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Children and young people - Chapter 11

Adolescent-to-parent violence

      1. Adolescent-to-parent violence

‘The role of GPs is to identify affected families, build a rapport with them and support them to seek help in managing adolescent-to-parent violence.’

Key messages

  • Adolescent-to-parent violence is a serious and gendered problem.1 The majority of victims/survivors are mothers, and perpetrators are usually young men.1–3 Fathers can also be victims/survivors and young women also use violence towards parents.2
  • Young people who use violence have often experienced or witnessed violence in the family home.3–5
  • The pattern of violence used is similar to that of adult family violence, in that young people use violence to obtain power and control.1
  • Unlike adult perpetrators, young people who use violence against their parents are legally children and therefore their protection, safety and developmental needs need to be taken into consideration.2,3,5
  • Health practitioners should adopt a youth friendly, developmentally appropriate and trauma-informed approach2,5,6 and focus on building a good rapport to increase the likelihood of the young person engaging in regular review and therapy.
Be aware of adolescent violence towards parents and how it might present to general practice.
(Practice point, consensus of experts)
Young people’s violence against their parents may be associated with other forms of family violence; therefore, family violence should be sensitively inquired about.
(Practice point, consensus of experts)
Offer young people with behavioural concerns, and other family members, referral for psychological therapy.
(Practice point, consensus of experts)

Definitions

Adolescent-to-parent violence and child-to-parent violence are terms used interchangeably to describe violence that is initiated by a child or adolescent (aged 12–18 years) against their parent(s) with the intent to cause them psychological, physical or financial harm and/or to gain power and control over them.1,2,7,8

Prevalence

Adolescent-to-parent violence is a significant but underreported issue.8 Data from Victoria shows that approximately 10% of family violence call-outs to police were due to young people aged 19 years or under perpetrating violence,3 and 7% were children aged 17 years or younger.9 However, the true prevalence is not really known, due to underreporting, inconsistent definitions of ‘adolescent’ used by the police and children’s court, and omission of the age of victims/survivors or perpetrators in data recording.3

Parents often struggle to recognise an adolescent’s behaviour as abusive, instead minimising it, or labelling it as ‘challenging’.1,3 Parents also hesitate to report adolescent-to-parent violence due to shame, stigma or fear of repercussions for their child’s future, such as involvement with child protection or the youth justice system resulting in a criminal record.1–3,5,8,10 When parents do decide to report adolescent-to-parent violence to police, it has usually been going on for years.8

Risk factors

A number of family and individual factors are associated with adolescent-to-parent violence.

Family factors include:

  • adverse childhood experiences, including poor family relationships, parent-to-child violence and witnessing family violence in the home3–5,8,11–13
  • White or European ethnicity, although the evidence is weak.12

The role of socioeconomic status is unclear.12

Individual factors include:

  • mental illness and use of alcohol and drugs2,3,8,14
  • having a disability, including acquired brain injury3
  • having learning and behavioural difficulties3
  • poor school attachment and running away from home8,14
  • poor emotional regulation, including experiencing high levels of hostility and anger,14–16 and low self-esteem and self-worth12
  • problematic use of social media15
  • attentional and motor impulsiveness15
  • exposure to a peer who uses violence at home15
  • other antisocial behaviour outside the home15
  • a lower positive attitude towards authority figures such as teachers and police.17

Interestingly, a 2020 study found that the relationship between child abuse and adolescent-to-parent violence was moderated by positive peer attachment.18

Presentation

GPs should be aware of adolescent-to-parent violence within families, know the risk factors and how to identify young people and their parents dealing with adolescent-to-parent violence. It is unknown whether screening for adolescent-to-parent violence is helpful, but we recommend case finding.

For young people, adolescent-to-parent violence can present in the following ways:

  • mental health concerns, including threats to harm self or others8
  • a history of intellectual disability3
  • use of alcohol and drugs3
  • behavioural concerns, including trouble at school, and the adolescent causing damage to the victim/survivor’s belongings and property3,5,8
  • a history of having experienced family violence, child abuse or bullying.3

Parents may present with health issues, such as substance abuse or mental illness, that could be related to adolescent violence in the home.1 GPs should investigate the surrounding factors that may be contributing to adolescent-to-parent violence so that appropriate referrals can be made.

Working with adolescents and young people

It would be helpful to adopt a youth-friendly,19 developmentally appropriate and trauma-informed approach5,6,8,20 with the young person (and/or parent) who might be experiencing adolescent-to-parent violence. A trauma-informed approach or trauma- and violence-informed approach is patient-centred and acknowledges the role of trauma and violence in patients’ lives while being focused on improving wellness rather than treating a mental illness.6,20 Further information can be found in Chapter 7: Trauma-informed care in general practice. Young people who use violence against their parents sometimes become isolated from the family,1,8 but also tend to lack empathy for the victims/survivors.2

Box 11.1 outlines some practice points for working with young people who might be using adolescent-to-parent violence at home, and Box 11.2 outlines examples of specific questions that you could ask a young person who you suspect was using violence towards their parents.

Box 11.1. Working with adolescents who might be using violence at home

  • Incorporate a youth-friendly19 and trauma-informed care approach.5,6
  • Explain confidentiality and the exceptions to this, including risk of harm to the young person or risk of the young person causing harm to others.19 It is acknowledged that this may be challenging to do given the context of adolescent-to-parent violence and while attempting to build a good rapport and trust.
  • Build a good rapport with the young person and thank them for coming in to seek help; this is a good investment in the therapeutic relationship to engage the young person and their family in the long term.
  • Conduct a thorough HEEADSSS assessment.21 A young person might be using violence at home if they present with risk-taking behaviours8,22 or mental health issues.1,23
  • Ask open-ended questions.
  • When safe and appropriate to do so, inquire about family violence, sibling violence and dating violence, and manage as appropriate.
  • Use the LIVES framework24 where appropriate with the CARE approach,25 particularly for family members experiencing violence.
  • Educate the young person about types of violence and emphasise that violence is not acceptable.
  • Assess risk of harm to self and others.
  • Assess the young person’s support network.
  • Consider referral to appropriate psychologist for counselling. Family therapy may not be appropriate, particularly if there is a power imbalance that may put the victim at risk of further violence.
  • Don’t forget routine care, including preventive healthcare19 (eg screening for sexually transmitted infections).
  • Organise extended consultations and regular follow-up.
  • Continue consultations over telehealth when safe and appropriate to do so.
  • Manage patient expectations and make a plan together.

Box 11.2. Example questions to ask adolescents using violence towards parents

  • ‘What or who made you come in today?’
  • ‘Have you talked about this to anyone else? Did you find this helpful? How did you feel?’
  • ‘Are you worried about your behaviour?’
  • ‘What happens when you get angry?’
  • ‘Do you ever regret some of the things you have done?’
  • ‘What would you like to change?’

Working with parents or carers

If there is high clinical suspicion that a parent is experiencing violence or abuse from a child or young person, asking sensitively about adolescent violence in the home can be helpful.

As with suspicion of intimate partner abuse, broad questions can be asked first, such as, ‘How are things at home?’, followed by a statement to encourage the parent to talk, such as, ‘It can be challenging parenting a young person sometimes – how is it going for you?’

If adolescent-to-parent violence is still suspected, more-detailed questions can be asked about the violence, such as those listed in Chapter 2: Intimate partner abuse and violence: Identification and initial response and Box 11.3.

Conducting a safety and risk assessment is very important – for both the young person, and their parent, if both are in your care. Ways to inquire about safety are outlined in Chapter 3: First-line response to intimate partner abuse and violence: Safety and risk assessment.

Box 11.3. Example questions to ask parents about adolescent-to-parent violence

  • ‘How are things at home?’
  • ‘It can be really tough sometimes parenting young people. How are you going?’
  • ‘Do you feel safe at home?’
  • ‘What happens when your child does not get what they want?’
  • ‘What happens when you set rules or boundaries around the house (eg screen time)?’
  • ‘Do you feel afraid when your child feels out of control?’
  • ‘Do you feel the need to protect siblings at home?’
  • ‘What is the worst thing that has happened?’
  • ‘Are you worried about your child’s behaviour?’
  • ‘What would you like to change?’

While there have been years of studies into adolescent-to-parent violence, the evidence is of poor quality,12 and therefore there is no thorough understanding of how young people and their families can best be supported, and no evidence-based, developmentally appropriate interventions for young people who use violence against their parents.2,6,8

The lack of evidence-based knowledge in dealing with young people using violence at home from Aboriginal and Torres Strait Islander and culturally and linguistically diverse communities adds further challenges in management of this problem.5 Additionally, young people with a history of undiagnosed disabilities who use violence already experience the increased burdens of these disabilities, while their families are also already struggling to cope, without appropriate supports to address issues associated with the disability.3

There is little available help and support for adolescents and their families affected by adolescent-to-parent violence,5 with services having limited understanding of the impact on carers and parents.8,10 This can leave parents feeling frustrated and isolated in their attempts to seek help.8

The role of GPs is to identify affected families, build a rapport with them and support them to seek help in managing adolescent-to-parent violence. Patients may benefit from GPs adopting a trauma- and violence-informed approach, which includes recognising the impact of trauma and violence on patient behaviour and presentation, being flexible with consultation length according to the patient’s needs, creating a physically and emotionally safe environment, creating opportunities for collaboration and choice in healthcare and using a strengths-based approach.6,20,26 Part of this trauma-informed approach includes building positive and emotionally supportive connections and this might include the GP speaking to the adolescent about nurturing positive peer attachments, which have been shown to be useful.

There is some evidence that targeted psychosocial interventions delivered by specialised facilitators could be helpful for high-risk adolescents who exhibit a range of aggressive behaviours (not necessarily adolescent-to-parent violence).13

The 2015 Royal Commission into Family Violence emphasised that a therapeutic approach is needed for adolescent violence in the home, noting that targeted counselling and family therapy might be the most effective means to manage young people’s use of violence towards their parents.3 It is therefore suggested that young people who use violence in the home be referred to a youth-friendly psychological service for targeted counselling and family therapy that is trauma informed. Evidence-based interventions that address the multiple determinants of the adolescent-to-parent violence with a focus on promoting healing and good social connections is recommended.6

Victoria’s Adolescent Family Violence Program, which includes cognitive behavioural therapy, skill development and family involvement, is available to limited adolescents and their families in Victoria.3 Initial evaluation findings are positive, showing that the program improved adolescents’ violent behaviours and their overall wellbeing, and also increased parent confidence in managing the young person’s behaviour.3 Maintaining these good outcomes poses a challenge.

It would also be worthwhile exploring other forms of family violence in the home and addressing those on their own merit. Addressing substance abuse and mental illness would also be valuable in the primary care response to adolescent-to-parent violence.

It is acknowledged that looking after families experiencing adolescent violence in the home can be exhausting mentally and physically for the health professional. Therefore it is important that you look after yourself and debrief with colleagues. Have a look at Chapter 8: Keeping the health professional safe and healthy: Clinician support and self-care and the resources for health practitioners listed in the resource section.

Brad, aged 15 years, has been booked in by his father, Tim, to see the family GP for a general health check and review of his mental health.

Tim is a construction worker. Tim and his wife, Claire, separated about 11 years ago, and it was decided that Brad would live with his father, as he was always ‘difficult to handle’ and had ‘angry outbursts’, where he would throw things around. He visits Claire on some weekends, and she allows him to drink alcohol and smoke marijuana with her. Brad has had learning difficulties since primary school, and began attending a ‘special school’ in Grade 6 to address his learning difficulties and challenging behaviour. After attending several different primary schools and secondary schools he eventually dropped out of school in Year 8, aged 14 years, after being threatened with expulsion for his behaviour.

At the first consultation with the GP, Brad is reluctant to participate. The GP asks about his interests and manages to learn that he enjoys computer games, follows unpopular political leaders and dislikes the school system. He has no friends. At the end of the consult, the GP offers to call him on his mobile for a follow-up telehealth consult and encourages an open-door policy.

Brad does not return for several weeks, but meanwhile, Tim presents on several occasions following this initial appointment with Brad. Tim wants to be a good parent and get the right support for his son. In one appointment, Tim concedes that Brad has been violent towards him on several occasions but used no weapons. Brad also threatened to kill him on one occasion several months ago. Tim is often afraid for his own safety, and has set up his own escape strategy, which is to leave the house and ring the police.

The GP supports Tim with regular follow-up appointments and referrals for mental health support and support. A program at Berry Street (in consortia with other services), the Northern Healing and Recovery Program, has an adolescent family violence program that would provide support to Brad to address his behaviours. Tim might want to engage in two other Berry Street programs, the Matters program and their Teenage Aggression Responding Assertively workshop.

A couple of months later, Brad is brought in again by his father, who is becoming increasingly concerned for Brad’s mental health. Brad is feeling very depressed and suicidal and his angry outbursts have increased. He is increasingly threatening his father and throwing furniture around the house.

The GP makes referrals to the local youth mental health organisation and the mental health crisis team. However, Brad does not attend all of his appointments. He says he doesn’t want to speak to any more psychologists or psychiatrists, as he finds them to be unhelpful and feels that they don’t understand him.

One day the violence escalates so much that Tim has no choice but to call the police for protection. Following several such incidents, a referral is made to the juvenile court system.

The GP continues to offer support wherever possible and refers Brad to a paediatrician. The GP repeats a HEEADSSS screen to address any additional issues that might need to be addressed. Diagnoses of attention deficit hyperactivity disorder and Asperger syndrome are also queried.

Brad continues to return to the GP on an ad hoc basis, while the GP focuses on building trust and rapport in order to invest in a long-term therapeutic relationship. Appointments are kept flexible and last for at least 30 minutes so that consultations are not rushed. Telehealth is also utilised when appropriate but Brad does best when he comes in in person. A couple of years down the track, Brad has formed trust and a good rapport with the GP and has also started engaging with a psychologist more regularly. Tim is managing a bit better now and is able to recognise the warning signs and de-escalate the situation by prompting Brad with the appropriate advice from the psychologist to self-manage his outbursts. Calls to the police have not happened for a year. Tim continues to visit the GP fortnightly to seek support for his own mental health and coping strategies.

This event attracts CPD points and can be self recorded

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