There was a time not too long ago when young adults who lived at home were seen as somehow developmentally stunted and “failures to launch.” But the Great Recession and changing social norms have diminished much of the negative stigma associated with living with parents into adulthood. In fact, a whole new vocabulary has been built around young adults who either never left home or boomeranged back. They are now known as “emerging adults” and the family home that was once the “empty nest” is now called “the crowded nest,” “the full nest,” even “the refilled nest.”

Not since the 1950s has the percentage of young adults in the family home been so high, now at more than 22% according to a 2012 Pew Report (http://bit.ly/y3SSjT). In light of these recent changes, what is now considered developmentally normal? Both developmental and psychoanalytic theory describe important milestones in the transition from adolescence to adulthood: gradual psychological and physical separation from parents with substitution of strong social and sexually intimate relationships, consolidation of identity, educational/occupational focus, financial independence, and eventual formation of a new family (Erickson E, Childhood and Society New York, NY: W. W. Norton & Company,1993; Colarusso C, Psychoanalytic Stud Child 1990;45:179–194). Given the fragile economy, how might a clinician help families determine what are now reasonable expectations, especially in adult children with special needs?

Mary, a 21-year-old woman with a history of ADHD and significant learning disabilities, came to my office with her parents following a grand-mal seizure from benzodiazepine, opiate, and alcohol withdrawal. She had been attending a local college, working part-time and, along with her 27-year-old brother and his girlfriend, living in her parents’ home. Historically her family had helped to calm her and solve her problems and, as she began to take steps to separate emotionally from them, she used the drugs and alcohol to numb her anxieties about functioning independently. Her parents were confused about how active they should be in her recovery and treatment. How much of their intervention should be punitive and how much therapeutic? Should they drug test her? Should they monitor her expenditures? Should they impose rent, board, or chores? Essentially, should they treat her as an adolescent or as an adult?

Steps to Treatment
The first step in treatment is obtaining consent from the emerging adult for the parents to participate in family therapy and/or parent work, since the patient is over 18. In my experience, the financially dependent patient feels obligated to consent but can be assisted to think through the limits of confidentiality that might be imposed. Learning to set formal privacy limits and boundaries can give patients a view of themselves as independent adults able to make informed choices, not just as children being controlled or punished. The next step is helping the family identify which adolescent behaviors need parental management and which symptoms and developmental conflicts can be addressed by the patient with therapeutic support. Acknowledging that health, safety, and legal issues, which were primarily parental responsibilities before the age of 18, now have been shifted to the young adult, can be a wake-up call for families. Clarifying that the parents are generous in choosing to extend such privileges as medical insurance and liability protection can further add a dose of reality. You could help the parents consider that the patient pass a routinely but randomly administered drug test in order to continue to be included on the family car insurance policy or to use a family vehicle. Depending on the family circumstances and the family’s acceptance of the young adult’s level of responsibility, he or she could participate in household chores and be asked to contribute money for room and board. I have found that a mix of therapies customized to each patient works best with this group. These could include medication, interpersonal therapy, cognitive therapy, psychoanalytic psychotherapy, and family therapy. In spite of initial family sessions and parent work, Mary’s parents did not follow through with mutually agreed upon contingencies. Over a period of several weeks, Mary watched her parents become frozen in a kind of paralysis. As long as she didn’t create any new crisis, they were content not to take action. It became clear that the household’s goal was to maintain a fragile equilibrium and not aim towards growth, health, differentiation or acceptance of the inevitable aging of all the family members.

Some Guiding Questions
How can you predict which families might not be able to establish limits needed to promote development in the struggling young adult? Here are some guiding questions:

1. Does the emerging adult or another family member have a developmental, medical, psychiatric, educational, or legal history that would give reason for parents to be overly involved and/or anxious?


2. Does the family have a history of family losses, traumas, or stressors that would result in needing to avoid separation or circumvent conflict?


3. Developmental psychology and psychoanalytic theory point to multiple “moments” of separation-individuation, the first in toddlerhood, the second in adolescence, the third in parenthood, the final in death. How have these family members navigated these moments in their own past? What are their philosophies about trials and failures and their explicit and even implicit expectations about what “should” be happening?

If the parents are not able or willing to provide an environmental scaffold, it can be very difficult for many young adults to build their own internal set of rules and guidelines. Ideally, the goal of therapy would be to help the family feel confident enough to offer environmental demands in a supportive way, and to help the individual accept and internalize them. Not all families are able to do this, and so at times the goal has to be to create these within the individual de novo. Group therapy or other ways to learn about other people’s expectations of them can be useful. In our case, Mary’s family was not able to negotiate the transition. Mary, however, showed unexpected strength as she engaged in treatment. Along with a 12-step program and psychopharmacologic interventions, Mary participated in twice a week psychoanalytic psychotherapy where she discovered that her long standing difficulties with self-soothing and separation anxiety had been masked by her ADHD symptoms of distractibility and low frustration tolerance. She had been able to use her parents and friends as psychological supports but now, with therapeutic support, was able to observe her own feelings and behaviors. She also was able to perceive her family members’ particular vulnerabilities that made creating boundaries and limits very difficult. She mourned the fact that they could or would not be firm with her and that she had to develop that ability herself, a huge developmental step in becoming a grown-up. Within months, it was clear to the entire household that Mary, even with an occasional setback, was maturing at a faster rate than her older sibling. Mary was able to see that her drug use, just like the permeable boundaries in the family, served various tacit purposes and had had complex effects on her emotions and sense of self over time. Periodic work with her family allowed her parents to tolerate and eventually support Mary’s independence in her work, social life, and judgment. She was even able to address financial issues with her father that allowed her to take greater responsibility. As she ended the two and a half years of treatment, she slowly orchestrated a move into an apartment with roommates while maintaining loving and caring relations with her family that did not compromise her competence, sobriety, or emotional stability. Her successful launching unlocked the rest of the family, and, 10 months later, her brother and his girlfriend found their own apartment.