Genogram: a tool for characterizing the families of adolescents parents in João Pessoa, Paraíba State, Brazil

. The study aimed to characterize the family composition of adolescent fathers in the city of João Pessoa, Paraíba State. This is a part of a multicenter survey developed in the states of Paraíba, Rio Grande do Sul and Santa Catarina. The population was composed of ten teenage fathers living in the urban area of João Pessoa. Data collection occurred from December 2008 to October 2010 through semi-structured interview and construction of the genogram and eco-map. Participants' age ranged from 16 to 19 years. They all lived with his partner and most had low education. The unemployed and those with income below one minimum wage indicated the family as the keeper of the home. Most fathers also depended on other family housing, and the amount of people living in the same house ranged from three to seven. Despite the existence of conflicting and/or distant relationships, all respondents reported that seek emotional and financial support in their own family. Fatherhood and motherhood in adolescence had already been experienced by some families. Understanding adolescent parents requires a broader view about composition and family dynamics, a task to be faced by health professionals committed to the care, being the genogram a viable and important tool in this process.


Introduction
The adolescence is the development stage when the human being experiences a diversity of conflicts in front of the discovery of a new world.The role reversal that the adolescent naturally acquires brings restlessness, anxiety and insecurity, typical of the phase of changes.The inclusion of parenthood in this stage is to experience a process of changes, constructions and reconstructions (SILVA et al., 2009).
According to Pelloso et al. (2008), the adolescence phase consists of a period when the young person needs support, understanding and clear information, since the consolidation of a number of changes.It is noteworthy that the family involvement is essential to face these new experiences, because it is the more direct source of care, responsibility and trust.It is in the support, solidarity and encouragement provided by the family that young parents can find the foundation to fulfill the new role as a parent.
In this context, the family has a key role in providing emotional and financial support during the experience of parenthood in adolescence (SILVA et al., 2009).This familial support is present regardless the conditions of life that the nuclear family is exposed to.Thus knowing the family composition and capture the bonds between its members is one way to plan the care with adolescent parents.One of the suitable tools for this assessment is the genogram, a diagram of the familiar group that details the structure and history of the family and provides information about the diverse roles of its members and of the different generations that made up it (ATHAYDE; GIL, 2005;WENDT;CREPALDI, 2008).
Despite this understanding, the genogram represents through symbols, the three generational components of a family, in which the male is represented by a square, and the female, by a circle.Couples are connected by a horizontal line, by which it is identified the current marital status, and each member is identified by the name, age and occupation.It is important to emphasize that the genogram goes beyond the visual representation of the origin of individuals, and this tool for data survey allows collecting qualitative information about the dimensions of family dynamics, like the processes of communication, established relationships, link building, and other important events, such as illness, birth and death (MUNIZ; EISENSTEIN, 2009).
Therefore, by collecting this information, the genogram can be used to promote reflections about this issue in a broad context of the relationships that arise.In this way, the present study presents a relevant contribution by enabling discussions about possible interventions in health of adolescent father, considered quite precarious, since there is no government proposal for assistance to this population profile.In contrast, the teenage motherhood is not only socially recognized but also legally supported by the Child and Adolescent Statute (BRASIL, 2010).
The health services that provide care to teen pregnancy, organized to meet ministry policies and norms, are directed to assist women through prenatal, elaborated in the lines of the medical model of health care, in which the father is not included.The attention is only directed to the adolescent in pregnancy, and not the teenage couple who experiences the pregnancy, the motherhood and fatherhood (CORRÊA; FERRIANI, 2007).
In this way, due to the great relevance of fatherhood in adolescence and the lack of studies on this subject when compared to motherhood, our interest emerges to develop this study, as nurses and researchers of the multicenter project Social Support Networks to Adolescent Fatherhood (RAPAD) funded by the National Council for Scientific and Technological Development (CNPq).The goal was to characterize the familiar composition of adolescent fathers in the city of João Pessoa, Paraíba State.

Material and methods
This is a descriptive exploratory study, with qualitative approach.According to Minayo (2007), a qualitative study responds particular questions, a reality that cannot be quantified, by working a universe of meanings and phenomena that cannot be reduced to the operationalization of variables.
The study was performed from a part of the database of the multicenter research (RAPAD) developed in the states of Paraíba, Rio Grande do Sul and Santa Catarina, obeying criteria established, as follow: consent to participate in the survey; have less than 20 years old; reside within the urban perimeter of the city of João Pessoa, Paraíba State, and present permission from legal guardians.
The selection of adolescent parents was established after the quantitative substudy of the RAPAD research, with adolescent mothers whose deliveries occurred in a university hospital of the municipality.The collection of the quantitative substudy was made between December 2008 and November 2009, when there were 85 admissions of adolescents in the obstetric ward of the referred hospital, of which 72 had their pregnancies with partners aged over 20 years, and 13 got pregnant of adolescent partners.Of these 13 adolescent parents, three have given no consent to participate the study.Thus, based on inclusion criteria, the study population was made up by ten adolescent fathers, who were contacted and scheduled for an interview, during the period when their partners had been hospitalized for delivery.
They were informed about the goals of the study, the justification, procedures, contribution, guaranteed anonymity, reliability in data analysis and the right of freedom to participate or not, in addition to the guarantee of being able to withdrawn from the study at any time, without any problem.
We followed the ethical guidelines and standards specified in Resolution 196/96 of the National Health Council, which regulates the research involving human beings and guarantees the free and informed consent of the participants, as well as their anonymity.
The RAPAD research project was approved by the Research Ethics Committee of the Dentistry Faculty of the Federal University of Pelotas, under protocol number 007/2008.Data collection with the adolescent parents took place during the period from December 2008 to October 2010, and started after the reading and signing the Consent Statement by the adolescent father and his legal guardian.
Importantly, a script was used during the interview, which contained guiding questions relative to the objective of the study besides the construction of the genogram and ecomap.After the consent, the interviews were recorded in MP3 player, in order to capture accurately their statements.The interviewer attended the Training Course of RAPAD Research developed in the Federal University of Paraíba, which prepared the interviewer for using the tools genogram and ecomap, as well as for the interview.
Before addressing the guiding question, a dialogue was established with the participants, in order to create a warm and conducive environment for the interview.Moreover, other family members present during the interview and that were available, participated in the construction of the genogram with the adolescent father.
To construct the genogram, we used a blank sheet and, as they were building the family tree, the demographic data was included (age, name, education, marital status) and health data (diseases that affected and/or affect each family member and the causes of mortality among the members).The relationships of emotional closeness among the family members were also represented in the diagram.Three generations were included, starting from the grandparents of the adolescent fathers, and grouped and highlighted in the diagram the people living in the same house, and the occurrence of fatherhood and/or motherhood in adolescence among other family members.In this process, different symbols were employed to important events, like pregnancy, death, and separation, which followed the standards given by Wrigth and Leahey (2002).The symbols of pregnancy and fatherhood in the adolescence were created, given their lack in literature, and we changed the nomenclature referred by Wrigth and Leahey (2002) from normal, next, and close ties, to strong, tenuous, and negative links, because it is more adequate to the purposes of this research.The construction of genograms presented in results section was undertaken in the software Word for Windows (Figure 1).

Results and discussion
Ten genograms were constructed to represent the family structure of the interviewed adolescent fathers.In order to better understand the theme, we present the data obtained in the proposed survey, providing some results with the genograms of some families.
The age of the participants ranged from 16 to 19 years old.In eight cases, the age of 19 years prevailed.The study revealed that all adolescent fathers lived with their partners and most of them had low educationsix did not complete the elementary education, two have quit at the end of this level, and only two reached secondary education.
Regarding the main source of income to support the family, five of the employed parents pointed their own work, but the unemployed, and those with income below one minimum wage, have indicated the family as the keeper of the home.Therefore, the average income of the adolescent fathers was lower than one minimum wage, about R$ 200.00 (the Brazilian minimum wage at the period of this study was R$ 465.00).The average income of the family varied between less than one and more than four minimum wages, and the average of 5.4 people dependent on this income per family.
In relation to the number of generations living in the house of the adolescent father, it was considered that of the first generation are the siblings of the adolescent father; of the second generation, the parents, aunts and uncles; and of the third generation, the grandparents.Almost all adolescent fathers still depended on other family housing, like parents, siblings or parents-in-law.Therefore, they lived with family members of other generations.Only the parents of the families of André, Mateus and Bartolomeu lived exclusively with the partner and the child, constituting an independent family unit and of first generation.Figure 2 illustrates the family of Mateus.Considering the amount of people living in the same house of the adolescent father, the study pointed a maximum number of seven people, and a minimum of three.Figure 3 shows the amount of people in the nuclear family of João Evangelista.In order to better understand the family dynamics, we inquired about the status of diseases affecting the family.According to Muniz and Eisenstein (2009), due to the interdependence relationship among family members, the emergence of diseases or any dysfunction requires adjustments in the family system.Besides the presence of diabetes mellitus and systemic arterial hypertension, it was observed the existence of heart disease, cerebral stroke, myocardial infarction, cancer, arthrosis, rheumatism and hydrocephalus.
Among the causes of mortality of the family members, it was cited the myocardial infarction as the main reason, death by cerebral stroke, accidents and murder.The morbimortality of the families of Tiago and João Batista are shown in the Figures 4 and 5.  Regarding the affective relationships among the family members of the adolescent fathers, despite the conflicting and/or distant relationships, all the interviewees reported that seek support on their own family to face emotions.Among the family members that justified this assertion, it was evidenced demonstrations of love, affection and understanding.Corroborating this result, other studies confirm that the family is the main source of emotional support to the respondents (DIAS et al., 2007;LAVALL et al., 2009;PEREIRA et al., 2009;SILVA et al., 2009;MEINCKE;CARRARO, 2009).
The adolescent fathers also pointed out the family as a strong financial support, considering that they depend on it to survive.Furthermore, even the existence of conflict with members, the family remained being their safe haven.Under the same focus, Figure 6 illustrates the affective relationships between the member of Pedro's family, which enable them to share feelings.Taking into account the particular moment that the family was experiencing -the fatherhood in adolescence -we sought to investigate if it had been previously experienced by the family.Then it was observed that the brothers of the adolescent fathers of the families of Pedro and Mateus have been parents in adolescence, at 17 and 19 years old, respectively.For Carvalho et al. (2009), the repetition of fatherhood in adolescence have increased, and is more apparent in developing countries, considering the poor schooling, lack of information, family breakdown, and economic instability, especially in adolescents of lower socioeconomic status.
Also, in the families of André, Tiago and Tomé, some members have become fathers in their twenties.In the Tiago's family, the fatherhood experience with twenty years was experienced by the father of the adolescent father, and in the other families, by the brothers.We also emphasize that the adolescent father Felipe was experiencing the fatherhood for the second time at this phase of life, as shown in Figure 7.
The families expressed a concern in face of this new reality, mainly regarding the structure of family and financial stability of these young fathers.In this way, other studies also demonstrate the concern of families with the adolescents, referring to the responsibility and physical and emotional immaturity of the son to assume the role of father (MEINCKE; CARRARO, 2009;SILVA;TONETE, 2006).The news of fatherhood was given by people of the family and social circle of the adolescent father, among them, cousins, and mostly by the partner.The ways to tell the news also differed and regardless the adopted strategy, these moments were fraught with anxiety and fear.
At first, the feeling was of joy, knowing that a new being was being generated.However, for most fathers, the feeling of concern evident in the statements, permeated during the new situation, especially when they felt the new responsibilities, such as the decrease in leisure activities, interruption of studies, job search, a real change of behavior that put these adolescents into the adult world.A study carried out with teenage mothers and fathers in São Paulo revealed that the fathers also reported the same feelings when facing fatherhood (CARVALHO et al., 2009).
In this context, the news of fatherhood in adolescence caused surprise to the family, both in the first experience and in the current, because it was not expected (SILVA; TONETE, 2006;Acta Scientiarum. Health Sciences Maringá, v. 34, Special Edition, p. 287-293, 2012BUENO et al., 2012;MEINCKE;CARRARO 2009).Thus, despite the previous experience, the family members reported that they experienced everything with the same intensity.
All the families examined in this study provided some kind of support for the adolescents.This occurred in several ways, either by accommodation of the adolescents, their child and partner in his own home, either in the decision regarding the continuation or not of student life and the beginning or redirection of adolescents to the world of work, either through financial aid or assistance in raising their children.
The family support is an aspect that deserves attention, since the adolescents feel safer when supported by the family (BRANDÃO; HEILBORN, 2006;TRINDADE;MENANDRO, 2002;BUENO et al., 2012;MEINCKE;CARRARO, 2009).Meincke and Carraro (2009, p. 87) stated that the family is an important factor "[…] for the experience of parenthood, mainly during adolescence", corroborating the assertion above.
Importantly, the affective and relational bonds were strengthened between the family members and the adolescents, contributing to the establishment of an environment permeated by affection, encouragement and affection, besides the material support.
Moreover, the presence of motherhood during adolescence was analyzed in the other generations, which was evidenced in the families of Pedro and Mateus (sisters-in-law of the adolescent father) and Bartolomeu (mother of the adolescent father).In the families of João Batista and Tiago, the mothers of the adolescent fathers got pregnant with 22 and 21 years old, respectively.It is worth adding that all the partners of the adolescent fathers herein interviewed were teenage mothers.Felipe's partner experienced the motherhood for the second time.Figure 8 shows the pregnancy during the adolescence in Bartolomeu's family.
Adolescent motherhood led to changes both in the life of the couple and in the life of the family members living with the adolescent.The care to the child and mother by the family were necessary to face the difficulties from the young mothers, especially in relation to the basic need of the baby, such as changing diapers and breastfeeding.
From this viewpoint, Motta et al. ( 2004) affirm that family relationships undergo changes and require alterations in the life of the adolescent and family to adapt to the child's birth.The family seeks to create a support network for the binomial mother/child, based on socioeconomic and cultural reality, the schooling, and on the experience of early motherhood.
In a study performed with the family of teenage mothers, it was verified that the pregnancy caused anxieties, especially when occurred in an early stage of the relationship between the couple, or absence of marriage, because it was contrary to moral principles, adversely affecting the concept of family in their social group.Concerns were milder when the link between the couple was consolidated and there were already plans for marriage.Regardless the bond between the partners and the circumstances involved, the pregnancy caused frustration once it implied the need to interrupt or modify the project of family life (HOGA et al., 2009).The occurrence of teenage motherhood is permeated by various historical and sociocultural factors and its recurrence is still remarkably common.Statistical data revealed that 40% of adolescents got pregnant again 36 months after the first gestation (BOCARDI, 2003).A study conducted with 140 adolescents in the interior of São Paulo State, it was observed that 24% were already in the second, third, fourth, or even fifth pregnancy, and 10% had already practiced abortion, at least once (ALMEIDA et al., 2003).

Conclusion
The results indicated that for most teenage parents, the nuclear family had two generations, since they were still financially and/or emotionally dependent on maternal or paternal figure to face the difficulties in the exercise of parenthood in this life period.
The family unit was presented not only as a place for residence, but also a space where feelings and behaviors emerged in the process of interaction Acta Scientiarum.Health Sciences Maringá, v. 34, Special Edition, p. 287-293, 2012 between the members, being essential to the experience of identity and competence that the adolescent father assumed in this new stage.In summary, understand an adolescent father requires a broad view about family dynamics.This is a task that should be faced by health professionals committed with the care.The genogram has been shown as one tool that allows characterizing the composition of the family of adolescent fathers and can be developed to reflect about the work process in health services.

Figure 3 .
Figure 3. Genogram of the family of João Evangelista.

Figure 5 .
Figure 5. Genogram of the family of João Batista.