Both parents and pediatricians are in a bind when it comes to knowing how much guidance to give adolescents or whether or not the pediatrician should remain the adolescents' primary physician as they grow older.
For years there has been controversy among our colleagues regarding the age at which the adolescent no longer needs a pediatrician and can move on to another physician. As pediatricians have become more interested in adolescent medicine, many have tended to remain the primary physician. I believe this is helpful because the adolescent needs some consistency in his rapidly changing life. The pediatrician, however, has often not known whether he is the appropriate counselor and confidant to the older teenager. Similarly, parents of adolescents often feel out of place when they give too much guidance or provide too many controls. The pediatrician can readily sympathize with the parents' struggles with both normal and problem adolescents.
Adolescent psychosocial development has much to do with why parents and pediatricians are in such a difficult position to know how and how much to help. The pediatrician, like the parent of an adolescent, is similar to a wise football coach who has been guiding a team for many years. Even though he still has a great deal of wisdom to offer, his players have grown and gained a lot of their own. The coach may even assume they have surpassed him. Although he may not be accurate in that assumption, he will often stay on the sidelines more and participate less. If he should participate too vigorously, he may be ignored.
Parents are also on the sidelines, watching the adolescent handle things either well or poorly. They watch his struggles with identity, school life, peer relationships, sexual development, and the temptations of drugs and alcohol. They also watch with great trepidation their child's way of relating to members of the immediate family, the extended family, and the community family. All adolescents, at times, are very much a part of the community and their families. At other times, they remove themselves completely. Parents and pediatricians know a great deal about the "game" of adolescent development but are often at a loss to gauge how to help the adolescent grow in autonomy, independence, and identity by providing the correct amount of value-setting and the amount of dependency support needed.
THE PROBLEM ADOLESCENT
When you are a parent or a pediatrician sitting on the sidelines watching a selfdestructive, depressed young man, a girl abusing her diet and heading for anorexia nervosa, or a runaway girl being dragged back by the police from out-of-town, it is difficult to know what course of action to take. The pediatrician, when called, is especially at a loss, even though he usually knows the youngster better than anyone other than the parents. Teachers and friends come and go; but the pediatrician has often been one of the constant figures in the adolescent's life - even though the adolescent may not admit it to himself. The pediatrician should not think of himself as an intruder, but he should be prepared to understand and offer advice, particularly in times of stress.
The independence-dependency balance lies at the root of many cases of drug usage, depression, and teenage running away. This delicate balance between the teenager's struggle for autonomy and self-control and his continued needs for care and support can readily tilt under pressure.
The pediatrician can help parents with that balance, so that it does not tilt too drastically either in the direction of serious disturbance or in the direction of overinfantilization and retarded social development. This is not always easy. Very often when child psychiatrists or pediatricians see a teenager struggling for independence but being blocked by the parents, they assume that the youngster is ready for more autonomy but that his parents are unduly repressive. Such assumptions are often inaccurate.
A case in point is of a 17-year-old boy who, when seen alone, seemed to be a bright, wellintegrated young man capable of holding down a job and living by himself. He wanted very much to have an apartment, but his parents absolutely refused to let him do so. They claimed he was too "irresponsible." I, on the other hand, experienced him as quite responsible, with the capacity to meet certain tasks of life with wholesome problem solving. He also seemed to be getting along well with friends and teachers. So I assumed his parents were stifling, controlling, and infantilizing.
It was later an eye-opening experience for me to see him with his parents over a period of several months. During that time, I learned that although his parents were frightened people with their own anxieties about independence, this boy managed to trigger those anxieties. He would actually cue them to become anxious about his capacity to take care of himself. As I would underline his strengths, he would undermine them in subtle ways. Again, when I met with the boy alone, he kept convincing me that he could take care of himself. When I met with the parents separately, they convinced me they were hard-nosed, irritable, and anxiety-ridden. When I saw them all together, I gained a different and more productive view of the situation.
One day, after three months of working with them, I finally convinced the parents to let him get his own apartment on a twomonth trial basis. They even agreed to pay part of the rent, provided he worked and handled all other expenses. In that session, they actually appeared to be very relaxed parents. As the session was about to end, the mother said something like, "Well, maybe you shouldn't move out until next month. By then you will have worked a little and saved some money for your part of the first month's rent." The boy responded, "Don't worry about it - I can do it now. I'll sell some drugs and stay at a crash-pad for a while."
At the moment when his parents were about to give him the autonomy he had been begging for, he deliberately stirred up their anxieties and undid his gains. When he had the choice of saying nothing or something constructive, he chose to drop a "worry bomb" - which, incidentally, led to six more months of therapy before his parents would again consider his leaving home.
Similar triggering of anxieties, but by the parents, often occurs in cases of anorexia nervosa. A 16-year-old girl with anorexia nervosa convinced me that she was afraid to grow up because she feared sexuality. When I met with her parents alone, they seemed to have a wholesome attitude about sex and growing up and did not appear the least bit "old-fashioned." They genuinely sounded as if they wanted their daughter to date and to mature. Since most girls with anorexia nervosa are generally exquisitely terrified of growing up, and particularly afraid of their sexuality, they often develop the illness on the brink of menarche. Starvation sets in, periods stop, and breast development is arrested. The message to all around seems to be: "I'm not ready to grow up - particularly sexually!" So when this girl's mother said, "I want my girl to have normal dating - to go out - to have sex," it seemed as if she could help her daughter overcome the anorexia.
When I saw the girl alone, it appeared as if she was the only one who was anxious about dating and about the meaning of being a sexual woman. After six months of psychotherapy around her fears of womanhood and sex, she began to gain weight regularly and her periods and breast development returned. She soon accepted her first date with only mild anxiety.
Suddenly, I received a call from her mother stating, "Something terrible has happened - she came home after accepting her first date and began to starve herself again. She's called the boy and canceled the date." My immediate reaction was that this girl's psyche had automatically again become riddled with anxieties and that she was not ready to fulfill herself as a young woman.
A subsequent family meeting was very revealing. For the first time I saw the mother blatantly, but unwittingly, trigger her daughter's anxiety. The girl began to speak about her sexual desires and her wish to date, stating that she did not understand why she suddenly had the urge to starve herself. The mother intervened with, "Look, I've always wanted you to go out; this boy is a nice boy, and he's not going to take advantage of you." I thought to myself: "Why is she reassuring her of the negative?" I asked her what she meant by "not taking advantage of her." She responded, "Well, you know, sometimes girls feel that boys are only after one thing, and I've always told my daughter that sex is healthy and that she shouldn't worry about those things. Right, Mary? I even taught her how to use contraceptives. Right, Mary? By the way, doctor, did you hear about the coed who got murdered and raped on the U. C. L. A. campus the other night?" That apparently came out of nowhere, so I asked the mother, "What made you think ofthat?" She answered, "Oh, I just wondered if you'd heard about it. Do you think that girl was asking for it? She must have been seductive!"
In this clinical example, we see a mother without awareness of the impact she is having upon her daughter. It was later revealed that the mother's father was a policeman, who would often tell her stories about girls getting raped in the streets. Her repressed anxieties were now being communicated to her daughter. She was unwittingly dropping "worry bombs" that had to provoke this girl's anxieties about sex and womanhood.
DRUG ABUSE AND THE RUNAWAY ADOLESCENT
In my experience with adolescents, I often find drug abuse related to a lack of individual identity. If you see adolescents in the absence of other family members, you may miss spotting this relationship. On the other hand, if you have the entire family in for a meeting, you may learn a great deal about the identity struggle that is often at the root of such problems.
An extreme case example involved a family of five children. This particular family had a great deal of family identity, but its members seriously lacked individual identities. Establishing an individuated identity, and existing as a unique human being, is central to adolescent development. This talented television and theatrical family often played instruments and sang together. The children were 1 1 through 20. Their wholesome family identity gave one a good, warm feeling when one was with them. However, after several family meetings, I realized I could not tell who was who. I had difficulty remembering individual children's names. Who was John, and who was Joe? Which was Mary, and which was Helen? I noticed that the parents, too, often confused the names of their children. At the end of each session, I had a Gestalt-type recollection of the entire family but could not recall the individuals, except for Steve - the substance abuser, the problem teenager. He had established the only identity in his family. People in their community knew none of the children by name, except Steve - the drug user, the "kid who was loaded and ran away all the time!"
This drug-abuse and runaway method of handling an identity quest is a striking one, and it is often overlooked in adolescents. Many of us are more familiar with adolescents who use drugs because they do not feel loved.
The pediatrician has an opportunity to focus on such identity problems in a family. He can say things like: "I notice you always do everything with your sons and daughters as a family unit. How come you never do something with just one son or one daughter?" One can help parents recognize that even though it is hard to find time to do things with each of the children, they are better off finding out about the budding identity of each child. They can then spend special time - albeit brief - helping each child's identity from becoming submerged within the identity of the family.
If pediatricians can encourage parents to help their sons and daughters establish their own identities, these youngsters will not need to take drugs or run away to advertise their uniqueness.
THE RUNAWAY TEENAGE GIRL
The problem adolescent girl will rarely admit that she craves her mother's and father's love and guidance. Too, she will rarely reveal that she feels unhappy that her mother and father are both working, for example. Instead of being able to ask for time with them, she may run away. When she does, she often finds for herself an older man who can take care of her. Sex is the price she pays for boodegged parenting. Her parents may stress self-reliance so much that she may fear asking them for help. The pediatrician can say to the parents, "She will never ask for your help and time. In fact, if you tell her you're taking her with you to the movies, she'll scream and pout - or if you tell her you want her to go on a picnic with you once a month, she'll say, 'Who needs such stupid things?' But take her, and offer these things - and she may stop running away."
DEPRESSION IN ADOLESCENTS
Depression is, of course, multidetermined, but regardless of what leads to depression in teenagers, the most common end-point is one of hopelessness. This often comes after a series of rejections, deprivations, bad relationships, school problems, fighting, loss of friends, breakups with boyfriends or girlfriends, and/or parental divorce. There seems to be no way out of the sense of failure and the lowered self-esteem. The point of depression that brings an adolescent close to suicide is usually just past the time at which parents need to be mobilized to give that little extra attention. Sometimes the parents are just not available. They may have died or moved, or the teenager may have left home. Pediatricians or child psychiatrists may need to provide such youngsters with a parental figure from whom they can get counseling and with whom they can fight. Teenagers actually need to fight with parents as well as receive care from them, if they do not have someone to fight with, they may get more depressed and start to beat up on themselves, thereby internalizing their anger, with subsequent severe depression.
In some families, children with very strong consciences have been raised to experience guilt over incestuous thoughts. That guilt can become so intense that they need to punish themselves by hating and even thinking of killing themselves. Some children are similarly raised with strong consciences and related guilt feelings about aggression. They feel it is just as sinful to think of injuring or murdering someone as it is to actually injure or murder someone.
When such a guilt-prone adolescent has his normal rage stirred up, particularly towards a mother, father, or sibling, his family conscience system may make him feel he is evil and deserving of punishment - perhaps even death, through suicide. One needs to work very hard with such a teenager in letting him know the difference between deeds and thoughts - in effect, that thoughts are not deeds and that one should be punished only for his bad actions, not his bad thoughts.
The parents of such depressed adolescents, too, need guidance about the difference between thoughts and deeds. Some parents are so threatened by feelings of rage that they cannot always react logically to verbal expressions of anger. I have been impressed with how one can modify the strict consciences of some parents even though one cannot change their entire internal psychic structure. If they can ease up enough to allow their child, once in a while, to say, "I actually felt like killing my kid brother. I won't do it, but I felt like it," they may be helping that youngster fight off an imminent depression.
Another cause of depression about which little has been written occurs in older adolescents - 17, 18, or 19 years old. It has to do with their lack of training for personal intimate relations. We spend much of our young people's educational and family lives training them to achieve - to attain high grades, to compete, to shine in a group - but often negleet training them to value empathy for other human beings. Although we preach love in our churches and temples, most of our cultural emphasis is upon the individual's achievements and performance record. We expect that suddenly, at age 17, our teenagers will go out and get boyfriends or girlfriends and have meaningful "love relationships." But in fact, they cannot suddenly learn how to love at 17 or 18 - how to empathize with someone, how to feel what another human being is feeling. Because of this shortcoming, these youngsters often fail at love and become severely depressed in their isolated, alienated states. When an adolescent comes to me feeling depressed and does not know why, I try to find out if it is because he wants to feel close to someone but does not know how.
Pediatricians can advise parents about the need to help their children learn to empathize and to praise children for caring about others as well as for achievements. It will also relieve parents to know that children can learn to love if they start by loving their parents once in a while.
The pediatrician has many opportunities to spot the interactions between adolescents and their parents. Although teenagers need to have a confidential relationship with their pediatrician, family meetings can supplement and complement that relationship. The trouble frequently lies in the family interactions. If the pediatrician observes these interactions, he will be in a better position to know which part of the system needs propping up, guidance, or redirection and which part of the system should be left to its own course. He will also know whom to advise - the teenager or the parents - as well as whether psychiatric help is necessary for either or both.
The responsibility of being a parent to an adolescent - particularly a problem adolescent - is a most sensitive and taxing one. The burden, however, can be significantly lessened when the parents feel free to turn to a pediatrician who can help their child look at the many facets of adolescent development without being judgmental or placing blame.
Brown. S. L Famiy therapy tor adolescents. Psychiatric Opinion. February 1970.
Wiliams, F. S. Family therapy: Its role ii adolescent psychiatry, in Feinstein, S. C and Gbvacchini, P. (eds.) Adolescent Psychiatry, Developmental and OSnicat Stuctes, Volume 2. New York: Base Books. 1973. pp. 324-339.
Wiliams. F. S. The adolescent sexual revolution. In Feinster. S. C. and Gbvacchhi, P. (eds.). Addescent Psychiatry. Developmental and Clinical Studes. Volume 2. New York: Base Books. 1973. pp. 160-194.