ceases. Absence of menstruation for 1 year is one definition of the end of menopause. Although some women experience emotional distress during menopause, most women have few significant physical or psychological problems. Many women feel instead that menopause has given them new freedom from menstrual problems and fears of unwanted pregnancy.

Case 3.1

The Patient

A successful, 54-year-old attorney tells his physician that he has decided to leave his wife of 20 years and start dating again. He explains, “I love my wife but I feel like life is passing me by.” The patient has a history of hypertension and was recently diagnosed with coronary artery disease. When interviewing him, the doctor discovers that both of the attorney’s elderly parents died in the past year.


This attorney is showing signs of a midlife crisis. This transitional period, occurring primarily in middle-aged men, often leads to a change in profession or marital status—in this case, divorce. A midlife crisis can be precipitated by a medical illness (the patient’s diagnosis of coronary artery disease here) or important lifestyle changes, such as the death of a close relative (the patient’s parents in this case).


People who change lifestyles in middle age may be at particular risk for physical and psychological problems. In fact, suicide is more common in middle-aged and elderly divorced men than in any other group (see Chapter 14). Because of this and because of this patient’s medical history, the physician should follow him closely with regularly scheduled visits. Because the midlife crisis may be associated with risk-taking behavior, the physician should remember to question the patient about his alcohol and drug use and provide counseling and treatment where appropriate.

Vasomotor instability, called hot flashes or flushes, is a common physical problem associated with menopause in women in all countries and cultural groups. The flushes are characterized by a sudden onset of an intense feeling of heat accompanied by profuse sweating that lasts up to a few minutes. These experiences, which can interrupt sleep and lead to chronic tiredness, may continue for years but can be relieved by estrogen replacement therapy (ERT). Although ERT can also prevent or slow the progression of menopausal symptoms like vaginal dryness and bone changes leading to osteoporosis, other claims for ERT, such as reduction in risk of psychiatric symptoms or cardiovascular disease, have little scientific support (see Chapter 21). On the negative side, long-term use of ERT has been associated with an increased risk of cancer of the uterus and, when used in combination with progesterone, of the breast as well [Chlebowski et al., 2009]. Alternatives to ERT include specific medications, such as alendronate sodium (Fosamax), to prevent or reverse bone loss.