Adolescents strive for freedom and autonomy; thus, communication with their parents needs to be enhanced. Building solid healthy relationships at this stage of their lives is of utmost importance to help them cope with the changes and challenges they are experiencing. The purpose of this chapter is to explore the parent-adolescent relationship in the substance dependency field. The focus is on the relationship between parents and their adolescents who have a substance use disorder. Parenting adolescents poses its own set of challenges, making it difficult to build and maintain healthy parent-adolescent relationships. We argue that although adolescent substance use disorder has been extensively researched, the relationship between parents and adolescents with substance use disorder has surprisingly not received the same attention. It is this gap that this chapter seeks to address. With this in mind, the ecological systems theory was employed here to shed light on the importance and significance of developing healthy parent-adolescent relationships. The findings show that the parent-adolescent relationship primarily informs the daily living of both the parents and the adolescents. The parent-adolescent relationship is therefore very important as it represents whole-family functioning.
- substance misuse
- substance use disorder
The parent–adolescent relationship is one of the most important relationships in the life of an adolescent. During this stage, many changes take place in the parent–adolescent relationship. Differences in opinion may at times exacerbate conflict between adolescents and their parents. Parents want to be protective of their adolescents while adolescents feel controlled. Besides an increase in conflict, adolescents find their parents less supportive in early to middle adolescence . Parents also gradually relinquish power and control over the course of adolescence. Adolescents tend to resort to substance use and misuse for the same reasons as adults mainly for stress relief and enjoyment; however, with adolescents, there may be additional reasons such as the desire to take risks, demonstrate independency, and the need for approval from friends, peer pressure, curiosity, demonstration to adults that they can make their own decisions, and reaction to parental styles . In terms of the latter, parenting styles have been linked to adolescents taking substances . This is confirmed by Brewer  who attests that parenting behaviours such as parental involvement, monitoring of children, and inconsistent discipline play a role in adolescent substance use. In the quest to distinguish the two parenting styles, Bares et al.  caution that the authoritative parenting style is a protective factor, while the neglectful style is a risk factor for adolescents. Amidst all these changes, in striving for autonomy and less parental control, and in their search for a sense of belonging, adolescents often get caught up in the web of substance misuse. Parents try to instil discipline hoping that this will put the child on the path to success and help them to become responsible adults. Conversely, these acts of discipline have an adverse effect, sometimes even increasing the risk of adolescents using substances.
Substance use disorder among adolescents is a major problem not just in South Africa but the world all over, affecting young people from all races . In sub-Saharan Africa, studies have confirmed that there is a growing epidemic of substance abuse among adolescents showing approximately 41.6%, with the highest rate in Central Africa at 55.5% . In South Africa, 2018 estimates indicated that 376,000 adolescents aged 12–17 were recorded to be using hallucinogens and heroin . This data reveals the high prevalence rates of substance use by adolescents, exacerbating the concerns of parents. Many South African adolescents are dependent on, experimenting with, or misusing substances . Often adolescent substance use disorder can be attributed to difficulties in upbringing. However, the dearth of studies on the parent-adolescent relationship where the adolescent is misusing substances is confirmed by Hoeck and van Hal  and Waini . From an ecological systems perspective, both parties—the parent and the adolescent—need a lot of support from the family, groups, and the community at large. For this reason, by means of this chapter and our research, we have endeavoured to develop, understand, and further explore the relationship of parents who are living with adolescents with substances use disorder in the realm of the social science fraternity.
This chapter begins with some basic information on the adolescence developmental stage. This is followed by an exploration of the relationship between the parents and the adolescent with substance use disorder. Particular attention is given to the parent-adolescent relationship where the adolescent is involved in substance misuse. In addition to a general discussion on the topic, the chapter then considers a number of factors that hamper the parent-adolescent relationship. Finally, some conclusions are drawn based on the above literature and discussion.
1.1 Adolescent stage
Adolescence is a crucial developmental stage to build a healthy parent–adolescent relationship. It is also an important transitional period in the development of a child. Although striving for and seeking greater independence, the adolescent is still in need of a warm and close relationship with her or his parents. Adolescence is a period of mostly biological and psychosocial changes, which might have a significant impact on the parent-adolescent relationship. During this stage, adolescents and their parents are faced with the challenge of learning and recognising new responsibilities and changes in their relationship. Furthermore, in this transition phase, progressively less time is spent at home and with their parents, as adolescents push for greater freedom and independence . They begin to test parents’ rules, boundaries, and role expectancies. Intense peer pressure heightens conflict as family beliefs and practices are questioned. Struggling with a sense of inferiority, they constantly seek a sense of belonging. As they make space and privacy demands, conflict with parents may increase. With these changes come crucial questions regarding who they are, what they want, and what they need. During this period, parents and adolescents may experience more communication difficulties and challenges in building their relationship. Good and open instead of bad and closed family communication can contribute to their relationship, as well as to the adolescent’s development and self-esteem. The causes of substance abuse among adolescents cannot be singled down to one cause. Substance abuse is associated with different factors including peer pressure, boredom, low self-esteem, experimenting, economic factors, and poor performance academically . On the other hand, poor parent-adolescent communication, compounded by external forces such as genetic vulnerability, environmental stressors, social pressures, individual personality characteristics, and psychiatric problems, may contribute to the adolescent misusing substances. Furthermore, the literature review [4, 13] reveals that parenting styles that include low parental involvement, inconsistent discipline, and poor monitoring of adolescents can lead to teens having mood disorders and depression. It is therefore an undisputed fact that having a good relationship and more open communication with the adolescent will yield more positive results. In other words, the quality of the parent-adolescents relationship—whether good and open—or bad and closed—may lead to adolescent substance use disorder.
1.2 The use of substances by adolescents
The use of substances by adolescents may be devastating for parents, particularly as they begin to find them exhibiting unpredictable and uncontrollable behaviours of smoking and drinking substances more frequently. Consequently, they perceive their adolescents as being difficult children, which in turn challenges parent-adolescent interaction, affecting the quality of their relationship. The importance of this cannot be understated. The quality of the parent-adolescent relationship may serve as a buffer against future problems such as substance misuse and substance use disorder. Parents might feel like their lives revolve around their substance-dependent adolescent as they are in constant need of support. In light of this background information, it can be deduced that the parent-adolescent relationship is in most cases faced with uncertainties and mismatch of communication that can lead to disagreements and further conflict. In families where adolescents are using and misusing substances, the parent-adolescent relationship may be negatively impacted. The following section discusses factors that hamper the parent-adolescent relationship.
1.3 The parent-adolescent relationship in the midst of substance use disorder: hampering factors
The first hampering factor to consider is tension in the parent-adolescent relationship. As detailed earlier, adolescents have a drive to seek independence and achieve greater autonomy. The stress of having an adolescent with substances use disorder may cause problems between parents as they might also be in disagreement on how to handle the adolescent with substance use disorder. The ensuing conflict may result in a breakdown of the marital relationship, perhaps even lead to separation or divorce in some cases. In such a situation, the adolescent will end up with one primary caregiver, usually the mother. To earn an income and make a living, she may have multiple jobs requiring her to spend hours away from the home. As a result, the adolescent may be left unsupervised and on their own for long periods of time. Without having curfews and being left to their own devices, they are vulnerable and exposed to undesirable influences, such as gang membership and drug use. It becomes difficult for the family to continue with their lives without taking into consideration the life of the adolescent with a substance use disorder. Furthermore, the emotional burden of having a child that is dependent on chemical substances has a significant impact on the health and wellbeing of parents as they constantly worry about their child.
Adolescents are particularly sensitive to control issues and thus become extremely rebellious. Parents sometimes feel they must choose between their partner/spouse and adolescent with substance use disorder. To support this further, Waini  states that parents often have disagreements on how to deal with their adolescents’ addiction. Increased parent-adolescent conflict often spills over into the relationship between parents, causing marital conflict and discord between parents, creating high levels of tension in the family. There is thus a clear link between adolescents’ addiction and distressed parental and family relationships. Arguments often erupt over how the child needs to be raised, with one parent sometimes feeling that the other has been too lenient or even spoilt the adolescent that is misusing substances. Further eruptions revolve around how the troublesome behaviour of the adolescent should be managed. Communication between parents becomes strained and abrasive as they struggle to agree on ways to deal with and manage their substance-abusing adolescent. Parental conflict and tension between the parents may also cause deterioration in the father–adolescent relationship. However, with constant attention being focused on the adolescent with substance use disorder, these families often end up broken and divided . Supporting this, Winters et al.  contend that having an adolescent with substance use disorder within the family can disrupt the entire family’s life by arousing complex emotions, fracturing family values, and advancing family dysfunction.
The second factor hampering the parent-adolescent relationship is self-blame. Overcome with guilt, parents are often angry at themselves for focusing more on work and other related issues than spending time with their adolescent children. They thus blame themselves for their child’s misuse of substances. In this regard, Barlow  opines that parents often report feeling guilty and responsible for their adolescent’s substance-use habits and behaviour, believing they failed in their role as a parent. As a result, they feel ashamed, angry, and even guilty about their adolescent’s use of illicit substances. Dreyer  reiterates that parents often blame themselves for their child’s behaviour, or they may even cover up for their adolescent child so that he/she does not have to take responsibility for his/her actions.
Thirdly, family detachment places the adolescent in the vulnerable position of experimenting with and being addicted to chemical substances . According to Segal et al. , divorce and marital problems have a negative impact on children. Adolescents who struggle to deal with the loss of the intact family are particularly affected, often leading to acting-out behaviours, including the misuse of substances. In reflecting on dysfunctional and blended families, Barnard  and Dreyer  note that adolescents within such families may be vulnerable to substance misuse as they lack love and care they need from their biological parents. However, this is not the case with all families. Parents may feel that they have failed their adolescents and themselves, believing that family problems and divorce are the cause of their adolescent child’s substance use disorder.
Fourthly, feelings of helplessness accompany the parent-adolescent relationship: Adolescents usually want to do things their own way—it’s either their way or the highway. Parents at this point often express a sense of helplessness, feeling that they have tried all they can to help their child by either booking them into a rehabilitation centre or providing constant counsel and assistance, but to no avail. These feelings are further compounded by their inability to control the behaviour of their adolescents, which in turn has a direct impact on the family unit. It should be noted that substance misuse does not only affect the person who is abusing it, but also the lives of their family members, which can become strained as the parents begin to feel angry, anxious, and even guilty about the situation . Parents of adolescents with substance use disorder typically experience significant hardships as they are unsure of how to deal with their delinquent adolescent and often receive limited support and assistance from family, friends, or the community.
Fifthly, parents might find it difficult to trust their adolescent to make their own decisions regarding important matters like career choice, relationships, and other significant issues. However, an adolescent with a good healthy parent-adolescent relationship will be able to make those crucial choices and request assistance when he/she needs. When parents reject their adolescents for not heeding their advice, they risk impairing their relationship with their adolescent.
The last point looks at the psychological effects of the parent-adolescent relationship. Adolescent substance use disorder places a heavy burden on the physical health, mental health, and general well-being of families, especially the parents . Raising a responsible adolescent requires a lot of effort and time, and if an adolescent misuses substances, the household experiences constant conflict and continual crises. Adolescent substance use disorder causes severe strain on parents and this causes parents to experience negative psychosocial functioning, including higher rates of depression, and a range of negative feelings, such as anxiety, guilt, tearfulness, and confusion [9, 23]. Parents of adolescents abusing substances may constantly worry about the well-being, safety, and whereabouts of their children. They may also experience additional strain due to the increased financial burden associated with their belongings being stolen by their substance abusing adolescent. Parents may even unknowingly enable the adolescent to continue abusing substances by covering up for them, making excuses for their behaviour, supplying them with money to buy more drugs, or even denying that they have a problem. In actual fact, some parents are physically abused by their adolescents when they require money to buy more substances [14, 24]. When adolescents do not get the support they need from their parents, they may turn to their peers.
From the above background, it can be deduced that the parent-adolescent relationship needs to be nurtured. Parents need to be involved in the lives of their adolescent and they should be aware of their friends, activities, and where they socialise . Adolescents need particularly positive and supportive relationships with their peers and family. Parents have difficulty trusting their substance-misusing adolescent, especially because of their lying and stealing behaviours. Barnard  indicates that it is a simple yet largely ignored truism that substance use disorder has a profound impact on families. According to Mhlongo , parents often accept that adolescents in general are typically rebellious, insecure, and emotionally labile, and do not recognise these as possible symptoms of substance use disorder until it is too late to manage the problem appropriately. By the time parents realise that their adolescents are abusing substances, they may already be caught up in the web of addiction.
2. The theoretical framework
According to Zastrow and Kirst-Ashman , ecological systems theory looks at how people adjust to the demands of the environment, at the needs and growth of the people, and at the individual, group, and community at large. In addition, Schenk, Mbedzi, Qalinge, Schultz, Sekudu and Sesoko  affirm that ecological systems theory focuses on the individual and on understanding the individual holistically, with particular attention given to how individuals are influenced by the environment, including the people they interact with. The ecological systems theory is based on how parents relate to their adolescents who are abusing substances and other systems in the environment, paying particular attention to how individuals and systems influence each other. Emphasis is therefore not only on the behaviour of the individual, or in this case, on the behaviour of the substance-dependent adolescent, but also on significant others, especially parents who are affected by the substances use disorder of their adolescents.
Traditional family structure has undergone drastic changes over the years. Developmental models and intervention outcome studies recommend that ecological systems theory is a sustainable way to work on maintaining the parent-adolescent relationship in order to prevent the challenges of substance use and misuse among adolescents. Payne  reiterates that ecological systems theory focuses not only on the adolescent, but on the whole family, significant others, and the surrounding community. Among the major roles of parents in times of disruption is to maintain and restore family rules and routines that afford a sense of coherence, stability, and well-being during such times. Accordingly, attention is not only given to the behaviour of the individual, or in this case, the behaviour of the adolescent, but also to that of the parents; hence the parent-adolescent relationship is looked at holistically.
The environment, basically everything and everyone that surrounds them, exerts a significant impact on the adolescent. Building a good parent-adolescent relationship will assist parents in guiding and advising their adolescents about the dangers of, among others, substance misuse, and how to cope with peer pressure [29, 30]. In addition, studies on parental closeness and emotional support [4, 31] shows that a close parent-adolescent relationship is a direct buffer to substance use when adolescents experience challenges in their lives, as they are likely to receive the emotional support they require. Finally, positive parent–adolescent relationships protect adolescents from the negative effects of authoritarian and permissive parenting styles .
Adolescents often grow and flourish in the context of close and dependable relationships that provide love and nurturance. The absence of such relationships disrupts the development of adolescents, the outcome of which may be long and severe. This is sometimes exacerbated by the challenges of family discord and broken families.
Parents today are mostly working and that makes it difficult for them to have time to play or spend with their children, especially adolescents. If parents are not engaged in the lives of their adolescents, it becomes difficult for them to follow through their milestones. They also struggle to ascertain where their adolescents are psychologically and physically. Thus, building a healthy relationship helps both parties understand the family as a complex emotional system, not a business entity. Parents ought to nurture, encourage, show firmness, guide, respect, facilitate, love, and respect their adolescents. The understanding should be that when they disagree on issues it is not about who is in control, but rather about building each other up for the better.
The report by Mohasoa  indicates that parents who give their adolescents a lot of money without monitoring how it is spent might find their adolescents falling into the trap of misusing substances. Due to the fact that parents spend most of their time working, they go through life oblivious of what is going on around them and in the lives of their adolescents. Thus, Masombuka  asserts that adolescents of working parents are at higher risk of misusing substances than adolescents of retired and unemployed parents, as these parents might have more time to spend with their adolescents. Some parents are not even aware that their adolescents are misusing substances and only learn about their substance use disorder when their child is either arrested or from complaints from the school. This chapter has established that adolescents need a lot of support and care from their parents. When this is lacking, they are particularly vulnerable to the strong influence of peer pressure, which can result in substance misuse. The parent-adolescent relationship should encourage warmth and support. It should be a supportive environment where an adolescent feels comfortable enough to share and discuss any issues or concern in their lives, without the fear of judgement or punishment . One of the goals of building the parent-adolescent relationship is to encourage and facilitate open communication between adolescents and their parents, which will inadvertently address many of the social ills the world is facing. Uninvolved parents have pushed their adolescents to be more negative in comparison to their adolescent friends who have a good relationship with their parents.
Bezuidenhout and Joubert  point out that adolescents have a powerful need to spend more time with their peers and less time with their parents. Because they highly value friends and socialising and eagerly desire to fit in with their peers, adolescents may end up engaging in dangerous activities. In support of this, Berk  alludes to research that shows that adolescents who are insecure and feel incompetent are susceptible to peer pressure, frequently giving in to peer influences to fit in, and may consequently engage in substance misuse. Troubled parent-adolescent relationships contribute to some adolescents feeling that they are of no value to their parents. Losing hope, they end up socialising with deviant peer groups, increasing their risk of engaging in substance misuse. Highlighting the impact of negative peer groups, Cottrell and Monk  assert that peers can incite spiteful behaviour towards their parents, especially in broken relationships, and that adolescents always have many reasons to be vindictive, vengeful and spiteful. Parents need to be actively involved in their adolescents’ lives. This means, they should be cognisant of which friends their adolescents are socialising with, where they are hanging out, and what activities they are engaging in. This awareness will assist parents in guarding their adolescents against the dangers of substance misuse as well as teach them how to cope with peer pressure.
Children in the adolescence stage feel that they are maturing enough to make their own decisions. Parents therefore need to act more cautiously when handling their adolescents, as they are more likely to follow the rules of their parents if they are treated with love and respect . Some adolescents have a hard time communicating with their parents about certain problems they are experiencing within the home, at school, at work, or in their relationships. However, research [3, 4, 32] shows that parents have a special role to play in nurturing healthy adolescents. Fathers are seen as the head of the family in African households, and they lay the foundation for the upbringing of adolescents, especially the boy child. However, parents need to continue to soothe and stimulate their adolescents, set limits on aggressive/impulsive behaviour, and reinforce self-control. Depending on the specific system, these behavioural patterns can lead to either balance or dysfunction of the system, or both, at various points in time. Family plays an indispensable role in nurturing, developing, providing for, and supporting the adolescent to become an independent and responsible adult .
Ecological systems theory views individuals as being linked to different levels of structures, such as the micro, mezzo, and macro levels, meaning that people are not islands, but interconnected. In other words, their behaviour and actions might affect and be affected by other family members, peers, groups, or even the community .
Parent-adolescent relationships can be challenging because as the child gets to the adolescence stage parents might feel that they need less parenting. Parents mostly struggle with the emotional instability of their adolescents during this stage because they sometimes overlook their responsibility of nurturing and guiding their adolescent. However, if healthy relationships are maintained, it gets better after the adolescence stage. It is quite normal and common for adolescents to be moody or seem uncommunicative, but they nonetheless still need parents as a source of support and strength. Parents need always know that their adolescents’ value them and need them to be involved in their lives, irrespective of their attitude, behaviour, or body language.
As they grow up and reach the adolescence stage, adolescents want to have more control over their lives and the freedom to make their own decisions. Intrigued by the idea of autonomy, they start to fight for more control and freedom. The challenge of moving into young adulthood is a very sensitive stage, not only are they eager to explore their newly acquired freedom, they are simultaneously afraid of losing the most important thing in their lives—the love and care of their parents . This is the stage where adolescents are taught by their parents how to be men or women in the African culture. Adolescents often feel a great burden in trying to meet their parents’ expectations, and thus find a solution is substance use as a way of proving their adulthood. Being an adjustment for both parties, some parents feel rejected when their adolescents start practicing their independence, while others feel proud to see their adolescent maturing into a young adult. Allowing adolescents to exercise their judgement and be themselves rather than who their parents want them to be, will allow them to grow into independent, confident, secure individuals, without cutting their parents off. Thus, having supportive parents will give them the confidence that no matter what, their parents will always be there for them.
During this transition phase, while adolescents are experiencing challenges in self-discovery, parents are also adjusting to the changes their adolescent is going through, e.g. physical changes, emotional ups and downs, and so on. Parents may express anxiety about seeing their little child growing up and having to deal with the new set of challenges this phase brings. Rebellion is harmful to the parent-adolescent relationship, so if the parent is dealing with a rebellious child, this might lead to the breakdown of the relationship, as parents find such behaviour very discouraging.
Parents should always remember that adolescents continue to look up to them, even though most of the time they do not show it. Parents continue to be the most important influence in the lives of their adolescents. Branje  cautions that parents often think they should suppress the negative emotions of their adolescent children and encourage their positive emotions, or they should avoid expressing their own negative emotions during conflicts. Instead, adaptive interactions during adolescence seem to be characterised by a range of emotions. Thus, Branje  advises that parents should learn to guide adolescents to express, share, and regulate a range of positive and negative emotions.
Peer pressure is the manifestation of social influences that affect individuals in a positive or negative way, and it is mostly peers who influence each other to engage in activities so that they can be accepted in their social groups. According to Bezuidenhout and Joubert , adolescents have a powerful need to spend more time with their peers and less time with their families. Among adolescents, there is a craving to fit in with their peers, and as a result, they can end up engaging in dangerous activities, especially if left unsupervised or to their own devices, as explained previously. Adolescents who feel they are of no value to their parents are vulnerable to the influence of deviant peer groups, and consequently, substance misuse. Cottrell and Monk  highlight the link between substance misuse and negative peer influence, stating that peer groups can easily sway or influence each other to rebel against their parents. Recommendations by Dreyer  include that parents need to be more involved in their adolescents’ lives, and that they should be aware of who their children’s friends are, the kinds of activities they are involved in, and their social positions and relations. This awareness will steer parents in advising and guiding their adolescents about the dangers of substance use disorder and how to cope with peer pressure, thereby diverting adolescents from engaging in risky and deviant behaviours.
Substance use impacts all life domains and parents of adolescents who are misusing substances are affected spiritually, physically, psychologically, and emotionally. Often experiencing high levels of stress and anxiety , the severe strain placed on parents gives rise to a wide range of negative feelings such as depression, guilt, tearfulness, and confusion. This shows that the impact on parents’ mental health is enormous.
As noted earlier, substance misuse does not only affect the individual with substance use, but also his/her family, and every facet of society. Howard, Hesston, Key and McCrery  draw attention to the impact substance misuse has on family relationships, often causing enormously strained family interactions, bitterness, and resentment. The effects of substance misuse frequently extend beyond the individual with substance use disorder, placing a heavy burden on the physical and mental health of both the individual and his/her family. The problem with substance and alcohol misuse is that it drains the physical, intellectual, and economic resources of each individual as well as his/her family . A further noteworthy point is that substance misuse has physical implications for the developing child or adolescent and may produce symptoms that mimic other psychopathological behaviours . The repercussions of these implications on the child’s development might lead parents to worry about the well-being of their adolescents.
This chapter explored the parent-adolescent relationship in broken families. It was found that when disrupted, the parent-adolescent relationship brings about challenges in families, especially for adolescents. This is because they need to adapt to the new family circumstances which can bring about much instability and insecurity, although this is not the case with all adolescents from broken families. Furthermore, Hamilton et al.  emphasise that parental conflict and family detachment are often contributing factors for succumbing to peer pressure and subsequent adolescent drug-involvement. In addition, factors such as feelings of helplessness and self-blame were highlighted, as some parents internalise anger and blame themselves for unsatisfactory or non-existent father-adolescent relationships, which they feel could have been avoided or handled in a much better way for the sake of their children.
Adolescents are also affected by on-going conflict in the parental/marital relationship and the subsequent non-involvement of one parent. When they do not get enough attention from their parents, they become increasingly dependent on their peers for support, comfort, and even advice. However, this is not the case with all adolescents, and many turn out fine, despite being under the care of one parent. The notion was rebuffed that all adolescents raised by single parents end up abusing chemical substances, as some adolescents raised by both parents still ended up being addicted to chemical substances for various reasons.
In the event of divorce or separation, parents are encouraged to maintain involvement in the lives of their adolescents. As adolescents traverse the relatively vulnerable stage of adolescence and are in the process of becoming adults, they need support from their parents in the form of healthy parent-adolescent relationships that will help them to become responsible young adults. In building such a relationship, parents need to understand that it does not matter how good they are in giving advice, they must be flexible enough to allow their adolescent to solve their own problems.
In making sure that adolescents are prepared to be independent, fully-functioning adults as well as reach their full potential, parents need to provide constant on-going support and focus on building a healthy parent-adolescent relationship. Mentoring adolescents is an important component of good parenting. Parental skills continue to play an important role in assisting and empowering parents to adopt better ways of building relationships with their adolescents. By utilising the ecological systems theory, parents and communities are empowered to build strong healthy relationships, which will in turn buffer adolescents from engaging in delinquent behaviours, such as substance misuse. Of particular importance is understanding how one’s parenting is linked to their child’s addiction, and using this knowledge to rebuild a stronger parent–adolescent bond, collaborating with them in the process of healing and recovery.
To the parents who participated in the research study and were willing to share their experiences and challenges, we are very grateful. For my mentor who continues to support me in this journey as a young researcher I appreciate all your efforts. To SANCA Castle Carey Clinic and Hammanskraal SANCA, I am grateful for all your support. There is no funding that was acquired by the researchers for this project.
Conflict of interest
The authors declare no conflict of interest working on this project.