Physicians who care for adolescents are periodically confronted with patients whom parents, schools, or social agencies contend are "out of control." The labels may differ, and terms such as oppositional, oppositional defiant, conduct disorder, and behavioral problems are also used. However, the consistent meaning of all of the designations is that these adolescents are behaving in ways that are out of the bounds of acceptability to the adults who are supervising them. The behaviors are getting these adolescents into trouble at home, at school, or in the community, or they are behaviors that the responsible adults, usually the parents, deem unacceptable for various reasons.
The actual behaviors can range from not listening, minor insolence, and "back talking" to outright verbal or physical abuse or assault on adults to risk behaviors such as substance abuse, wanton sexual activity, or running away. To an objective third party, such as a pediatrician, these actions can appear to be anywhere on the scale from nonpathologic normal adolescent developmental behaviors to abnormal behaviors. This article assists the primary care physician in assessing where a given behavior falls on that scale and, accordingly, whether to focus attention on the adolescent, his or her parents, or both to help alleviate the problem.
NORMAL ADOLESCENT DEVELOPMENT
Emotional and psychological separation from parents is accepted as a normal part of adolescence in American society. Adolescents are expected to distance themselves from their parents or guardians first emotionally, then intellectually, and ultimately physically as they enter adulthood. The degree to which the distancing occurs and the forms it takes can vary based on culture, family mores, and parenting styles.
Young adolescents demonstrate a subconscious need to be separate from their parents.1 This urge is facilitated by the development of same-sex peer groups and is nurtured by technologic means of communication, such as the telephone and the computer. Young adolescents can be clingy and infantile at one moment, and defiant, sullen, and distinctly uncomfortable in the presence of their parents at the next moment.
Adolescents who are in the mid teens challenge parental norms by testing behavior limits established by their parents and by testing their parents' beliefs and ideals. They do this by trying out other ways of behaving or by stating that they support positions that are diametrically opposite to their parents' positions. They find support for their behaviors from their mixed-sex peer group and from newly developed romantic partners.
Older adolescents, who have negotiated the earlier two stages successfully come to understand that their parents are fine folks and that they agree more and more with their parents' standards and positions. Older adolescents maintain the separation already established but are not afraid to enter into close emotional and intellectual ties with their parents, albeit more as peers than as subordinates.
Parents who understand the changes of adolescence and that their adolescents will, at times, be sullen, verbally defiant, and oppositional, take these behaviors in stride. These parents do not enjoy the behaviors, but they are not concerned that such behaviors are signs of major psychosocial pathology. They do not feel that their adolescents are out of control.
However, parents who are not well versed in the expected and normal strivings of adolescents to separate can be disturbed by these behaviors, often to the point of seeking help from their pediatrician or primary care physician.2 In these situations, physicians often can alleviate parental anxiety by educating parents about what is normal adolescent separation behavior and what is not. They can coach parents on discipline strategies, and can help them understand what new behaviors are likely as the adolescents traverse the stages of normal development.
TRADITIONAL VERSUS POSTINDUSTRIAL CULTURES
Adolescents in the United States at the dawn of the 21st century are expected to be independent, culturally savvy, able to make difficult decisions in a world in which choices are often perceived to be offered randomly, and able to find their own way in the world, a way that is qualitatively different from that which their parents chose.*'5 Today's adolescents are given autonomy early concerning decisions about clothing, diet, leisure activities, peers, and use of media. Parents, faced with the media's transmission of societal norms about behavior and appearance, frequently abdicate their authority to the culture at large.
When compared with parents in the first 60 years of the 20th century, parents today have less structure in their lives and, consequently, more freedom to make lifestyle choices.4·5 They also may lack the geographically contiguous extended family to whom they can turn for advice and support when they encounter worrisome behavior in their adolescents.
Currently, many parents lack not only the support of an extended family, but also the support of a spouse. More than half of all children today live in a single-parent household.6 Although this may not be a higher percentage than existed a hundred years ago, today's single parents usually have arrived at that status due to divorce or never being married rather than having been widowed. Single parents may have to contend with former spouses and in-laws or stepparents while trying to work full time. Again, all of this frequently occurs without the support of a local, extended family. Parents in this situation may feel overwhelmed and unsure of themselves to the point that they are unable to set clear and enforceable limits for their adolescents. This can lead to the perception that their adolescents are out of control. That perception may, indeed, be accurate, but it can also result from their feelings of inadequacy in the parental role.2
Today's adolescents also may feel overwhelmed. In the early part of the 20th century, children had few expectations placed on them.5 As they progressed through adolescence, expectations increased, but they had time to match their increasing maturity to what was expected of them. Today, children are expected to function with mature decision-making skills at an early age. They are put into organized, adult-supervised (and adult-created) activities at young ages, and they can feel significant pressure to meet external expectations at young ages. By the time these children reach adolescence, they begin to rebel against this pressure, and they may start behaving in ways that are perceived as being out of control.
Another factor that may make adolescents seem out of control is a conflict of cultural norms. This can occur when families whose cultures are of the traditional type (which expects adolescence to be an extension of childhood) migrate to the United States or Western Europe and confront the societal culture that celebrates early adolescent maturation and independence.7 Immigrant parents may believe that their adolescents are out of control when they are just behaving similarly to adolescents who are fully immersed in "postmodern," postindustrial culture.
Such parents may be used to children who live at home until marriage, begin sexual activity after marriage, and have heterosexual unions. When their adolescents sample different lifestyles and do not pursue the path that they lay out for them, these parents can have considerable trouble coping. Examples include families who have recently immigrated from countries such as Somalia, China, or Ecuador. Domestic examples include Orthodox Jews, Mormons, or Southern Baptists. A poignant article by an anonymous Orthodox Jewish mother describing her tribulations when her youngest daughter veered away from the path of development expected by her parents is an example of the angst that can be generated when a child's behavior is outside the bounds of cultural norms as perceived by parents.8
CHILD TEMPERAMENT AND PARENTING STYLE OR EFFECTIVENESS
Another factor that can affect parents' perceptions of their children's behaviors is the "fit" between their parenting style and the temperaments of the children.9 This interface can determine whether parents feel that their adolescents are out of control.
Temperament can be defined as the inherent way an individual responds to environmental stimuli. Temperaments are usually evident from the earliest days of life, and because temperament is a biological phenomenon, it makes sense that the temperament of a child tends to fit with those of his or her parents. However, this is not always the case. Sometimes parents who expect a child to be quiet and self-contained may have one who responds overactively to all stimuli and thus needs consistent, firm supervision. If the parents are unable to cope with such a demanding child, the child's behavior may deteriorate, and, when he or she reaches adolescence, may be labeled by the parents as out of control. Once again, this perception may be accurate or it may be due to parents' feelings of inadequacy. Similarly, should a child have a quiet, placid temperament, parents who need constant feedback to affirm that the child is listening and obeying might consider him or her out of control in that he or she "never listens to them."
Early in her article, the Orthodox Jewish mother states, "We are a close-knit, traditional family. . . . Without our ever having to enforce strict disciplinary measures, our children seemed to share our values and culture."8 Then the youngest child began to adopt the look and behaviors of an experimenting adolescent and the parents had problems coping. In some respects, their daughter's behavior could be described as conduct disordered. However, this article also describes elements of a temperament disconnect between the parents and the child. The parents were not ready for a child who was energetic, craved stimuli, and was easily bored.
Actual parenting style can contribute to the perception or actuality that children are out of control.4 Parents who do not communicate well and are alienated from one another will have more problems handling even normal adolescent developmental behaviors. Alternatively, parents who construct a family in which everyone knows everyone else's business and where boundaries between members are hard to define (ie, enmeshed) may perceive mildly deviant behavior as out of control. Parents also can be so stressed by their life situations that they perceive normal adolescent developmental behavior as out of control, or can be so unavailable literally, emotionally, or both that their children, perceiving no parental limits, actually are out of control.
TRUE OUT-OF-CONTROL BEHAVIOR
Parents who complain that their adolescent is out of control may be correct. The adolescent may either be oppositional and defiant or demonstrate behavior that qualifies as conduct disorder. These disruptive behaviors are defined in the DSM-IV, and the criteria for their diagnoses are listed in Tables 1 and 2. Conduct disorder and oppositionaï defiant disorder have many overlapping features, and both have features in common with attention-deficit hyperactivity disorder.10,11 This article does not explore these syndromes other than to mention that the physician must rule these out before concluding that the problem lies with the parent rather than the child.
Diagnostic Criteria for 312.8 Conduct Disorder
Diagnostic Criteria for 313.81 Oppositional Defiant Disorder
PEDlATRIC ASSESSMENT AND MANAGEMENT
When confronted with parents who insist that their adolescent is out of control, the physician needs to examine the various factors that led to this conclusion. The previous discussion indicated that the problem can emanate from the adolescent, the parents, or both. The adolescent could just be expressing normal adolescent development, and the parents may need only some education on what to expect during this period of their adolescent's life to realize that what they perceive as out-of-control behavior is, in fact, normal developmental separation-individuation behavior. For example, an adolescent might be spending more time on the telephone or in computer chat rooms with peers, and he or she may not respond readily to parental requests to come to meals, dean up rooms, or go on family outings. Here the physician needs only to educate and counsel the parents to defuse the situation.
On the other hand, the adolescent might be unresponsive to parental requests because of obtundation from substance abuse or because he or she is literally not present, having sneaked out of the house to participate in some illicit activity. In-depth interviewing of the parents and the adolescent, both together and alone, can provide the answer. Even then, consultation with an adolescent medicine specialist, a behavioral pediatrician, a psychologist, a psychiatrist, or a social worker may be necessary to determine the real source of the problem.
A key point in determining whether an adolescent is truly out of control is to consider the basic question: does the adolescent really do what the parents want even if superficially it looks as if there is out-of-control behavior? Does the adolescent come home at or near curfew? Does the adolescent refrain from substance abuse and wanton sexual behavior? Does the adolescent continue to do well in school? If not, the behavior may be out of control.2
The clinician should ask parents to describe the response of the adolescent when they lose their tempers. Does the adolescent then obey, or does he or she continue the aberrant behavior? The adolescent who obeys when a parent "loses it" may just be testing and may not be out of control. However, the adolescent who still misbehaves may truly be out of control.
If the adolescent toes the line on these basic, most important issues, perhaps the clothes, hairstyle, and music that the parents have trouble coping with are not out-of-control behavior. For example, when one of the authors would lose patience with some behavior, attitude, or superficial characteristic of his youngest daughter during her early adolescent years, she would be quick to retort, "Am I having sex? No. Am I using drugs? No. Am I doing well in school? Yes. Then what are you so upset about?"
The physician needs to have the time and the interest to obtain a complete psychosocial history and to provide supportive and compassionate counseling. He or she also needs knowledge of professional community resources that can be consulted for further diagnostic assistance, therapeutic assistance, or both. With these thoughts in mind, caring for adolescents who might be out of control may not be as daunting as it sometimes seems.
1. Strasburger VC, Brown RT. Growth and development. In: Adolescent Medicine: A Practical Guide, 2nd ed. Philadelphia: Lippincott-Raven; 1998:1-22.
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8. Anonymous. A mother's reaction to a rebellious adolescent. Adolesc Med. 1998;9: 197-203.
9. Bates JE, Pétrit GS, Dodge KA, Ridge B. Interaction of tempermental resistance to control and restrictive parenting in the development of externalizing behavior. Dev Psychol. 1998;34:982-995.
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11. Mezacappa E, Earls F. The adolescent with conduct disorder. Adolesc Med. 1998;9:363-371.
Diagnostic Criteria for 312.8 Conduct Disorder
Diagnostic Criteria for 313.81 Oppositional Defiant Disorder