The transitional phase in our lives from childhood to adulthood is known as adolescence. It is a time of disorientation and discovery, when our world shifts from one ruled by parents to the pursuit of our own goals and fulfilment of our own dreams. In this phase we are more prone to risk-taking and we seek out and explore new relationships and sexual identities. We start to try to understand who we are as well as preparing for ‘adult’ life including a career and emotional and financial independence. This change brings much to learn, and it can be a challenging time for adolescents and their family who live with them.
The relationships we develop throughout our childhood dramatically impact this transition to adulthood. Supportive families can help us reach adulthood in an emotionally stable state, but overwhelming stress and trauma (involving multiple collective stressors such as neglect or abuse – emotional, physical or sexual, substance use disorders, inter-partner violence, separation of parents, mental disorders and criminal activity) can negatively affect our development. Children whose experience with adults is negative or unpredictable are more likely to believe that adults are unreliable and do not easily trust others. Tragically, children growing up within such an environment develop skills to manage these situations that do not prepare them well for adolescence. The anxiety they feel can lead to maladaptive skills manifesting as behavioural problems. These may make sense to the adolescent in the context of their past but in reality, they can put themselves and others in danger. Many parents and carers can find themselves at their wits end as to how to deal with teenagers showing disruptive behaviour or internalised severe depression and anxiety and the crises that follow. The most serious crises usually fall into one of three main categories: suicide-related behaviours, aggression and vandalism, and elopement. Although there is a wide variety of advice in books and online, there is little standardised literature on the best courses of action in such situations.
In the Western world, adolescents with serious maladaptive behaviours often receive support and help outside of the home in intensive treatment settings, including inpatient units, day treatment services or via intensive community outreach. These settings are focused on helping young people develop a healthier life trajectory. However, current guidelines, recommendations and strategies for the three serious crises do not include immediately usable detailed steps for how to manage them. In an attempt to help both affected adolescents and their parents and clinicians, Dr Wade Junek from Dalhousie University and IWK Health Centre, has undertaken a feasibility project developing a detailed strategy with specific instructions for each of the three crisis types.
Adolescents are in charge of choices; adults are in charge of responses’ is the daily mantra.
Dr Junek worked with a daytime treatment centre, offering sessions including empathic support, relationships, family involvement and healthy coping skills. However, he found that the presence of any of the three crises prevented treatment progress. The seriousness and frequency of the behaviours meant that strategies for coping with the crises were a necessity. The strategies that Dr Junek and the team developed constantly evolved as they received feedback from the adolescents, parents and clinicians. Over time particular roles began to take shape and guidelines to help families in the future began to be drawn up.
Development of these guidelines was not an easy task; clinicians and parents had to be aware of the risk of death, injury and criminal charges involved, as well as the immense stress for both the adults and adolescents involved. Throughout the process, difficult decisions needed to be made, such as admissions to hospital or the involvement of the police. Although the end goal was to develop healthy and working coping strategies for their future, during one of the three crises, parents and clinicians had to focus on the immediate situation only. If a crisis was not managed immediately (and death, injury or criminal charges not avoided) the end goal may not be reached at all. The adolescents needed be alive now to thrive in the future.
Over the course of seven years, the team built a conceptual strategy for coping with these crises. During this time, the strategy was constantly evolving so it could not be used to draw any research-based outcomes. It will, however, contribute to ongoing literature on managing such adolescent crises and potential areas for further research.
A guiding hand
When an adolescent exhibits a serious crisis behaviour, families often feel helpless, frustrated and scared. The situation feels out of control. Parents long for a better relationship with the adolescent which adds to their frustration, but they want to help and, therefore, are willing to learn in order to rebuild relationships and their household. Seeking professional help is the first step. Healthcare professionals meet with the parents to review their ability and motivation to put in the work. Parents are taught when to take action and how to use community resources; ‘Adolescents are in charge of choices; adults are in charge of responses’ is the mantra. The parents should leave with a copy of the guide to use to support their adolescent in crisis.
The guide provides detailed procedures on what to do during a crisis, such as talking calmly with the adolescent and calling upon the correct community or emergency services. When the adolescent is showing suicidal behaviours, there is no goal more important than keeping the adolescent alive. If the parents have a concern about self-harm, they can ask and review two questions: ‘Are you planning to end your life and kill yourself right now?’ and ‘Are you able and willing to look after your safety?’ If the parent is in doubt about the response to either of these questions, they must obtain professional help where there will be one of two outcomes: admission to hospital or discharge home.
Parents gained skills and developed healthier relationships with their adolescents, and all had new hopes for the future.
The guide also provides parents with essential guidance on hospital admission and how to help the adolescent take back control of their safety through working with hospital staff. For non-admission, parents and the adolescent will still be under much stress, so the guide helps parents with follow-up procedures at home. These include a 24-hour calm down routine and loss of privileges to allow time for the adolescent and parents to reflect on the importance of life and to develop additional skills when facing these crises. These responses are recommended by healthcare professionals and do not reinforce the actions of suicide-related behaviour. When implemented consistently, the adolescent soon stops the maladaptive behaviour as a result of the consequences and implications of their actions.
The parent guide also advises what to do if other members of the family do not feel safe in their own home or if they are living with the fear that their house may be damaged by the adolescent. In this situation the police must be called; this is incredibly difficult for parents but not stopping the danger will only allow the adolescent more power. When the police arrive they will assess if the adolescent needs to be removed from the house. If the adolescent settles while the police are present, the parent declares a 24-hour calm down and the removal of privileges again giving time for reflection (as in the response to the suicide crisis). The guide emphasises the importance of doing this while the police are present as the maladaptive behaviour may occur again.
The final detailed guidance involves the mutual development of a curfew rule. All adolescents must learn to conclude their activities within the normally allotted time before the curfew or they face consequences. However, some adolescents repeatedly test the curfew to the point of not returning at all. The consequences need to recognise the shift from breaking the curfew rule to not returning at all. At this point, the home essentially becomes a drop-in centre and the adolescent has little incentive to change anything as they are now doing what they want, when they want and are avoiding all consequences. This prevents any ability to provide supervision. The guide manages this in different stages. Stage one involves controlling when the adolescent is allowed out but in some cases this isn’t enough. Stage two is for adolescents who do not return home repeatedly; an adolescent cannot be forced to stay inside but the adolescent should be informed that the door will be locked all night and that they will not be allowed in after curfew. When they decide to return they will face the consequences of loss of privileges. In the case of an adolescent under the age of 16 years the police and child welfare should be notified.
Dr Junek’s purpose was to add to the development and evolution of strategies and guidelines for working with adolescent behaviour crises. It was clear to him from his own extensive experience that parents, carers and clinicians needed very particular guidelines to follow in the often precarious and dangerous situations that arise from the maladaptive behaviours of children transitioning to adulthood. Although the development of the guide had no specific research outcomes, careful estimates using the 30 adolescents involved in the guide development showed no deaths, the ceasing of assault and vandalism, better management of elopement and the reclaiming of the home as a safe place for parents and others. Throughout the process parents gained skills and developed healthier relationships with their adolescents, and all had new hopes for the future. First and foremost, Dr Junek’s guide will help keep adolescents and their carers safe in critical situations, but Dr Junek hopes this feasibility study will also contribute to the advancement of patient care and provide the basis for future research.
This study shows extremely promising preliminary results. How long will it be before this support is available to everyone who needs it?