DOI 10.1515/ijamh-2013-0312 Int J Adolesc Med Health 2014; 26(3): 393–402
Betânia da Mata Ribeiro Gomes*, Lucila Castanheira Nascimento, Marta Angélica Iossi Silva, Edemilson Antunes de Campos and Sandra Cristina Pillon
The context of alcohol consumption among adolescents and their families Abstract Aims: Alcohol consumption in adolescence has been an important topic in the study of public health policies. This study aimed to analyze and interpret the influence of the family in teenage alcohol consumption. Materials and methods: A qualitative research was undertaken, using interviews, observation, genogram and ecomap, in order to investigate 22 participants at a Family Health Unit in the city of Recife, Pernambuco, Brazil. The family structure, composition, interaction, communication, and religion of the participants were considered. Results: The results were analyzed using inductive thematic analysis and indicated three themes, namely, the internality of the family: fragility and conflicts; among us: limits, responsibilities and hope; and the decision to drink: fun permeated by risks. Conclusion: The family and sociocultural context of adolescents can positively and negatively influence the use and abuse of alcohol and, therefore, can be a target of intervention in nursing. Keywords: adolescents; alcohol; family; pediatric nursing. *Corresponding author: Betânia da Mata Ribeiro Gomes, Nossa Senhora das Graças School of Nursing, Universidade de Pernambuco, Recife, Brazil; and Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil, E-mail: [email protected] Lucila Castanheira Nascimento, Marta Angélica Iossi Silva and Sandra Cristina Pillon: University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil Edemilson Antunes de Campos: University of São Paulo School of Arts, Sciences and Humanities, University of São Paulo, Brazil
Introduction Alcohol consumption is a cultural matter. It is permitted in almost all societies around the world, and the consequences of inappropriate use affect the population that is considered most at risk: adolescents and young adults (1).
In a 2011 report about the harm alcohol abuse causes, the World Health Organization affirms that alcohol provokes almost 10% of deaths among young people; it corresponds to 320,000 deaths among young people and adolescents per year and is responsible for 9% of deaths around the world in the age group between 15 and 29 years (2). Alcohol abuse imposes a considerable burden of unwanted and very costly problems on societies. In Brazil, the events attributed to alcohol abuse, considered as a multifactorial phenomenon with psychological, biological and social implications, comprise traffic accidents, risky sexual behavior (sexually transmitted diseases, unwanted pregnancy), violence, unintentional injuries, and academic problems (3). Part of these factors fits into the family domain, including the lack of affective involvement between parents and children, separated parents, cultural conflict between generations, and parents’ lack of authority (4). From that interest, we were motivated to seek answers to the following hypothesis: does the family dynamics influence the develo pment of the use and abuse of alcohol among adolescents? In view of evidence that alcohol consumption is a social practice, the theoretical frameworks of Symbolic Interactions and Family Systems Theory were adopted to understand this study. Symbolic Interactionism analyzes human experiences and their interactions and, in family research, is mainly focused on families’ internal functioning (5, 6). Adapted from General Systems Theory (7), Family Systems Theory, when applied to Family Nursing, considers the family as a care unit (6). The systemic approach focuses on the relations among the members of the family system, in an attempt to understand the functioning of each. What happens to each family member affects the system as a whole, thus influencing its behaviors, beliefs, and feelings (8). The aim of the current study was to analyze and interpret family influence in teenage alcohol consumption.
Materials and methods A qualitative research was undertaken. This is generally considered an adequate approach to family research and permits understanding
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394 Ribeiro Gomes et al.: Alcohol consumption among adolescents family processes, as it is concerned with the universe of meanings, with the experiences, values, beliefs, aspirations, and attitudes linked to human relations (9, 10). In this approach, subjects’ specificity can be combined with their sociocultural context and their discourse and practices can be interpreted, based on their certainties, contradictions, and ambiguities (11). The research was developed in Recife, Pernambuco, Brazil. Among the places where adolescents can be recruited in the city, the Family Health Strategy (FHS) was chosen as the place of study. The territory of Recife is subdivided into 94 neighborhoods and, for planning and management purposes, the city is divided into six political-administrative regions (PARs), each of which is subdivided into three microregions (12). Thus, public health system actions (Unified Health System – SUS) in Recife are decentralized through six health districts (HD) that correspond to the spatial division of the six PARs. The Family Health Unit (FHU) Emocy Krause is located in the West of Recife and the families attending at the unit belong to popular classes. Based on the selection of 11 adolescents from 10 families, 22 informants participated in the research, including mothers, fathers and siblings, who complied with the following inclusion criteria: adolescents registered at FHU Emocy Krause; between 14 and 19 years of age; alcohol consumption and/or abuse; and living with family members, independently of the type of family structure, i.e., the families could be nuclear, single-parent, separated parents, reconstituted families, homosexual parents, or families in which the oldest sibling or another relative was responsible for the adolescent, whether biologically related or not. In each family, family members present at the adolescent’s home on the occasion of the first meeting with the family were invited. In the course of the research, interaction with the family and the informants’ discourse indicated whether or not there was a need to include other members in the research. The data were collected through in-depth interviews, guided by questions that were elaborated based on the Calgary Family Assessment and Intervention Model. The genogram and eco-map were elaborated for each family; non-participant observation was used to immerse the researcher into the family environment as a complementary data collection technique (13–15). The interviews with the family were held at each adolescent’s home and, upon request, two families were interviewed at the FHU. Each meeting took approximately 1 h. While two and three meetings could be held with some families, with others, the study problem was explored during a single moment of interaction. To avoid common weak points in family research, such as a lack of clarity that family members and individuals with particular characteristics and that family groups were groups with group characteristics (16), we adopted the following family definition, appropriate to the interactionist perspective: “family is a group of individuals in symbolic interaction, reaching situations with other signifiers or reference groups, with symbols, perspectives, self, mind and ability to take on roles” (17). As it involved human beings, the research project was submitted to the Research Ethics Committee (CEP) at Universidade de Pernambuco, Opinion 050/11, in compliance with National Health Council Resolution 196/96. Once the CEP approved the project and the Recife Municipal Health Secretary granted its official and formal agreement, the study was authorized to be implemented in Health District IV. As a part of the necessary documentation, free and informed consent forms were given to the adolescents and their relatives, which served to orient the study participants. Out of respect for the adolescents, their assent was obtained, along with the consent of their parents or legal representatives, The informants’ names were replaced by fictitious names or identified according to the degree of
parenthood or affinity with the adolescent, in order to guarantee the participants’ anonymity. Names starting with the letter R were used to identify the adolescents, as the index-cases in this study, in combination with the letter F for family, followed by the number that indicated the order of inclusion in the research. For the purpose of data analysis, the inductive thematic content analysis method was adopted (18). Six phases were accomplished: getting familiar with the data, producing initial codes, searching for themes, reviewing themes identified, defining and naming the themes, and elaborating the final report. Moreover, efforts were made to interpret the participants’ discourse and develop a latent, non-explicit analysis, which went beyond the semantic contents of the data, identifying the meaning found “between the lines” (18).
Results The families under analysis had few resources and, as mentioned, came from popular classes. Their occupations reflect non-specialized work with lower remuneration levels. In general, the family providers’ education level was not higher than primary education. The investigation involved the following: single-parent families or families in which the parents got married once and lived with their children, and families whose parents got divorced, remarried, and constituted new nuclear families. The social characteristics of the adolescents who participated in the research, including some particularities of family members, is displayed in Table 1.
Discussion Thematic units Based on the data analysis, three themes were elaborated: the internality of the family: fragility and conflicts; among us: limits, responsibilities and hope; and the decision to drink: fun permeated by risks.
The internality of the family: fragility and conflicts The family context in which the actions and interactions among its members take place, thereby comprising different family structures and compositions and distinct relationship patterns, provides for an interaction environment marked by weaknesses and conflicts. Therefore, this thematic unit is composed. The adolescents’ families revealed diverse family structures, ranging from traditional to single-parent families. In three of the single-parent families,
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Renato
Ronaldo
Renata
Rosa
Ricardo
Reinaldo
Rosangela
Rosana
Rafael
F2
F3
F4
F5
F6
F7
F8
F9
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F10
18
18
18
16
19
19
17
15
17
Dropped out
Education
1.60
1.60
0.96
1.12
1.68
1.68
1
Monthly income (minimum wage)
Non-practicing Catholic
Pension + Family Program Grant 2.08
SENAI monitoring grant 0.51 Non-practicing Catholic
Practicing Catholic
Practicing Evangelic
Non-practicing Catholic
Non-practicing Catholic
Non-practicing Catholic
No religion
No religion
No religion
No religion
Religion
Adolescent, mother and two siblings Mother and siblings Beer Adolescent, mother and siblings Mother and siblings Beer Adolescent, mother and siblings Mother and sibling Beer, rum Adolescent and mother Father, mother, and Beer Adolescent and siblings mother Father and sister Beer, Adolescent and whisky father Father, mother, and Beer Adolescent and siblings mother Father, mother, and Ice Adolescent sister Father, mother, and Beer, Adolescent daughter vodka Mother and brother Beer Adolescent and mother Mother and siblings Beer Adolescent and sister
Beverage Participants consumed
Mother and siblings Beer
Lives with
Unfinished primary education Single Young adult and adult education Single Remedial primary education Single Unfinished secondary 8-month-old son education Single Young adult and adult education Single Finished secondary education Single Unfinished secondary education Single Dropped out 4-month-old daughter Single Unfinished secondary education Single Dropped out
19 Single
18 Single
Age, Marital status and years children
Source: Field diary and interviews.
Raimundo
F2
Rodrigo
F1
Family Adolescent identification index-case
Table 1 Characterization of adolescents according to age, marital status, education, family members living with the adolescent, beverage consumed, family members participating in the research, religion, and monthly income.
Ribeiro Gomes et al.: Alcohol consumption among adolescents 395
396 Ribeiro Gomes et al.: Alcohol consumption among adolescents the father was absent due to death or abandonment and, in one case, the mother had passed away. Despite the particular family compositions, the interpretation process revealed common aspects, which permeated the adolescents’ experiences. In general, the adolescents’ family lives were marked by conflicts among relatives, violence among parents and other family members, separation, and death. Three adolescents mentioned having witnessed their father beat up and humiliate their mother. One of them added that his older brother copied this psychologically and physically aggressive behavior. These adolescents learned about this way of acting at home. This is a cycle perpetuated from one generation to another. The domestic violence in these families is associated with variables in the family context, such as marital disagreement, alcohol abuse by the parents, and the experience of separation and loss. In addition, after a divorce in one of the participating families, the mother became fully responsible for the double activity of housekeeper and family provider, and this new context entailed the alcohol consumption habit. The divorce caused negative reflexes, emotionally destabilizing the woman and making her look for compensation in alcoholic beverages, according to the statement: “I almost turned into an alcoholic” (Mother, F9). For this mother, being an alcohol addict meant suffering and having the feeling that she was responsible for the possibility of having triggered her own daughter’s alcohol consumption. The mother reported that she considered her drinking behavior as a negative example for her. Moreover, women who become addicted to alcohol suffer from an intensified prejudice, considering gender differences in alcoholism, as reflected in men’s drinking behavior, which is more socially acceptable than for women (19). In any case, family members’ inappropriate alcohol consumption habit favors its introduction into the children’s daily life, representing a predictive factor for the latter to assimilate it as a way to cope with the problems of reality. In fact, the children of alcoholic parents can learn to interact within the social context, using the artifice of alcohol in a way similar to their parents. However, this is not always the rule, considering that the children may also develop an aversion against alcohol, as they perceive its harmful results. Unpredictable critical events that happened in these families (e.g., separations, illnesses and losses, among others) can strongly affect the family context, which may bring about pressure and disorganization. Experts call this a family functioning crisis, which needs a solution to maintain family health. The authors highlight, however, that keeping the family healthy does not only depend on overcoming crises, but mainly on a
good relationship among the family members, including the marital relation, as it directly influences the children’s development (20). Analyzing actions and interactions among family members implies the consideration of families beyond a group of people linked by blood bonds. This presupposes the inference that, at the heart of their relations, members are joined by affinities, feelings and moral responsibility, and are permeated by mutual representations, practices, and relations of mutual obligations. These obligations, in turn, are organized according to the age range as well as generational and gender relations that define the person’s status in the system of family relations. The first noteworthy detail was the fact that the adolescents demonstrated difficulties in talking about their feelings and about the way the family members relate mutually, with the extended family and with the community. Often, monosyllabic expressions or few words were used to express themselves about a given aspect. Some adolescents were able to further elaborate their answers, while others limited themselves to short answers and, sometimes, not even a word. These adolescents’ low education level may have hampered their expression, due to their limited vocabulary. This may also be characteristic of the adolescent phase in the lifecycle, considering that teenagers prefer to talk to their peers. In other cases, it may perpetuate some family patterns learned as a consequence of living in an environment, in which individual and family weaknesses are exposed, aside from conflicts and various types of violence wherein silence can constitute a defense mechanism. The following statements express this: “I have nothing to say about him. He’s a good person” (Rosa, F5); “If you want to ask about me, [feel free]. No, I don’t want to talk about my family” (Rodrigo, F1). The adolescents interviewed revealed a range of misunderstandings and dislikes in the family. Renata mentioned that the daughters were always present during their parents’ fights; the father hit and the mother reviled to defend herself. She summarized the situation as follows: “My father likes to attack my mother. My mother’s always trying to put the house in order and my father was always choosing his friends’ side” (Renata, F4). Ricardo commented that his parents lived together, but in a turbulent relationship, because the father “rebases” the mother (Ricardo, F6). Rosangela discussed the reason for her parents’ fight from her own viewpoint: “Well, they fight, my father spends all of his time in the streets, gambling. He keeps on asking my mother for money to play and buy cigarettes” (Rosangela, F8). The relationship between Rafael’s mother and father was also conflicting. There were always fights at his home: “My mother used to drink and fight with my father” (Rafael, F10).
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Concerning their relationship with their father, only four of the adolescents interviewed mentioned a positive affective relationship: “He was loving to us. He liked to give advice.” (Ronaldo, F3); “It was good. We used to watch games together” (Raimundo, F2); “My father was thoughtful” (Renato, F2); “We used to get along well. He was like my sister, helped me to do things, taught me, played soccer with me” (Rafael, F10). These four adolescents’ fathers were all deceased. By contrast, other teenagers’ reports demonstrated bad relationships with their paternal figure. They considered that their fathers did not represent any model behavior: “My father is aggressive, absent and I haven’t seen him for quite some time” (Rodrigo, F1); “The relationship with my father is bad, he’s aggressive, hysterical. I haven’t talked to him for some time” (Ricardo, F6); “He used to come to our house. Now he’s living with his family” (Rosana, F9). His father’s abandonment widened the gap between him and Rodrigo, who affirmed that he had not seen his father for some time. In Ronaldo’s case, his mourning about the recent loss of his father due to death may have mitigated any feeling deriving from his parents’ earlier divorce. The adolescents harbored a sense of longing for their father or mother who had passed on. The following reports illustrate this: “I used to go and see my father, every day. I couldn’t spend a day without seeing my father or I’d get sad. I miss him a lot [cries]” (Ronaldo, F3); “The only thing, if I could change it, was my mother being alive” (Rosa, F5). A mother talked about the changes in her children’s education after her husband’s death. His alcohol abuse permeated hers and her children’s lives, culminating in his death. She gave up her passive way of being and the exercise of authority and setting of standards in the family sphere strengthened her. In that sense, the absence of the father figure ended up building different relations in family life, making the mother more demanding, intolerant and inflexible, in the attempt to fill the void the father left behind in the relationship with his children. The quality of the relations established between parents and children influences the orientation of family principles, attitudes, and practices. The involvement, support, and affection between parents and children are a prerequisite for the children to identify themselves with their parents, thus increasing the chances of adopting them as behavioral models (21). The children absorb any model the parents transmit through their behavior, their attitudes, and expressions of feelings in daily life, as the parents are their first influential models. What was not taught in the course of the children’s development but which they learned affects their community life as part of society (22). Although angry and suffering, these
adolescents are not free from identification, even if negatively, with their family members. Thus, often, they display the same violent behaviors, in an ambivalent process of distancing and approximation, through similar ways of acting. Their statements reveal the behavioral model learned: “We’ve never gotten along well. Ever since I was little, always fighting, she used to hit us. Very intolerable, she used to talk too much. Then I fought with her, and she left [referring to his maternal grandmother]” (Rodrigo, F1). The grandmother does not live with the family anymore and, according to Rodrigo’s mother: “She left because Rodrigo hit her” (Rodrigo, F1). Despite the prevalent expressions of weaknesses in the families, to give an example, in terms of difficulties in maintaining one’s life, continuing one’s studies, communicating among family members, and experiencing conflicts among relatives, also with the mothers, a strong bond was observed between some teenagers and their mothers. The adolescents described the quality of the relationship with their mothers as appropriate. Sometimes, the mothers were asked to serve as a source of support in view of the unique need to open up to the other; on other occasions, they served as counselors and protectors of their offspring, alerting them about the risk of getting involved with drugs and inappropriate company. On the one hand, in the families under analysis, half of the mothers had a paid job to complement the family income, which came from the father or the help of another family member. Thus, the mothers were absent from home, which affected the children’s supervision. This absence represented another weakness expressed in this study, which affected the adolescents’ health. On the other hand, the adolescents valued the mothers who generally provided for their family alone or somehow contributed to sustaining the family, as women who sacrificed themselves and gave everything they have to benefit their children. In a broader sense, the mothers who offered affection, looked out for their children, and strengthened their family were similarly valued in their roles and positively influence the adolescents. The relation between parents and children reveals the strongest bond in the family context. It is inside the family that values, standards, symbolic codes and rules of conduct are transmitted, with parents helping their children to grow up healthily and conquer maturity and autonomy. According to Symbolic Interactionism, the family represents a group of people who interact and create their own set of symbols and meanings. These will influence the formation of their members’ identities, the transmission of family values and the learning of the social roles each member is supposed to play (23). These factors, which
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398 Ribeiro Gomes et al.: Alcohol consumption among adolescents affect the family’s functioning, are involved in the social culture the families are inserted in and the culture they identify themselves with, that is, lifestyle, values, ideals, beliefs and practices that are transmitted from generation to generation, influencing the family’s behaviors and health (6). In a broader context, family balance is aimed for, with a strengthened and healthy structure that promotes harmony and solidarity in the family context. This perspective was apprehended from the adolescents’ desire to somehow modify their families, so as to respond to their expectations of participating in a healthy social life with their members. In addition, as revealed by the desire to obtain abundant financial resources, adolescents tended to respect and value individualities and motivations for life, apart from attention to material existential needs.
Among us: limits, responsibilities, and hope This theme refers to the adolescents’ contact with alcohol consumption, facilitated by the presence of drinks in the family context and their offering by peers. “Among us”, that is, in the interaction among family members, relates to the loss of family structure experienced by the adolescents due to different kinds of conflicts, especially those involving family members’ alcohol abuse; it sets the limits of the family’s own actions, helping them understand how the adolescents became acquainted with alcoholic beverages. Nevertheless, the family does not refuse to assume its responsibilities of looking out for its members, especially for the adolescents, who are already vulnerable to alcohol consumption. Hope, often nourished by religion and aspirations, keeps alive the motivation to maintain the family and its objectives, reinforcing the culture of protecting its members and the private environment, thereby capable of finding its own resources to cope with the adversities of life. The teenagers found alcohol use at their own homes. Through their experiences, they took part in their parents’ relation with alcohol and apprehended that, within that environment, most situations caused suffering and losses: “My father taught me to drink. He put a glass of beer in front of me, then I took it and drank. So I liked it and started” (Rodrigo, F1); “He was the one who drank, every day. He got sick” (Raimundo, F2); “When he gets home from his current job, if he gets home early, he immediately goes to look for a stand to drink. My mom quit, because she got sick” (Renata, F4); “In the last three months, he started drinking a lot. He didn’t use to before. It’s because he lost his job. My father was smart, he had a curriculum. Then he stopped looking for a job and decided to seek another way out. He got into
the wrong business [drug trafficking]. Then, [when] he started selling more than the others, [they] got jealous and killed my father” (Ronaldo, F3). As the parents’ attitudes towards their children can be both protective while stimulating the use and abuse of alcohol and other drugs, parents’ alcoholism can play a mediating role in the inter-generational transmission of these behaviors. Growing up in a family environment ruled by alcohol abuse facilitates the development of somatic and emotional problems, low self-esteem, low educational performance, behavioral problems and delinquency, among others, which can ultimately lead to alcoholism (24). The I National Survey on Alcohol Consumption Patterns in the Brazilian Population found that 24% of the interviewees are frequent or binge drinkers (once or more per week, more than five doses each time), 48% of the population described themselves as abstemious, and 29% affirmed infrequent drinking. These data, however, reflect not just a habit, but a social problem: 28% of the population already experienced binge drinking and 12% suffer from some alcohol-related problem. Physical problems are cited most frequently, followed by family problems. The research also found that Brazilians start to drink at an increasingly young age, with 24% of the adolescents drinking at least once per month (25). Studies appoint different problems to explain alcoholism, including the hypothesis of genetic vulnerability, that is, the probability of becoming alcoholics is higher among children of alcoholic parents. Others ascribe the habit of consuming alcoholic beverages and other psychoactive drugs to social learning (26). Since a young age, adolescents exposed to a model of parents who consume alcohol, and who often give their parents beverages to try out, see this habit as a part of fraternization and release of daily tensions, which can cause dependence. Yet others consider the maturity of the brain structures responsible for inhibiting impulses, which are not fully closed during adolescence, making young people more vulnerable when in contact with the genetic or social learning hypothesis (27). Avoiding contact with drugs during the most vulnerable period gives the brain time to complete its maturing process and to put in practice strengthening measures to cope with environmental situations, allowing the adolescents to find alternatives ways of satisfaction in life. Concerns should be focused on findings ways to assist and protect the adolescents, in actual risk situations or not. Becoming an adult is not only a mere matter of time, of evolution in the lifecycle – it also involves a slow construction of a series of events relevant for this period. This construction is not the adolescents’ sole undertaking, but
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Ribeiro Gomes et al.: Alcohol consumption among adolescents 399
the sum of their family and social history. If the conditions experienced are satisfactory and more structured, they will be better able to come out of this period enriched and with greater possibilities of facing the adult world (28). Family functioning is focused on the needs of its members that should be met through the available health resources. The family system offers conditions to monitor and develop its members’ health-disease process (6), provided that it is properly stimulated and accompanied in this sense (29). Another part of this theme is the limit of family action, which surrenders to the adolescents’ approximation with alcoholic beverages. Nevertheless, the family does not escape from its responsibilities for its members, like encouraging continuing education, orienting the choice of appropriate company, offering advice and teaching principles to organize home and healthcare. Responsibilities linked to the education process extend across the lifetime, and its long-term effects are not easily changed because they are a part of people’s education system. The parents’ concern with their children’s freedom is related to their exposure to risk behaviors, which can emerge in function of the curiosity that is characteristic of this phase of life. This is the case, for example, with the consumption of alcohol and other drugs, which has become a source of concern because of its increased prevalence among adolescents nowadays. In this study, the family way of life derived from different emotional climates among its members, such as acceptance/love, rejection/anger, and indifference. The lack of limits and responsibilities in the relation between parents and children served as a condition for the development of role conflicts in the family system and involvement with alcohol use and abuse, as observed in the following report: “I set the limits at home, like waking up early, time to get home at night, but these are not always complied with. I consider that I am the authority because I stay at home” (Mother, F1). The mother also considered that the agreements about the children’s participation in housework were always violated, putting a burden on herself, her daughter, and her youngest son. Responsibility and limits are also terms that indicate the quality of using authority in the relation between parents and children. The limits of family action were also identified through the parents’ disrespect for other family members. In these cases, alcohol abuse among fathers and mothers and violence, mostly practiced by the fathers, broke any possibility of productive interaction, which also entailed negative repercussions for the entire family system. The opposite was also observed. The adolescents demonstrated disrespect for their parents’ authority and surpassed their limits in different ways, like alcohol use
or abuse, neglect of housework and personal care. As a consequence of this process, fathers’ and mothers’ feelings of impotence were identified, mainly because they did not know how to use their authority appropriately; as opposed to feelings of hope, often resting on religion, which brought the possibility of a more promising future. As regards religiosity, the study results demonstrated that four adolescents did not have any link whatsoever with any religion; five of them mentioned having a religion but considered themselves non-practicing, and two identified they had a religion and were practicing. Catholicism was the most mentioned, but not practiced, in accordance with other studies (30). Considering religion in the family, most mothers believed in a religion and underlined its importance in their lives. Five families indicated the Evangelic religion. Catholicism appeared in four families’ reports, although less practiced, as opposed to Evangelical and Protestant religions, with higher attendance and participation levels. Evangelical and Protestant religions appear as the most cited and practiced ones in studies that assess the consumption of alcohol and other drugs among adolescents (30). Having a religion can inhibit alcohol consumption and serve as a form of protection. Religion can also indicate effects against involvement with alcohol, such as the sense of belonging to a community of values and life projects and ethics, as well as choices that are not necessarily exclusive to ideologies and religious practices. Religion can also favor the feeling of hope, which entails future perspectives, that is, the establishment of a target or plan in life as a form of personal accomplishment. This positive influence, manifested through desires and dreams about a better future, relieves difficulties and exerts positive influence on the adolescents, favoring the maintenance of healthy aspects of life. In this study, parents’ aspirations for their children and vice-versa were identified to give lightness to possible difficulties that could be faced by the family. The parents want their children to be more successful in life than themselves, at the same time as the adolescents acknowledge the need to exert efforts to reach the objectives their parents were unable to achieve. Interrupting these aspirations may make the task of overcoming barriers and challenges more difficult. The aspirations identified in the discourse included the conquest of a qualified job, the possibility of studying, and building a family. Working, having a profession, and building a family emerged in some adolescents’ future plans. It can be inferred that the adolescents rested their future on family system and work values, as these possibly represented stability and security as the only course for their future (20).
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400 Ribeiro Gomes et al.: Alcohol consumption among adolescents Thus, the family does not only exert direct influence over the acquisition of beliefs and values, but also plays a central role in the construction of the plan the adolescents define for their lives. This explains why it is at the heart of the family organization that the personal project generally starts, based on which these young people go for their dreams and objectives (20). Some adolescents experienced the need to give up their plans or leave them in the background, at least temporarily. In these cases, the need to start a paid job and contribute to the family income motivated the event. This scenario meant that the parents were apprehensive about the future. On the one hand, work played a central role as a reference point, as it was a constant concern. On the other hand, many participants had an irregular or unstable job, a reality in both the adolescents’ and their parents’ lives, many of whom were unemployed. Paradoxically, work can be a means to take distance from activities considered inappropriate, such as alcohol and drugs use, as well as to guarantee access to them. In any situation, support from the family system was considered fundamental in this context.
The decision to drink: fun permeated by risks This theme relates to the context of the adolescents’ alcohol consumption and/or their motivations to drink, summarized as pleasure and fun, without ignoring the risks they are exposed to, mainly because their families are concrete examples of the repercussions of alcohol abuse. Different factors, such as the family and social context, expectations and beliefs, commercial availability and easy access, influenced the adolescents’ drinking behavior. Alcohol consumption was generally intense, took place at weekends, and depended on the resources available. The places in which the adolescents preferred to consume alcohol were bars, parties, and shows. They also used to drink at home, in the company of siblings and family members. The beverages the adolescents most frequently mentioned were beer, followed by liquor, and such alcoholic drinks as ice and energy drinks. Other studies also identified beer and liquor as the most consumed beverages, with the latter consumed after the beer, due to their higher alcohol contents (25, 31). According to the teenagers, alcohol represented a factor of social aggregation, which was an internal factor of gaining a more important social image and developing an identity that includes the assumption of adult roles. In most cases, alcohol consumption started among family members, followed by friends; the adolescents hardly drank alone.
The context and expected leisure also influenced this consumption and the type of beverage consumed. Thus, at weekends, the young adults adhered to a consumption pattern in which they consumed large numbers of drinks in a relatively short time period, something commonly undertaken in big cities. This pattern has been called binge drinking and is combined with the preference of liquor. The consumption of these beverages is characterized by lesser quantities, but with higher alcohol content (32). Everything indicated that, for the adolescents, it was part of the range of behavioral options they had at their disposal within their sociocultural context. The adolescents consumed alcohol more frequently when with friends. In that situation, the adolescents somehow felt pressured to do the same as the others. As regards the motive for consumption, fun appeared as the main motive for the adolescents to consume alcoholic beverages. This information suggested that alcoholic beverages were used as a means of sociability, as the act of drinking mainly happened in public places, bars, and parties; done together with other people such as relatives and friends; and was associated with leisure. Below are some examples of reasons the adolescents gave for drinking: “It’s fun. I think drinking is fun” (Rosa, F5); “Fun” (Rosangela, F8); “Because they want to have fun, relax… These things alcohol does to us” (Rosana, F9); “I drink a lot, I drink plenty” (Rodrigo, F1); “I drink to enjoy the evening, invite the girls to dance. If it weren’t for that I wouldn’t have the guts, but as I drink” (Raimundo, F2); “Because they like it. Getting drunk, enjoying themselves, dancing” (Renata, F4). The pleasure of consumption and its role as a mediator of sociability, loss of inhibition and encouragement of peer relations derived from a naturalized culture, characterized by social drinking, curiosity and the desire for social inclusion, which were mixed up in the adolescents’ desire to drink. In addition, the act of starting to drink is considered a symbol of being an adult (33). However, no influential factor alone is responsible for alcohol consumption. Other factors – some to a more limited and others to a greater extent – facilitate the characterization of drinking. In this study, the motive curiosity as a form of consumption figured in only one adolescent’s discourse: “Because I wanted to, I was curious” (Reinaldo, F7). In another study, curiosity was also identified as a motive for adolescent drinking (33). Curiosity rests on easy access to drugs, on propaganda, on symbolic appeals, and on the collective and existential social meanings individuals attribute to the consumption of these substances such as hedonistic gains, violation of rational order or the right to fantasy and the unconscious (34).
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Ribeiro Gomes et al.: Alcohol consumption among adolescents 401
Based on the data presented in this research, the adolescents’ alcohol abuse was also highlighted, in accordance with the following statements: “I drink until I see the light [get sort of dizzy]” (Raimundo, F2); “I only stop drinking when the party ends” (Ronaldo, F3); “I drink a lot! I only stop when I’m drunk” (Rosa, F5). The attitude towards social standards is expressed in the belief that exaggerated consumption is something adolescents do, as a part of the growth process (35). It should be highlighted, however, that inappropriate alcohol consumption can cause dependence and other disorders related to the quantity and frequency of consumption, including social losses, illnesses, use and abuse of other substances and violence, among others (36). As for biological effects, alcohol causes disinhibition sensation, thus encouraging conversation and interaction among peers. Especially, if consumed in greater amount in the same time, alcohol increases sensitivity in stimulating phase as well as tolerance phase depressant. Although this pattern of consumption does not cause harm as intense as those of chronic consumption, impulsivity and loss of reflexes can bring about social impairments, such as engaging in risky sexual behavior and traffic accidents. Poisoning by acute alcohol intake can also generate discouragement, apathy, irritability, decreased motor skills, nausea and vomiting, among others. Therefore, greater attention and
caution should be given in order to understand alcohol consumption-related problems among adolescents, especially because childhood and adolescence are fundamental phases in the structuring process of adult life.
Final considerations In view of the collected data, which generated the texts and the elaboration of the themes that represented the family’s influence on adolescent alcohol consumption, it was concluded that both the family system and the sociocultural context the adolescents are part of can positively and negatively influence alcohol use and abuse simultaneously. Moreover, the family structure and composition, the family interaction pattern, the phases in the lifecycle the family has reached, communication among family members, religion, and hope are components that are directly linked to adolescent alcohol consumption. Thus, they can be targeted in interventions carried out by nurses and other health professionals, with the aim of further improving related care and treatment. Received June 24, 2013; accepted August 26, 2013; previously published online January 22, 2014
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402 Ribeiro Gomes et al.: Alcohol consumption among adolescents 19. Biasoli-Alves ZM. Pesquisando e intervindo com famílias de camadas diversificadas. In: Althoff CR, Elsen I, Nitschke A, editors. Pesquisando a família: olhares contemporâneos. Florianópolis, SC: Pipa-livro, 2004:91–106. 20. Pratta EM, Santoas MA. Família e adolescência: a influência do contexto familiar no desenvolvimento psicológico de seus membros. Psicol Est, Maringá 2007;12:247–56. 21. Brook JS, Brook DW, Gordon AS, Whitmam Cohen P. The psychosocial etiology of adolescent drug use: a family international approach. Genetic, Soc, General Psychol Monogr 1990;116:111–67. 22. Nolte DL, Harris DR. Children learn what they leave: parenting to inspirit values. New York: Workman Publishing, 1998. 23. Mosmann C, Wagner A, Feres-Carneiro T. Qualidade conjugal: mapeando conceitos. Paidéia, Ribeirão Preto, Ribeirão Preto 2006;16:35. 24. Figlie N, Fontes A, Moraes E, Payá R. Filhos de dependentes químicos com fatores de risco biopsicossociais: necessitam de um olhar especial? Rev Psiquiatr Clin 2004;31:53–62. 25. Laranjeira R, Pinsky I, Zaleski M, Caetano R. I Levantamento Nacional sobre os Padrões de Consumo de Álcool na População Brasileira. Uniad – Unidade de Pesquisa em Álcool e Drogas, Departamento de Psiquiatria da Universidade Federal de São Paulo, e Senad – Secretaria Nacional Antidrogas, Presidência da República, Gabinete de Segurança Nacional, 2007. 26. Pillon SC, Luis MA. Modelos explicativos para o uso de álcool e drogas e a prática da enfermagem. Rev Latino-Am Enferm, Ribeirão Preto, 2004:12:676–82. 27. Pechansky F, Szobot CM, Scivoletto S. Uso de álcool entre adolescentes: conceitos, características epidemiológicas e fatores etiopatogênicos. Rev Bras Psiquiatr 2004;26:14–7.
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Betânia da Mata Ribeiro Gomes*, Lucila Castanheira Nascimento, Marta Angélica Iossi Silva, Edemilson Antunes de Campos and Sandra Cristina Pillon
The context of alcohol consumption among adolescents and their families Abstract Aims: Alcohol consumption in adolescence has been an important topic in the study of public health policies. This study aimed to analyze and interpret the influence of the family in teenage alcohol consumption. Materials and methods: A qualitative research was undertaken, using interviews, observation, genogram and ecomap, in order to investigate 22 participants at a Family Health Unit in the city of Recife, Pernambuco, Brazil. The family structure, composition, interaction, communication, and religion of the participants were considered. Results: The results were analyzed using inductive thematic analysis and indicated three themes, namely, the internality of the family: fragility and conflicts; among us: limits, responsibilities and hope; and the decision to drink: fun permeated by risks. Conclusion: The family and sociocultural context of adolescents can positively and negatively influence the use and abuse of alcohol and, therefore, can be a target of intervention in nursing. Keywords: adolescents; alcohol; family; pediatric nursing. *Corresponding author: Betânia da Mata Ribeiro Gomes, Nossa Senhora das Graças School of Nursing, Universidade de Pernambuco, Recife, Brazil; and Interunit Doctoral Program in Nursing, University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil, E-mail: [email protected] Lucila Castanheira Nascimento, Marta Angélica Iossi Silva and Sandra Cristina Pillon: University of São Paulo at Ribeirão Preto College of Nursing, WHO Collaborating Centre for Nursing Research Development, Brazil Edemilson Antunes de Campos: University of São Paulo School of Arts, Sciences and Humanities, University of São Paulo, Brazil
Introduction Alcohol consumption is a cultural matter. It is permitted in almost all societies around the world, and the consequences of inappropriate use affect the population that is considered most at risk: adolescents and young adults (1).
In a 2011 report about the harm alcohol abuse causes, the World Health Organization affirms that alcohol provokes almost 10% of deaths among young people; it corresponds to 320,000 deaths among young people and adolescents per year and is responsible for 9% of deaths around the world in the age group between 15 and 29 years (2). Alcohol abuse imposes a considerable burden of unwanted and very costly problems on societies. In Brazil, the events attributed to alcohol abuse, considered as a multifactorial phenomenon with psychological, biological and social implications, comprise traffic accidents, risky sexual behavior (sexually transmitted diseases, unwanted pregnancy), violence, unintentional injuries, and academic problems (3). Part of these factors fits into the family domain, including the lack of affective involvement between parents and children, separated parents, cultural conflict between generations, and parents’ lack of authority (4). From that interest, we were motivated to seek answers to the following hypothesis: does the family dynamics influence the develo pment of the use and abuse of alcohol among adolescents? In view of evidence that alcohol consumption is a social practice, the theoretical frameworks of Symbolic Interactions and Family Systems Theory were adopted to understand this study. Symbolic Interactionism analyzes human experiences and their interactions and, in family research, is mainly focused on families’ internal functioning (5, 6). Adapted from General Systems Theory (7), Family Systems Theory, when applied to Family Nursing, considers the family as a care unit (6). The systemic approach focuses on the relations among the members of the family system, in an attempt to understand the functioning of each. What happens to each family member affects the system as a whole, thus influencing its behaviors, beliefs, and feelings (8). The aim of the current study was to analyze and interpret family influence in teenage alcohol consumption.
Materials and methods A qualitative research was undertaken. This is generally considered an adequate approach to family research and permits understanding
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394 Ribeiro Gomes et al.: Alcohol consumption among adolescents family processes, as it is concerned with the universe of meanings, with the experiences, values, beliefs, aspirations, and attitudes linked to human relations (9, 10). In this approach, subjects’ specificity can be combined with their sociocultural context and their discourse and practices can be interpreted, based on their certainties, contradictions, and ambiguities (11). The research was developed in Recife, Pernambuco, Brazil. Among the places where adolescents can be recruited in the city, the Family Health Strategy (FHS) was chosen as the place of study. The territory of Recife is subdivided into 94 neighborhoods and, for planning and management purposes, the city is divided into six political-administrative regions (PARs), each of which is subdivided into three microregions (12). Thus, public health system actions (Unified Health System – SUS) in Recife are decentralized through six health districts (HD) that correspond to the spatial division of the six PARs. The Family Health Unit (FHU) Emocy Krause is located in the West of Recife and the families attending at the unit belong to popular classes. Based on the selection of 11 adolescents from 10 families, 22 informants participated in the research, including mothers, fathers and siblings, who complied with the following inclusion criteria: adolescents registered at FHU Emocy Krause; between 14 and 19 years of age; alcohol consumption and/or abuse; and living with family members, independently of the type of family structure, i.e., the families could be nuclear, single-parent, separated parents, reconstituted families, homosexual parents, or families in which the oldest sibling or another relative was responsible for the adolescent, whether biologically related or not. In each family, family members present at the adolescent’s home on the occasion of the first meeting with the family were invited. In the course of the research, interaction with the family and the informants’ discourse indicated whether or not there was a need to include other members in the research. The data were collected through in-depth interviews, guided by questions that were elaborated based on the Calgary Family Assessment and Intervention Model. The genogram and eco-map were elaborated for each family; non-participant observation was used to immerse the researcher into the family environment as a complementary data collection technique (13–15). The interviews with the family were held at each adolescent’s home and, upon request, two families were interviewed at the FHU. Each meeting took approximately 1 h. While two and three meetings could be held with some families, with others, the study problem was explored during a single moment of interaction. To avoid common weak points in family research, such as a lack of clarity that family members and individuals with particular characteristics and that family groups were groups with group characteristics (16), we adopted the following family definition, appropriate to the interactionist perspective: “family is a group of individuals in symbolic interaction, reaching situations with other signifiers or reference groups, with symbols, perspectives, self, mind and ability to take on roles” (17). As it involved human beings, the research project was submitted to the Research Ethics Committee (CEP) at Universidade de Pernambuco, Opinion 050/11, in compliance with National Health Council Resolution 196/96. Once the CEP approved the project and the Recife Municipal Health Secretary granted its official and formal agreement, the study was authorized to be implemented in Health District IV. As a part of the necessary documentation, free and informed consent forms were given to the adolescents and their relatives, which served to orient the study participants. Out of respect for the adolescents, their assent was obtained, along with the consent of their parents or legal representatives, The informants’ names were replaced by fictitious names or identified according to the degree of
parenthood or affinity with the adolescent, in order to guarantee the participants’ anonymity. Names starting with the letter R were used to identify the adolescents, as the index-cases in this study, in combination with the letter F for family, followed by the number that indicated the order of inclusion in the research. For the purpose of data analysis, the inductive thematic content analysis method was adopted (18). Six phases were accomplished: getting familiar with the data, producing initial codes, searching for themes, reviewing themes identified, defining and naming the themes, and elaborating the final report. Moreover, efforts were made to interpret the participants’ discourse and develop a latent, non-explicit analysis, which went beyond the semantic contents of the data, identifying the meaning found “between the lines” (18).
Results The families under analysis had few resources and, as mentioned, came from popular classes. Their occupations reflect non-specialized work with lower remuneration levels. In general, the family providers’ education level was not higher than primary education. The investigation involved the following: single-parent families or families in which the parents got married once and lived with their children, and families whose parents got divorced, remarried, and constituted new nuclear families. The social characteristics of the adolescents who participated in the research, including some particularities of family members, is displayed in Table 1.
Discussion Thematic units Based on the data analysis, three themes were elaborated: the internality of the family: fragility and conflicts; among us: limits, responsibilities and hope; and the decision to drink: fun permeated by risks.
The internality of the family: fragility and conflicts The family context in which the actions and interactions among its members take place, thereby comprising different family structures and compositions and distinct relationship patterns, provides for an interaction environment marked by weaknesses and conflicts. Therefore, this thematic unit is composed. The adolescents’ families revealed diverse family structures, ranging from traditional to single-parent families. In three of the single-parent families,
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Renato
Ronaldo
Renata
Rosa
Ricardo
Reinaldo
Rosangela
Rosana
Rafael
F2
F3
F4
F5
F6
F7
F8
F9
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F10
18
18
18
16
19
19
17
15
17
Dropped out
Education
1.60
1.60
0.96
1.12
1.68
1.68
1
Monthly income (minimum wage)
Non-practicing Catholic
Pension + Family Program Grant 2.08
SENAI monitoring grant 0.51 Non-practicing Catholic
Practicing Catholic
Practicing Evangelic
Non-practicing Catholic
Non-practicing Catholic
Non-practicing Catholic
No religion
No religion
No religion
No religion
Religion
Adolescent, mother and two siblings Mother and siblings Beer Adolescent, mother and siblings Mother and siblings Beer Adolescent, mother and siblings Mother and sibling Beer, rum Adolescent and mother Father, mother, and Beer Adolescent and siblings mother Father and sister Beer, Adolescent and whisky father Father, mother, and Beer Adolescent and siblings mother Father, mother, and Ice Adolescent sister Father, mother, and Beer, Adolescent daughter vodka Mother and brother Beer Adolescent and mother Mother and siblings Beer Adolescent and sister
Beverage Participants consumed
Mother and siblings Beer
Lives with
Unfinished primary education Single Young adult and adult education Single Remedial primary education Single Unfinished secondary 8-month-old son education Single Young adult and adult education Single Finished secondary education Single Unfinished secondary education Single Dropped out 4-month-old daughter Single Unfinished secondary education Single Dropped out
19 Single
18 Single
Age, Marital status and years children
Source: Field diary and interviews.
Raimundo
F2
Rodrigo
F1
Family Adolescent identification index-case
Table 1 Characterization of adolescents according to age, marital status, education, family members living with the adolescent, beverage consumed, family members participating in the research, religion, and monthly income.
Ribeiro Gomes et al.: Alcohol consumption among adolescents 395
396 Ribeiro Gomes et al.: Alcohol consumption among adolescents the father was absent due to death or abandonment and, in one case, the mother had passed away. Despite the particular family compositions, the interpretation process revealed common aspects, which permeated the adolescents’ experiences. In general, the adolescents’ family lives were marked by conflicts among relatives, violence among parents and other family members, separation, and death. Three adolescents mentioned having witnessed their father beat up and humiliate their mother. One of them added that his older brother copied this psychologically and physically aggressive behavior. These adolescents learned about this way of acting at home. This is a cycle perpetuated from one generation to another. The domestic violence in these families is associated with variables in the family context, such as marital disagreement, alcohol abuse by the parents, and the experience of separation and loss. In addition, after a divorce in one of the participating families, the mother became fully responsible for the double activity of housekeeper and family provider, and this new context entailed the alcohol consumption habit. The divorce caused negative reflexes, emotionally destabilizing the woman and making her look for compensation in alcoholic beverages, according to the statement: “I almost turned into an alcoholic” (Mother, F9). For this mother, being an alcohol addict meant suffering and having the feeling that she was responsible for the possibility of having triggered her own daughter’s alcohol consumption. The mother reported that she considered her drinking behavior as a negative example for her. Moreover, women who become addicted to alcohol suffer from an intensified prejudice, considering gender differences in alcoholism, as reflected in men’s drinking behavior, which is more socially acceptable than for women (19). In any case, family members’ inappropriate alcohol consumption habit favors its introduction into the children’s daily life, representing a predictive factor for the latter to assimilate it as a way to cope with the problems of reality. In fact, the children of alcoholic parents can learn to interact within the social context, using the artifice of alcohol in a way similar to their parents. However, this is not always the rule, considering that the children may also develop an aversion against alcohol, as they perceive its harmful results. Unpredictable critical events that happened in these families (e.g., separations, illnesses and losses, among others) can strongly affect the family context, which may bring about pressure and disorganization. Experts call this a family functioning crisis, which needs a solution to maintain family health. The authors highlight, however, that keeping the family healthy does not only depend on overcoming crises, but mainly on a
good relationship among the family members, including the marital relation, as it directly influences the children’s development (20). Analyzing actions and interactions among family members implies the consideration of families beyond a group of people linked by blood bonds. This presupposes the inference that, at the heart of their relations, members are joined by affinities, feelings and moral responsibility, and are permeated by mutual representations, practices, and relations of mutual obligations. These obligations, in turn, are organized according to the age range as well as generational and gender relations that define the person’s status in the system of family relations. The first noteworthy detail was the fact that the adolescents demonstrated difficulties in talking about their feelings and about the way the family members relate mutually, with the extended family and with the community. Often, monosyllabic expressions or few words were used to express themselves about a given aspect. Some adolescents were able to further elaborate their answers, while others limited themselves to short answers and, sometimes, not even a word. These adolescents’ low education level may have hampered their expression, due to their limited vocabulary. This may also be characteristic of the adolescent phase in the lifecycle, considering that teenagers prefer to talk to their peers. In other cases, it may perpetuate some family patterns learned as a consequence of living in an environment, in which individual and family weaknesses are exposed, aside from conflicts and various types of violence wherein silence can constitute a defense mechanism. The following statements express this: “I have nothing to say about him. He’s a good person” (Rosa, F5); “If you want to ask about me, [feel free]. No, I don’t want to talk about my family” (Rodrigo, F1). The adolescents interviewed revealed a range of misunderstandings and dislikes in the family. Renata mentioned that the daughters were always present during their parents’ fights; the father hit and the mother reviled to defend herself. She summarized the situation as follows: “My father likes to attack my mother. My mother’s always trying to put the house in order and my father was always choosing his friends’ side” (Renata, F4). Ricardo commented that his parents lived together, but in a turbulent relationship, because the father “rebases” the mother (Ricardo, F6). Rosangela discussed the reason for her parents’ fight from her own viewpoint: “Well, they fight, my father spends all of his time in the streets, gambling. He keeps on asking my mother for money to play and buy cigarettes” (Rosangela, F8). The relationship between Rafael’s mother and father was also conflicting. There were always fights at his home: “My mother used to drink and fight with my father” (Rafael, F10).
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Ribeiro Gomes et al.: Alcohol consumption among adolescents 397
Concerning their relationship with their father, only four of the adolescents interviewed mentioned a positive affective relationship: “He was loving to us. He liked to give advice.” (Ronaldo, F3); “It was good. We used to watch games together” (Raimundo, F2); “My father was thoughtful” (Renato, F2); “We used to get along well. He was like my sister, helped me to do things, taught me, played soccer with me” (Rafael, F10). These four adolescents’ fathers were all deceased. By contrast, other teenagers’ reports demonstrated bad relationships with their paternal figure. They considered that their fathers did not represent any model behavior: “My father is aggressive, absent and I haven’t seen him for quite some time” (Rodrigo, F1); “The relationship with my father is bad, he’s aggressive, hysterical. I haven’t talked to him for some time” (Ricardo, F6); “He used to come to our house. Now he’s living with his family” (Rosana, F9). His father’s abandonment widened the gap between him and Rodrigo, who affirmed that he had not seen his father for some time. In Ronaldo’s case, his mourning about the recent loss of his father due to death may have mitigated any feeling deriving from his parents’ earlier divorce. The adolescents harbored a sense of longing for their father or mother who had passed on. The following reports illustrate this: “I used to go and see my father, every day. I couldn’t spend a day without seeing my father or I’d get sad. I miss him a lot [cries]” (Ronaldo, F3); “The only thing, if I could change it, was my mother being alive” (Rosa, F5). A mother talked about the changes in her children’s education after her husband’s death. His alcohol abuse permeated hers and her children’s lives, culminating in his death. She gave up her passive way of being and the exercise of authority and setting of standards in the family sphere strengthened her. In that sense, the absence of the father figure ended up building different relations in family life, making the mother more demanding, intolerant and inflexible, in the attempt to fill the void the father left behind in the relationship with his children. The quality of the relations established between parents and children influences the orientation of family principles, attitudes, and practices. The involvement, support, and affection between parents and children are a prerequisite for the children to identify themselves with their parents, thus increasing the chances of adopting them as behavioral models (21). The children absorb any model the parents transmit through their behavior, their attitudes, and expressions of feelings in daily life, as the parents are their first influential models. What was not taught in the course of the children’s development but which they learned affects their community life as part of society (22). Although angry and suffering, these
adolescents are not free from identification, even if negatively, with their family members. Thus, often, they display the same violent behaviors, in an ambivalent process of distancing and approximation, through similar ways of acting. Their statements reveal the behavioral model learned: “We’ve never gotten along well. Ever since I was little, always fighting, she used to hit us. Very intolerable, she used to talk too much. Then I fought with her, and she left [referring to his maternal grandmother]” (Rodrigo, F1). The grandmother does not live with the family anymore and, according to Rodrigo’s mother: “She left because Rodrigo hit her” (Rodrigo, F1). Despite the prevalent expressions of weaknesses in the families, to give an example, in terms of difficulties in maintaining one’s life, continuing one’s studies, communicating among family members, and experiencing conflicts among relatives, also with the mothers, a strong bond was observed between some teenagers and their mothers. The adolescents described the quality of the relationship with their mothers as appropriate. Sometimes, the mothers were asked to serve as a source of support in view of the unique need to open up to the other; on other occasions, they served as counselors and protectors of their offspring, alerting them about the risk of getting involved with drugs and inappropriate company. On the one hand, in the families under analysis, half of the mothers had a paid job to complement the family income, which came from the father or the help of another family member. Thus, the mothers were absent from home, which affected the children’s supervision. This absence represented another weakness expressed in this study, which affected the adolescents’ health. On the other hand, the adolescents valued the mothers who generally provided for their family alone or somehow contributed to sustaining the family, as women who sacrificed themselves and gave everything they have to benefit their children. In a broader sense, the mothers who offered affection, looked out for their children, and strengthened their family were similarly valued in their roles and positively influence the adolescents. The relation between parents and children reveals the strongest bond in the family context. It is inside the family that values, standards, symbolic codes and rules of conduct are transmitted, with parents helping their children to grow up healthily and conquer maturity and autonomy. According to Symbolic Interactionism, the family represents a group of people who interact and create their own set of symbols and meanings. These will influence the formation of their members’ identities, the transmission of family values and the learning of the social roles each member is supposed to play (23). These factors, which
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398 Ribeiro Gomes et al.: Alcohol consumption among adolescents affect the family’s functioning, are involved in the social culture the families are inserted in and the culture they identify themselves with, that is, lifestyle, values, ideals, beliefs and practices that are transmitted from generation to generation, influencing the family’s behaviors and health (6). In a broader context, family balance is aimed for, with a strengthened and healthy structure that promotes harmony and solidarity in the family context. This perspective was apprehended from the adolescents’ desire to somehow modify their families, so as to respond to their expectations of participating in a healthy social life with their members. In addition, as revealed by the desire to obtain abundant financial resources, adolescents tended to respect and value individualities and motivations for life, apart from attention to material existential needs.
Among us: limits, responsibilities, and hope This theme refers to the adolescents’ contact with alcohol consumption, facilitated by the presence of drinks in the family context and their offering by peers. “Among us”, that is, in the interaction among family members, relates to the loss of family structure experienced by the adolescents due to different kinds of conflicts, especially those involving family members’ alcohol abuse; it sets the limits of the family’s own actions, helping them understand how the adolescents became acquainted with alcoholic beverages. Nevertheless, the family does not refuse to assume its responsibilities of looking out for its members, especially for the adolescents, who are already vulnerable to alcohol consumption. Hope, often nourished by religion and aspirations, keeps alive the motivation to maintain the family and its objectives, reinforcing the culture of protecting its members and the private environment, thereby capable of finding its own resources to cope with the adversities of life. The teenagers found alcohol use at their own homes. Through their experiences, they took part in their parents’ relation with alcohol and apprehended that, within that environment, most situations caused suffering and losses: “My father taught me to drink. He put a glass of beer in front of me, then I took it and drank. So I liked it and started” (Rodrigo, F1); “He was the one who drank, every day. He got sick” (Raimundo, F2); “When he gets home from his current job, if he gets home early, he immediately goes to look for a stand to drink. My mom quit, because she got sick” (Renata, F4); “In the last three months, he started drinking a lot. He didn’t use to before. It’s because he lost his job. My father was smart, he had a curriculum. Then he stopped looking for a job and decided to seek another way out. He got into
the wrong business [drug trafficking]. Then, [when] he started selling more than the others, [they] got jealous and killed my father” (Ronaldo, F3). As the parents’ attitudes towards their children can be both protective while stimulating the use and abuse of alcohol and other drugs, parents’ alcoholism can play a mediating role in the inter-generational transmission of these behaviors. Growing up in a family environment ruled by alcohol abuse facilitates the development of somatic and emotional problems, low self-esteem, low educational performance, behavioral problems and delinquency, among others, which can ultimately lead to alcoholism (24). The I National Survey on Alcohol Consumption Patterns in the Brazilian Population found that 24% of the interviewees are frequent or binge drinkers (once or more per week, more than five doses each time), 48% of the population described themselves as abstemious, and 29% affirmed infrequent drinking. These data, however, reflect not just a habit, but a social problem: 28% of the population already experienced binge drinking and 12% suffer from some alcohol-related problem. Physical problems are cited most frequently, followed by family problems. The research also found that Brazilians start to drink at an increasingly young age, with 24% of the adolescents drinking at least once per month (25). Studies appoint different problems to explain alcoholism, including the hypothesis of genetic vulnerability, that is, the probability of becoming alcoholics is higher among children of alcoholic parents. Others ascribe the habit of consuming alcoholic beverages and other psychoactive drugs to social learning (26). Since a young age, adolescents exposed to a model of parents who consume alcohol, and who often give their parents beverages to try out, see this habit as a part of fraternization and release of daily tensions, which can cause dependence. Yet others consider the maturity of the brain structures responsible for inhibiting impulses, which are not fully closed during adolescence, making young people more vulnerable when in contact with the genetic or social learning hypothesis (27). Avoiding contact with drugs during the most vulnerable period gives the brain time to complete its maturing process and to put in practice strengthening measures to cope with environmental situations, allowing the adolescents to find alternatives ways of satisfaction in life. Concerns should be focused on findings ways to assist and protect the adolescents, in actual risk situations or not. Becoming an adult is not only a mere matter of time, of evolution in the lifecycle – it also involves a slow construction of a series of events relevant for this period. This construction is not the adolescents’ sole undertaking, but
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Ribeiro Gomes et al.: Alcohol consumption among adolescents 399
the sum of their family and social history. If the conditions experienced are satisfactory and more structured, they will be better able to come out of this period enriched and with greater possibilities of facing the adult world (28). Family functioning is focused on the needs of its members that should be met through the available health resources. The family system offers conditions to monitor and develop its members’ health-disease process (6), provided that it is properly stimulated and accompanied in this sense (29). Another part of this theme is the limit of family action, which surrenders to the adolescents’ approximation with alcoholic beverages. Nevertheless, the family does not escape from its responsibilities for its members, like encouraging continuing education, orienting the choice of appropriate company, offering advice and teaching principles to organize home and healthcare. Responsibilities linked to the education process extend across the lifetime, and its long-term effects are not easily changed because they are a part of people’s education system. The parents’ concern with their children’s freedom is related to their exposure to risk behaviors, which can emerge in function of the curiosity that is characteristic of this phase of life. This is the case, for example, with the consumption of alcohol and other drugs, which has become a source of concern because of its increased prevalence among adolescents nowadays. In this study, the family way of life derived from different emotional climates among its members, such as acceptance/love, rejection/anger, and indifference. The lack of limits and responsibilities in the relation between parents and children served as a condition for the development of role conflicts in the family system and involvement with alcohol use and abuse, as observed in the following report: “I set the limits at home, like waking up early, time to get home at night, but these are not always complied with. I consider that I am the authority because I stay at home” (Mother, F1). The mother also considered that the agreements about the children’s participation in housework were always violated, putting a burden on herself, her daughter, and her youngest son. Responsibility and limits are also terms that indicate the quality of using authority in the relation between parents and children. The limits of family action were also identified through the parents’ disrespect for other family members. In these cases, alcohol abuse among fathers and mothers and violence, mostly practiced by the fathers, broke any possibility of productive interaction, which also entailed negative repercussions for the entire family system. The opposite was also observed. The adolescents demonstrated disrespect for their parents’ authority and surpassed their limits in different ways, like alcohol use
or abuse, neglect of housework and personal care. As a consequence of this process, fathers’ and mothers’ feelings of impotence were identified, mainly because they did not know how to use their authority appropriately; as opposed to feelings of hope, often resting on religion, which brought the possibility of a more promising future. As regards religiosity, the study results demonstrated that four adolescents did not have any link whatsoever with any religion; five of them mentioned having a religion but considered themselves non-practicing, and two identified they had a religion and were practicing. Catholicism was the most mentioned, but not practiced, in accordance with other studies (30). Considering religion in the family, most mothers believed in a religion and underlined its importance in their lives. Five families indicated the Evangelic religion. Catholicism appeared in four families’ reports, although less practiced, as opposed to Evangelical and Protestant religions, with higher attendance and participation levels. Evangelical and Protestant religions appear as the most cited and practiced ones in studies that assess the consumption of alcohol and other drugs among adolescents (30). Having a religion can inhibit alcohol consumption and serve as a form of protection. Religion can also indicate effects against involvement with alcohol, such as the sense of belonging to a community of values and life projects and ethics, as well as choices that are not necessarily exclusive to ideologies and religious practices. Religion can also favor the feeling of hope, which entails future perspectives, that is, the establishment of a target or plan in life as a form of personal accomplishment. This positive influence, manifested through desires and dreams about a better future, relieves difficulties and exerts positive influence on the adolescents, favoring the maintenance of healthy aspects of life. In this study, parents’ aspirations for their children and vice-versa were identified to give lightness to possible difficulties that could be faced by the family. The parents want their children to be more successful in life than themselves, at the same time as the adolescents acknowledge the need to exert efforts to reach the objectives their parents were unable to achieve. Interrupting these aspirations may make the task of overcoming barriers and challenges more difficult. The aspirations identified in the discourse included the conquest of a qualified job, the possibility of studying, and building a family. Working, having a profession, and building a family emerged in some adolescents’ future plans. It can be inferred that the adolescents rested their future on family system and work values, as these possibly represented stability and security as the only course for their future (20).
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400 Ribeiro Gomes et al.: Alcohol consumption among adolescents Thus, the family does not only exert direct influence over the acquisition of beliefs and values, but also plays a central role in the construction of the plan the adolescents define for their lives. This explains why it is at the heart of the family organization that the personal project generally starts, based on which these young people go for their dreams and objectives (20). Some adolescents experienced the need to give up their plans or leave them in the background, at least temporarily. In these cases, the need to start a paid job and contribute to the family income motivated the event. This scenario meant that the parents were apprehensive about the future. On the one hand, work played a central role as a reference point, as it was a constant concern. On the other hand, many participants had an irregular or unstable job, a reality in both the adolescents’ and their parents’ lives, many of whom were unemployed. Paradoxically, work can be a means to take distance from activities considered inappropriate, such as alcohol and drugs use, as well as to guarantee access to them. In any situation, support from the family system was considered fundamental in this context.
The decision to drink: fun permeated by risks This theme relates to the context of the adolescents’ alcohol consumption and/or their motivations to drink, summarized as pleasure and fun, without ignoring the risks they are exposed to, mainly because their families are concrete examples of the repercussions of alcohol abuse. Different factors, such as the family and social context, expectations and beliefs, commercial availability and easy access, influenced the adolescents’ drinking behavior. Alcohol consumption was generally intense, took place at weekends, and depended on the resources available. The places in which the adolescents preferred to consume alcohol were bars, parties, and shows. They also used to drink at home, in the company of siblings and family members. The beverages the adolescents most frequently mentioned were beer, followed by liquor, and such alcoholic drinks as ice and energy drinks. Other studies also identified beer and liquor as the most consumed beverages, with the latter consumed after the beer, due to their higher alcohol contents (25, 31). According to the teenagers, alcohol represented a factor of social aggregation, which was an internal factor of gaining a more important social image and developing an identity that includes the assumption of adult roles. In most cases, alcohol consumption started among family members, followed by friends; the adolescents hardly drank alone.
The context and expected leisure also influenced this consumption and the type of beverage consumed. Thus, at weekends, the young adults adhered to a consumption pattern in which they consumed large numbers of drinks in a relatively short time period, something commonly undertaken in big cities. This pattern has been called binge drinking and is combined with the preference of liquor. The consumption of these beverages is characterized by lesser quantities, but with higher alcohol content (32). Everything indicated that, for the adolescents, it was part of the range of behavioral options they had at their disposal within their sociocultural context. The adolescents consumed alcohol more frequently when with friends. In that situation, the adolescents somehow felt pressured to do the same as the others. As regards the motive for consumption, fun appeared as the main motive for the adolescents to consume alcoholic beverages. This information suggested that alcoholic beverages were used as a means of sociability, as the act of drinking mainly happened in public places, bars, and parties; done together with other people such as relatives and friends; and was associated with leisure. Below are some examples of reasons the adolescents gave for drinking: “It’s fun. I think drinking is fun” (Rosa, F5); “Fun” (Rosangela, F8); “Because they want to have fun, relax… These things alcohol does to us” (Rosana, F9); “I drink a lot, I drink plenty” (Rodrigo, F1); “I drink to enjoy the evening, invite the girls to dance. If it weren’t for that I wouldn’t have the guts, but as I drink” (Raimundo, F2); “Because they like it. Getting drunk, enjoying themselves, dancing” (Renata, F4). The pleasure of consumption and its role as a mediator of sociability, loss of inhibition and encouragement of peer relations derived from a naturalized culture, characterized by social drinking, curiosity and the desire for social inclusion, which were mixed up in the adolescents’ desire to drink. In addition, the act of starting to drink is considered a symbol of being an adult (33). However, no influential factor alone is responsible for alcohol consumption. Other factors – some to a more limited and others to a greater extent – facilitate the characterization of drinking. In this study, the motive curiosity as a form of consumption figured in only one adolescent’s discourse: “Because I wanted to, I was curious” (Reinaldo, F7). In another study, curiosity was also identified as a motive for adolescent drinking (33). Curiosity rests on easy access to drugs, on propaganda, on symbolic appeals, and on the collective and existential social meanings individuals attribute to the consumption of these substances such as hedonistic gains, violation of rational order or the right to fantasy and the unconscious (34).
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Ribeiro Gomes et al.: Alcohol consumption among adolescents 401
Based on the data presented in this research, the adolescents’ alcohol abuse was also highlighted, in accordance with the following statements: “I drink until I see the light [get sort of dizzy]” (Raimundo, F2); “I only stop drinking when the party ends” (Ronaldo, F3); “I drink a lot! I only stop when I’m drunk” (Rosa, F5). The attitude towards social standards is expressed in the belief that exaggerated consumption is something adolescents do, as a part of the growth process (35). It should be highlighted, however, that inappropriate alcohol consumption can cause dependence and other disorders related to the quantity and frequency of consumption, including social losses, illnesses, use and abuse of other substances and violence, among others (36). As for biological effects, alcohol causes disinhibition sensation, thus encouraging conversation and interaction among peers. Especially, if consumed in greater amount in the same time, alcohol increases sensitivity in stimulating phase as well as tolerance phase depressant. Although this pattern of consumption does not cause harm as intense as those of chronic consumption, impulsivity and loss of reflexes can bring about social impairments, such as engaging in risky sexual behavior and traffic accidents. Poisoning by acute alcohol intake can also generate discouragement, apathy, irritability, decreased motor skills, nausea and vomiting, among others. Therefore, greater attention and
caution should be given in order to understand alcohol consumption-related problems among adolescents, especially because childhood and adolescence are fundamental phases in the structuring process of adult life.
Final considerations In view of the collected data, which generated the texts and the elaboration of the themes that represented the family’s influence on adolescent alcohol consumption, it was concluded that both the family system and the sociocultural context the adolescents are part of can positively and negatively influence alcohol use and abuse simultaneously. Moreover, the family structure and composition, the family interaction pattern, the phases in the lifecycle the family has reached, communication among family members, religion, and hope are components that are directly linked to adolescent alcohol consumption. Thus, they can be targeted in interventions carried out by nurses and other health professionals, with the aim of further improving related care and treatment. Received June 24, 2013; accepted August 26, 2013; previously published online January 22, 2014
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