INTRODUCTION

The approach to adolescents requires an appropriate posture from the health professional, technical knowledge and knowledge of the psychosocial changes that occur at this stage of the young person’s life, as well as an understanding of the impact and conflicts that they cause in family relationships.

Knowledge of family dynamics is of fundamental importance in the evaluation, treatment and prevention of health problems presented by adolescents. To this end, the health professional must observe how the family and the adolescent are going through this stage of life.

The family is an active system in constant transformation, which changes over time to ensure the continuity and psychosocial growth of its members (Minuchin, 1977). We cannot forget the significant realities that interact with the family: school, the parents’ work, the neighborhood, the surroundings and the group of friends.

Adolescence is a stage of human development marked by profound transformations, not only physical; it is also the beginning of the psychological transition from childhood to adulthood (Hopkins, 1983). This period has been described since Anna Freud as conflictual ; as an identity crisis by Erikson and has the universal name of “storm and stress” (Sturm and Drang). The characteristics of psychosocial development that occur in parallel with changes in the body are grouped into what Arminda Aberastury and Maurício Knobel called the syndrome of normal adolescence (SAN). Adolescence is, therefore, a concept related to a process and the adolescent is the subject who is experiencing this process.

FAMILY METAMORPHOSIS

As a consequence, adolescence affects the family life cycle and its lifestyle more than any other phase of life, as it destabilizes the system and causes new adjustments to maintain the relationships and mental health of its members. During this period, families are also adjusting to new demands from their members, who are entering new stages of the life cycle. Parents face major issues such as the “midlife crisis” of one or both spouses, with exploration of personal, professional, and marital satisfactions and dissatisfactions, while grandparents experience retirement and possible changes such as illness and death. Parents may have to become caregivers for their own parents or help them integrate the losses of old age.

The adolescent, trying to discover new directions and ways of life, challenges and questions the established family order. The ambivalence of independence/dependence experienced by the adolescent creates tension and instability in family relationships, which often leads to intense conflicts that can become chronic.

Because they are so intense, adolescent demands for greater autonomy and independence often precipitate changes in intergenerational relationships, bringing to the surface unresolved conflicts between parents and grandparents (of adolescents) from their childhood or adolescence. In addition to reevaluating and analyzing their own adolescence, as well as the parents of their adolescent period, parents face new stages in their life cycle, with new concerns emerging: the loss of their youthful bodies and the approach of retirement and old age.

The normal stress and tension caused in the family by an adolescent are exacerbated when parents feel deeply dissatisfied and are compelled to make changes within themselves. What often results is a field of conflicting demands, in which stress seems to be transmitted up and down between generations. Conflict between parents and grandparents can have a negative effect on the relationship between parents and adolescent. The impasse can also occur in the opposite direction: a conflict between parents and adolescent can affect the marital relationship, which ends up damaging the relationship between parents and grandparents.

During adolescence, the evolution from absolute dependence in childhood to adult autonomy can be a painful time for parents and children. Parents often feel a void when adolescents become more independent, as they realize that they are no longer needed as before, and feelings of loss (loss of the child) and fear of abandonment can occur. Sometimes parents, unable to cope with the loss of their child’s dependence, may become depressed. In the same way, adolescents need to deal with the loss of their childhood self and the loss of family as a primary source of affection. The loss of this first romantic bond can also trigger depression in adolescents. This dual movement of mourning in which parents and children participate was called dual ambivalence by Stone and Church. Every change implies acceptance of loss.

Thus, adolescence demands structural changes and renegotiation of roles in families, which are transformed. From units that protect and nurture children, families become the center of preparation for the adolescent’s entry into the universe of responsibilities and commitments of the adult world. They constitute more flexible boundaries, allowing adolescents to get closer and be dependent when they cannot manage their lives alone, and to move away and experience challenges, with increasing degrees of independence, when they are ready. This requires special efforts from all family members.

The psychological development of the adolescent takes into account their personal history, as well as their new sexual, cognitive and social skills. The family history of the adolescent does not begin in adolescence, but is present even before childhood, during pregnancy, whether planned or not.

ADOLESCENT TASKS

To live this stage of life satisfactorily, the adolescent must fulfill what Erickson calls developmental tasks:

• know yourself;
• adopt a sexual role;
• achieve autonomy in relation to the family;
• define oneself vocationally;
• achieve autonomous interpersonal relationships to consolidate their identity.

With rapid physical growth and sexual maturation during puberty, movements to solidify an identity and establish autonomy from the family are accelerated. In reality, these are lifelong developmental processes, as they involve changing social expectations that often conflict with sexual roles and behavioral norms imposed on adolescents by family, school, friends, and the media. Their ability to differentiate themselves from others depends on how they manage expected social behaviors to express the intense emotions precipitated by puberty. To establish autonomy, adolescents need to become increasingly responsible for their own decisions and, at the same time, feel secure in their parents’ guidance.

Flexibility is the key to success for families at this stage. For example, making family boundaries more flexible and modulating parental authority allows adolescents to develop more independence and develop. However, in an attempt to reduce the conflicts generated during this period, many families continue to seek solutions that used to work at earlier stages. Parents often try to “pull the reins” or withdraw emotionally to avoid further conflict. Adolescents, on the other hand, in an effort to forge their own path, resort to tantrums, withdraw emotionally behind closed doors, seek support from grandparents, and/or present endless examples of friends who have more freedom.

SEXUALITY

The physical and sexual changes that occur during puberty radically alter an adolescent’s self-image, since from ages 2 to 10 these physical changes occur more slowly than in adolescence. It is common for family members to feel anxious and confused when adolescents begin to express their new sexual interests.

Despite their daughter’s physical maturity, parents are concerned that she will be unable to protect herself from the dangers of the world, such as unplanned pregnancy, sexual abuse or exploitation, and sexually transmitted diseases (STDs), which are real problems. The first concern that arises with children is that their sexual interests will distract them from their schoolwork and harm their professional and personal future.

Personal experiences with sexuality influence the way parents set limits and expectations, better accepting the young person’s sexuality. This does not mean that all parents who have had negative experiences will repeat the pattern, but it is common to observe in families the repetition of an early onset of sexual activity, teenage pregnancy or even cases of sexual abuse.

In families where information is openly shared, minor transgressions are more likely to be accepted and more realistic limits set. On the other hand, when an adolescent’s sexuality is denied or rejected by parents, the development of a sexual self-concept is impaired and, consequently, the risks of early or dangerous sexual activity are greater.

In Freud’s view, incestuous impulses between the adolescent and the opposite-sex parent are likely to increase. A previously loving relationship between father and daughter can quickly evolve into a hostile relationship, with the father being punitive and possessive and the daughter being provocative. Mothers who are closer to their children may experience confusion and conflict when their children begin to want more privacy, just as the mother’s desire for closeness may be met by aggression and rejection. She may then react in a similar manner.

On the other hand, parents and children of the same sex tend to engage in more competitive struggles. Psychoanalytic theory is that adolescents compete for the love and attention of the opposite-sex parent (Freud, Blos). Another assumption is that they compete because of their conflicting perceptions of their gender roles. Thus, in adolescence, conflict may be most intense with the same-sex parent, who often serves as a role model in childhood.

Most parents of adolescents will have to review their attitudes toward gender roles and try to make changes that better fit the increasingly liberal sexual standards of the day. For many parents, this can be a very difficult task.

SEARCH FOR IDENTITY

Attempts to understand this process have been based mainly on the theories of Freud and Erickson. The sudden acceleration of identity formation that occurs in adolescence can become a source of mobilization and energy, but also of conflict for adolescents and their families.

Adolescents, because of their propensity to challenge and question norms, provoke transformations at home, at school, and in the community. They disagree with their parents about ideas, beliefs, and values. Typical comments from children (“My parents are old-fashioned, they don’t understand me”) or from parents (“I was so different at that age” or “I didn’t dare question my parents”) tend to create conflict between the generations, which can lead to fights over rules and relationships. The young person may avoid asking questions or sharing ideas for fear of escalating the conflict, leading to distance and lack of trust.

The relationship between children and same-sex parents has a powerful effect on the process of gender identification at this stage of life. Their views about who they are will be strongly connected to their feelings about being male or female. In addition, they will be influenced by opposite-sex parents to validate their sense of gender identity. This may influence future relationships with the opposite sex.

AUTONOMY

Teenagers need to venture outside the home to become more independent and self-confident. Alliances outside the home, which increase the influence of other young people, become stronger, and they will need permission and encouragement from their parents to be more responsible. Autonomy does not mean emotional detachment from their parents, but rather that teenagers are no longer as dependent on their parents psychologically and that they have more control over decision-making in their lives.

Teenagers tend to seek more autonomy in families that encourage them to participate in decision-making, but ultimately it is the parents who decide what is appropriate. On the contrary, those raised in environments where decision-making and self-regulation are limited tend to become more dependent and insecure.

Setting limits and being objective, supportive and democratic at the same time is not an easy task for many parents, especially when they feel judged and criticized by their children. Parents will be less tolerant if they have not been able to achieve emotional autonomy in relation to their own parents and/or when they have unresolved conflicts between them (the couple).

For adolescents to be able to master these stages of adolescent development, the family must be strong, flexible and capable of supporting the growth and transformation of their children.

CONCLUSION

Although it is not mandatory, family participation in the care of the adolescent enriches the evaluation process and makes it possible to observe the adolescent’s relationship with his/her parents/guardians, siblings and others. The adolescent should be encouraged to involve the family in monitoring his/her problems.

When the health professional interviews an adolescent, he/she should consider, in fact, the individual’s family as a whole. There is no such thing as “the individual”: each person is a collage of previous generations, even those unknown to us (transgenerational transmission), although each person has his or her own mark to a greater or lesser extent. It is very impoverishing to see only the individual. The goal should be to have a dynamic vision of the person in the family context.

The professional should avoid an authoritarian stance and show that he or she is there to help the family and the adolescent find the best way to get through that phase of life. He or she should also avoid assuming the role of judge, who is there to pass judgment, or that of ally and/or defender of those who seem weaker.

Sometimes parents who have difficulty understanding various aspects of this process seek out a health professional. When the family seeks help, this may mean confirmation of their inability to resolve their own difficulties independently. Thus, they delegate to the health professional the responsibility of changing what is not working or, at least, of providing some behavioral guidelines to overcome the problem. They do not expect any request for direct participation in the solution, therefore delegating to the professional the task that is the family’s responsibility.

Accepting the responsibility of solving the problems that the adolescent is creating for himself or herself, for the family and for the school confirms the idea that the family is incompetent and that it is we, the experts, who will solve these problems. The family leaves feeling relieved (“my child is being treated”), but they do not learn how to face and resolve the problems they are experiencing, nor how to accept those that will occur.

If this family is not confirmed as capable, they will be immersed in a belief of failure and incompetence. The ideal is to propose a change for the family, which believes itself to be incompetent, and especially for the professional who has graduated and is used to being seen as the one who will resolve problems and illnesses. We, professionals, must show that we are more efficient when we are able to partner with the family and that we will act as facilitators, enhancing their capacity.

The health professional must, therefore, be aware of the role he or she will play:

• understand the impact of adolescence on family dynamics;
• support parents so that they feel less lost and less alone in their experiences, in addition to alleviating feelings of rejection or guilt from the family;
• help in understanding conflicts in the family and in adolescents;
• encourage communication between the family and the young person;
• value the important role of families at this stage of life;
• detect psychopathological conditions early and make appropriate referrals.