Webster defines alienation as a "withdrawing or separation of a person from the values of one's society or family." When we think about the 30 million young people in this country between the ages of 12 and 20 years, it can be easily seen that this definition may apply to many of them.
The largest category of alienated young people are those of different ethnic backgrounds. While these young people may operate with somewhat different value systems from the society in general, their values and attitudes usually closely resemble those of their families and their countries of origin.
There are many other groups making up the category of alienated youths who are not ethnically or culturally different from the society in which they live: runaways, school drop-outs, street youths, punk rockers, and delinquents, to name but a few. Some are very visible because of their manner, unusual dress, or behaviors. There are also many young people who are not so visible but who have rejected the value system of both family and society. Many of these youths are withdrawn and depressed, have limited education, and are unemployed and have little possibility of becoming productive members of society. Many are living at home and come from intact families. There are no estimates of their numbers but we know that of the large numbers that drop out of school, most are not finding employment nor doing anything that will prepare them for employment in the future.
Everyone who works in social agencies and programs providing services to families and children is aware of the great number of such youths. It is easy to generalize and say that most of these young people came from homes where they have been neglected, abused, or at least have had poor relationships with parents. While there is no question that this is true for many of them, there are substantial numbers of children who have had no such experience but who became alienated. Many have had concerned, caring parents and have not been deprived of adequate nurturing.
When one adds all these groups together, the numbers are staggering. There are, by conservative estimates, approximately 1,25 million youths who run away from home each year.1,2 According to the U.S. Department of Education (1981) 25% of all high school students drop out of school. Half a million youths are incarcerated in juvenile detention facilities each year.3 Rough estimates of the numbers of street youths and "punks" exist, but it is impossible to obtain any more accurate figures for these large groups, in part because they do not congregate together and many still live at home. In common, these young people all have some degree of problem fitting into society and the likelihood is very high that as young adults they will have great difficulty in finding employment and becoming independent. Many continue to have difficulty in emotional adjustment.
Perhaps some examples would be helpful.
Pat is a 16-year-old street youth. He ran away from home at the age of 12, having been beaten repeatedly by his lather. He has never been successful in school although he is of average intelligence. He has been in and out of school and has only completed the seventh grade. After running away, he was in several foster homes and one group home. By the age of 14 he was on the street. He survived by picking parking meters, panhandling, and, occasionally, prostitution. He was in detention twice for short periods of time. He has no regular residence but lives with friends, prostitution clients ("tricks"), and occasionally bus or railway stations overnight. He uses both alcohol and drugs in increasing amounts and has never been employed.
Jerry is 17 years old. He was thrown out of his home when he was 14 because his father found out he was sexually involved with a neighbor youth. Since leaving home, he has been in several group homes where he was teased and picked on by some of the other residents. He is now on the street. Although at times he establishes contact with someone who will provide him with shelter for a few weeks, he is depressed, has tried to commit suicide twice, and says that he cannot see any future for himself. He is uncertain about his sexual orientation but says he is more accepted by gay people. He seems quite intelligent and has considera' ble skill in art, although he does not feel that his work is very good.
Susan is 15. She ran away from home at 13 because her mother's boyfriend was repeatedly attempting to have sex with her. Her mother refused to believe her and was frequently drunk and abusive. After running away she became acquainted with several street girls who were involved in prostitution. Susan was encouraged to try prostitution as a way to earn pocket money and has been involved in prostitution intermittently ever since. She was involved with a pimp for a while but tan away from him after he beat her. She has a small apartment which she shares with another girl, who is also a prostitute. She has had VD three times, been pregnant once but miscarried after 2 months, and has recently come into the clinic to find out if she is pregnant again. Tests were positive for pregnancy.
Roy is 18. He lives at home with his mother. His father has been out of the home since Roy was 3 years old. He has no contact with him. Roy's mother is a cocktail waitress. She has two smaller children at home and works mostly in the evening. Roy refused to go to school when he was in the eighth grade because he did not get along with teachers and other students. His mother had several conferences with school authorities and a short period of counseling. Nevertheless, Roy has continued to refuse to attend school and his mother has now given up. Roy sleeps until noon, watches television all afternoon and sometimes through the evening. Two or three nights a week he goes out with friends and they drink beer and smoke pot. He has tried sporadically to find work but does not like to work for minimum wage. He is becoming more depressed, has thought of suicide but has not tried it. His mother is threatening to throw him out if he does not find a job but she fears that he will get into more serious trouble if she does.
Most of these youths are not being served by any service agencies, and there are a number of reasons for this. First, most of these young people do not trust agencies or, for that matter, adults in general and will not actively seek assistance. Many agencies are not aware of them because they are not making themselves known to the agency by requesting services. Although at times there may be referrals made by an agency or a parent will request help, youths frequently refuse involvement with the agency. Those who provide service for this group know how often appointments are not kept.
Low self-esteem, depression, and lack of understanding and communication between the adolescent, parents, school officials, and other adults are all significant problems for this population. Many young people with specific medical problems or handicaps have parents who are aware of resources that would be of help and make use of them. In feet, many agitate for services if there are none available. This is not the case with the parents of alienated youths whose problems are behavioral and much less easy to define.
Pediatricians frequently see children and adolescents who are beginning to have the problems associated with ultimate alienation. This is most often in a medical context for an annual school physical examination, a sick visit, or a somatic problem that appears to have an underlying emotional or stress-related etiology. In addition, the clinician may have seen a youth, usually at the request of parents or the school, for evaluation of school absences, increasing alcohol or drug use, or new behaviors characterized by depression and withdrawal, irritability, or self-deprecation. Occasionally, parents ask physicians for advice when they recognize changes in their child's attire, the wearing of jewelry and makeup, or the adoption of unusual dress. These all may be early signs of alienation and should not necessarily be considered as normal teenage behavior or a passing phase.
The pediatrician should take every opportunity to explore with parents and children family concerns and problem behaviors. Commenting on the adolescent's dress and manner in a nonthreatening way can promote useful discussion and shows the youth that his or her physician is interested without being condescending.
A general psychosocial review of systems with alienated or potentially alienated young patients should be carried out in a confidential setting. It is appropriate to ask about family relationships, leisure time activities, propensity for the patient to associate with street peers, academic performance and school attendance, alcohol and drug experience, sexuality and concerns about sexual identity, and symptoms of social withdrawal and depression. All young people struggle with some of these issues; alienated youths usually are encountering problems in all of these areas of life.
Runaway behavior should be discussed, exploring the causes. As indicated, alienated youths do not always leave home because of an abusive, intolerable home situation but rather because they feel they have more in common with street youths or they are attracted to street life.
Short-term reconciliation between children and parents is almost always attainable and usually desirable, and the physician should make every attempt to advocate for the child first and then the family in their efforts to gain access to counseling and academic services. Every patient should have a comprehensive medical history and examination as unattended chronic medical problems often accompany alienation. This also validates the medical practitioner's role.
The pediatrician should be aware of specialized resources in the community for alienated youths, such as adolescent clinics, counseling or therapy groups for youths with sexual identity issues or histories of sexual abuse, adolescent chemical dependency treatment programs, and alternative schools. Employment services aimed at street youths and runaways are becoming more prevalent. In most cases, these youths need survival services and family reconciliation and not individual psychotherapy.
Having discussed alienated youths themselves, consideration of the society from which these youths are alienated is warranted. In the process let us consider a society from which these youths might not be so alienated. These are not new ideas. They have come to us many times from people of great knowledge.
The society from which these young people are alienated is a mechanized, production-oriented, highposition society. By no means is every developing young person oriented this way. Nonetheless, the social power structure and programs for living and education pressure children in this direction. There are many persons working diligently to shift the emphasis toward what one is rather than what one has. Unfortunately, the general trend is still not in this direction. In many caring families, the emphasis placed upon concern for others, about the world in which we live, and upon positive approaches to life (while making them see good in others with whom they disagree) might result in a different kind of family unit than the one we have currently. The many children from families in which parents are not able to provide this kind of approach to life need more active participation by others who can, such as physicians, teachers, counselors, court workers, neighbors, relatives, ministers - all people who are concerned about the well-being of children and youth and who can promote caring and minimize differences. Underneath a facade of "punk" dress or the distrust accompanying being young and gay are often children needing understanding instead of continual rejection, isolation, and alienation.
Many of our intervention approaches are designed to guide youth back into a society which they already reject. Many are saying that they just don't agree with the values that are being presented to them. There needs to be some thought regarding the reorganization of approaches from the time children are bom. Families, schools, churches, child care organizations, and physicians - all of us who deal with growing and developing children will need, from as early as possible, to give children a chance to see their choices and have an opportunity to experience the satisfaction of knowing their own worth and the worth of other individuals with whom they come in contact. Preset goals of obtaining a good job or of doing something in order to please someone else may not be as necessary to validate themselves as worthwhile. The joy of developing and learning from their own growth might be more easily experienced. The quality of knowing what others need and want and the ability to respond to that need may be enhanced, and it might not be necessary to become alienated to survive as an individual. These ideas may seem vague, theoretical, unattainable, or, to many, unacceptable. We cannot, however, escape the fact that we as a society have a tremendous legacy in the ever increasing number of alienated youth. The problem can no longer be avoided.
While individual practitioners have a responsibility for caring for these youths in clinical settings, this situation must be given national attention. There needs to be a concerned and committed group of professionals brought together who have knowledge about youths and their problems and recommendations created for the already large number of alienated youths that we now have, as well as consideration be given to the many causes in our society that lead youths to become alienated. We need a national consensus and intervention plan before we lose even more of our youths.
1. National Statistical Survey cf Runaway Youth, Pan I and II. Office of Youth Develop* ment (HHS), HHS 105-75-2105, 1976.
2. Deisher RW: Runaways: A growing social and femily problem. J Fam Pract 1975; 2:255,
3. Stone D: Juvenile crime rate: Myth vs. reality. Youth Law News 1982; 2(4):1-2.