ISSN 1363-8394

Journal of Adolescent Health
and Welfare

Volume 9
- No 3 - Summer 1996

Incorporating
the Newsletter of the International Regional Chapter of the Society for
Adolescent Medicine

Youth   * 1986 - 1996 *   Support

Letter from the editor -

Dear Colleagues,

Our Anniversary Year is progressing well ..   I hope you all enjoyed the
Souvenir special edition of the journal .. there was one misprint .. I wonder
who spotted it ... Youth Support were involved with Eastenders .. not
Neighbours .. sorry , my fault  -
the soaps sometimes merge in my mind ...

A milestone has
been reached with the Journal - it is now registered with the British Library -
that means that all the past copies are lodged in the Library and all the
copies in future will have the ISSN standard numbering.

It is nice to see new contributors to the journal
and we very much encourage colleagues to send in manuscripts for publication.
We welcome descriptions of qualitative research, which often get short shrift
elsewhere, and personal accounts of interventions or experiences with young
people.

Our celebration party was a great success -  on Friday 21st June 96 - midsummer day -
exactly 10 years to the day when our first Youth Support event took place - the
‘Jamaica benefit’ fair. Black shades and black pork pie hats were
‘de rigeur’ as we all danced the night away to  the support band ‘Scrummage’
ably led by two long term associates of Youth Support - Sean and Alistair
(available for engagements via our office!) and the ‘Blues Brothers
Experience’.

Our main scientific event of the year will be our
day conference at the Royal
College
of Physicians on 24th October. .. so far bookings have exceeded all
expectations and it looks as if we may have over 400 delegates! Unbelievable!
Hope to see you all there. Also don’t forget that those who are unable to
come during the day are very welcome to sign up just for the evening - why not
come to the keynote address and the dinner.

Best wishes and thanks for all your support
throughout the years,

Diana
Birch

Director
Youth Support

Youth Support are pleased to invite you to attend
our

Tenth Anniversary Dinner

At - The Royal
College of Physicians

St Andrew’s
Place, Regent’s Park, London

Thursday 24th
October 1996 - 7pm

Dinner preceded
by keynote lecture 5.30pm - 6.30pm

“Looking to the Future”

- delivered by
Professor Richard MacKenzie  -

- introduced by Dr Diana Birch - Director of Youth Support -

The dinner follows our conference -
but please note that attendance at the conference is not a prerequisite for
those attending the dinner or the keynote lecture at 5.30pm.

We very much welcome those who can
only attend in the evening.

Tickets for dinner £25

Youth
Support Conference Administration

13
Crescent Road, London, BR3 2NF.
R.S.V.P.

- International Chapter News -

News of the International
Regional Chapter (IRC) of SAM

(Society for Adolescent Medicine)

Co Chairs -
Diana Birch Gustavo Girard
Treasurer Aric Schichor

London      Buenos
Aires              Connecticut

England     Argentina                 USA

The 1996 SAM
(Society for Adolescent Medicine) meeting- “Assuring
Quality Care for Adolescents - Preparing for the 21st Century”
was held at the
Crystal Gateway Marriott Hotel, Arlington Virginia March 20-24th.

Our
International Chapter workshop on Thursday March 21st -  dealt with  “The
practice of Adolescent Medicine from an International Perspective” -
The theme was the management of ‘difficult cases’ with the emphasis
on clinical presentation and practical solutions. This was the subject that had
been asked for by the membership at the previous year’s Chapter meeting.
It was thus disappointing that not only was attendance very poor - but those
who had asked for this title on the basis that they wanted to present cases -
did not turn up and do so. Without wishing to winge too loudly - I would
implore members in future to put their committment behind their suggestions!

There are always
many conflicting interests at the SAM meeting and it is hard sometimes to
choose which workshop to go to. It is worth noting though that the last few
workshops have been excellent for those who have turned up and hopefully we can
attract a larger participation next year in San Francisco. Actually the timing
of this year’s workshop could hardly have been worse (4-6pm) and we are
looking for a different slot next time.

The plan which
was discussed at the Chapter Breakfast meeting was that we would have a session
on the day before the main SAM meeting so that there would be not so much
competition and conflicting timetabling. We are going to hold an
‘Institute’ on the Wednesday which will have a morning and
afternoon slot with a separate theme for each section. We hope that PAHO may be
involved in the programme and Bob Blum has consented to join us for the day.

The suggested
theme is ‘Poverty and Neglect - Deprived Youth in varied
societies’. Presentations will highlight the presence of deprivation in
all aspects of youth culture - from street children, starvation in so called
‘developing’ countries - to poverty in inner city Europe and north
America for example. The last part of the day will be devoted to ‘free
papers’ on a variety of subjects - Semi Snajderman has agreed to present
on eating disorder and Danny Hardoff has a paper on attitudes of non adolescent
health trained paediatricians to adolescent health.Write or fax with
suggestions you might have and also any contributions you wish to make.

I would also
like to suggest that we all bring examples of our work in our countries -
leaflets or display material which could be displayed in our meeting room and
give members a better feel of the work we are separately involved in back in
our own countries.

The
International Chapter of SAM is an important part of the society and this view
has been endorsed by this year’s president Gail Slap. The enthusiasm of
the members is reflected in the large numbers who do attend the - International Dinner - which once more
was a roaring success! This time the Restaurant had a ‘Cheers’ look
about it and was owned by a retired famous Football player (I apologise to fans
of Joe Theissiger for thinking he played baseball!).

We are trying
to get E mail on line for the International Chapter - not as easy as it might
first appear for those of us outside the US - but Aric has been working very hard
on the SAM technology committee and on the SAM home page of the World Wide
Webb.

Society for
Adolescent Medicine

San Francisco
March 5-9 1997

The International
Regional Chapter (IRC)SAM

‘Institute’

‘Poverty and Neglect - Deprived youth in
varied societies’.

Contributions and ‘free
papers’ welcome.

Also - for your diary - note that we will be having the following
‘events’ at the IRC.

Institute - Scientific session - as above - probably on Wednesday 5th
March

Dinner - Social event - probably on Thursday evening 6th March

Chapter Breakfast - discussions and recruitment of members.
Saturday  8th. am.

‘Board meeting’ - active members -
‘housekeeping’ TBA.

Dates to be confirmed after SAM programme decided upon.

Qualitative
Research

One of the very welcome aspects of the recent SAM (Society for Adolescent
medicine) meetings has been the inclusion of a special interest group on
‘Qualitative research’ under the leadership of  Richard Brown - (San Francisco).  It was thus thought appropriate to include
the following article which appears in slightly different format in the book
‘The Child that Rocks the Cradle’ describing the fifteen year
follow up of pregnant schoolgirls and their families.

Over the centuries the character and image of medicine has changed.
‘Doctors’, in other words Physicians, as opposed to surgeons who
were called ‘Mister’ and identified with the ‘Barber
surgeons’ - were not strictly thought of as scientists. Medicine was an
art.

With the advent of the ‘Scientific method’, new treatments
and investigations, new ways of ‘evaluating’ patients, Medicine has
become a science ... but patients are still people!

It is important that the ‘old skills’, the
‘art’ of medicine is not forgotten in the search for scientific
correctness. This statement can be no more important than in the field of
social medicine and the emotional territory of psychology, psychiatry and
psychotherapy. In fact at a  recent
meeting celebrating the centenary of the paediatrician and psychoanalyst Donald
Winnicott considerable time was given to debating whether the great man was a
scientist or a poet and we were reminded that ‘The art of Medicine is not
always scientifically analysable’.   Hence the need for qualitative as
well as quantitative research models.

Much of the schoolgirl pregnancy study described in ‘Are you my
sister, Mummy?’ and ‘The Child that Rocks the Cradle’   falls into the realm of
qualitative research. This is a field which has to a large extent been
neglected in the past, in the search for quantitative studies which often
require large numbers relying heavily on the statistical approach and thus
inevitably missing a great deal of valuable anecdotal information.

The word anecdotal was often regarded almost in a derogatory manner; to
say that something is anecdotal means that it is not quite good enough to be
regarded as scientific research or a valid finding in a research study.  However, when the content of the
anecdotal information is looked at and moreover when different incidences of
anecdotal reporting are put together they can make a whole picture which is
extremely revealing and valuable.

This is certainly the case when one comes to researching matters
concerning outcomes and success rates for example, in work with teenagers and
adolescents, and certainly when one looks at anything to do with emotional
responses, therapy and intervention. With regard to this present study,
qualitative research gives us a way to estimate coping skills in girls and
families, and to see why certain things happen and certain results ensue.

In many studies, particularly some coming from North America where teenage
pregnancy rates are much higher than in Europe, and study
samples tend therefore to be large, a lot of data has been collected by means
of questionnaires. The data has thus been quantified numerically, often
computerised and statistical analyses are read off at intervals according to
the need of the researcher. Thus the information ultimately derived is in a
mathematical format.

Unfortunately people do not behave like numbers, and although maths can
give some answers and allow us to produce some of the graphs and tables in this
book they nevertheless mask the true picture. By knowing girls over a long
period time on a personal basis one is not restricted just to looking at final
numbers, but one derives a sense of knowing ‘why’ and a better
understanding of what those numbers mean.

For instance - looking at number of pregnancies, or the average number
per girl, at various intervals after the first birth or at various ages,   is just precisely that  -
a statistical figure of number of pregnancies. But why are the girls having this number of pregnancies, and what is
actually meant by the
‘average’?

Looking beneath the crude numbers and knowing why certain particular girls got pregnant reveals another
picture  -  the fact that the group is not
homogenous,   there are
different factors operating which tend to draw some girls towards having one
child only and others towards repeated pregnancies. Without actually knowing
their individual stories it is difficult to come to valid suppositions and
conclusions on such a matter.

In qualitative research, the interaction between the researcher and the
client or patient and the emotional or psychotherapy input of that interview
are very important. With the self-esteem studies, particularly, it was
important to look at the psychodynamics of each individual and the assessment
made in the psychotherapy interview was, if anything, more important than the
actual numerical estimate of self-esteem which is derived from the
questionnaire.

Another example here - a mother might be seen as having a
matter-of-fact attitude towards her injured child. The casual observer might
regard this as callous, lacking feeling, denial etc. whereas a closer study of
the mother / child interaction or family situation might actually discover that
this is an effective coping strategy employed by the young mother who had
experienced a lot of pain; has perhaps been abused, and who has to cut off some
of her feelings when dealing with her injured child, taking the child to
hospital, being interviewed by medical staff etc.

If she allows her feelings through they could overwhelm her and she
would then break down and not be able to cope with the situation or caring for
her child. The same reaction could be seen in a positive or negative light,
depending on the depth of interview and the depth of understanding of the
totality of her situation.

The difficulty sometimes with entirely quantitative research is that
interviews tend to be too limited  -
perhaps confined to questionnaires alone. Not only does this limit the actual
information elicited but the questionnaire itself can be an enormous barrier
between the interviewer and the subject.

Some researchers will actually opt for using a questionnaire like this
because it provides a protective barrier for themselves - they do not actually engage closely with the patient
and do not want to because getting too close to some of the pain and difficulty
in the patient, or being exposed perhaps to the aggression and anger of the
patient, is something they cannot cope with. Perhaps they do not really want to
be involved with the ongoing care of the patient or taking responsibility for
any outcome of the interview. They just want to dip in, take their information,
and run.

Saying it this way might appear rather harsh and in a way condemning
the researcher. There are obviously a large number of researchers who would no
way wish to harm or use their patients. However, it must be acknowledged that
there are a number of researchers who are just using  patients in order to obtain information
for a research paper which may further their career but perhaps not actually in
the end help the patient.

Throughout all the contacts with
teenage mothers and their families we very much endeavoured to provide
support and service, hand in hand with the research project. To do otherwise is
unfair to families.

It is of course possible to look at the esoteric gains in terms of
telling the girls that by helping in the research model they would actually be
helping to make life easier for other girls who come into the same situation as
themselves.

They deserve more than that.

Putting patients into an esoteric group like that is playing into their
guilt and low self-esteem. It is like saying “Well - we don’t care
enough about you to try and make you feel better during this process, but you
could make a difference in helping others”. Many of the girls we deal
with, who may have low self-esteem are already into this mode of caring for
others, and not having their own needs met.

As I have said elsewhere, teenage mothers are often criticised for not
being able to place the needs of their children above their own, and this is
grossly unfair. Until they can fulfil their own needs it is impossible for them
to be able to fully love and care for their children. An empty vessel cannot
have the resources to care for others.
Thus one has to  take pains
to ensure the research model
presented to young mothers does not feed into this dynamic.

They need to be offered help and support at each stage in their own
right, and not merely as an esoteric gain. Practical help needs to be provided,
help with housing, nursery place for the child, counselling in the widest sense
of the word.

Same
time next year .. ?

Slowly the mass grows amoeba like as first  one by one  .. and then in ever larger groups, the
members reconvene like insects honing in on a pot of honey.

Expectations and excitement ebb and flow with each
new wave of arrivals destined to spend four days interred in some concrete
edifice which could be anywhere.

Old faces .. new faces,   warmth of long lost friends,
seeing the years pass on each others features, hearing of deaths, births and
comings and goings .. and ‘goings on’ .. Petty jealousies, disagreements,  cut throat networking ... a last
night’s party .. and then it’s gone!

Uneasy inactivity .. last stragglers wandering
disorientated past empty conference rooms... strewed literature like dead bones
of a carcass picked clean. Dismantled registration desk ... the reference point
gone.

Our space occupied by the next delegation - Postal
work supervisors .. teeming in slapping registration packs down on desk in
deliberate fashion of a clerk used to slapping and stamping.

The evanescent microcosm which was once SAM has
disappeared for one more year to reappear Brigadoon like in some other
location. ..

HELEN - A HISTORY

Carol Kremer

What happens to
a young person who falls victim to a major mental illness? Helen was just
fourteen when she began behaving in ways that were out of character: she became
withdrawn and retreated to her room. To her parents she seemed traumatised,
although nothing had happened to explain the frightened look that she now
wore.They went, all three, to the GP who fastened on the idea of food
deficiency and recommended vitamins and iron.

When Helen
swung into the hypomanic phase (although no one at that stage recognised manic
depressive symptoms) her parents consulted a private psychiatrist. They knew,
despite the fact that Helen’s behaviour had by that time involved the
police, that their daughter was ill. The psychiatrist talked about a shock
syndrome.

So did the
doctors in the adolescent unit of the mental hospital where Helen was next
sent, and where she was held for five months while her condition was
assessed.For four of those months she was denied any home visits, and she was
sedated daily with major tranquillisers. Her parents watched helplessly as her
physical health deteriorated. Still, they thought, she is ill and doctors and
hospitals are where you turn when illness strikes.

They lost faith
finally after Helen had been transferred to an adult ward on the grounds that
her behaviour was unmanageable, where she was eventually Sectioned. So deep was
her distress that she had not only run away but cut her wrist and cheek. The
authorities’ response was to lock her up on a secure ward. Any trust that
her parents had placed in the system had long gone - they wanted Helen home.

She was now on
Lithium - but because her blood levels fluctuated she was accused of not taking
it, and her parents were disbelieved when they confirmed she was complying with
the medication as prescribed. She spent further time in hospital being
monitored. Hopes of a family holiday in Italy were dashed; her brother and father
went alone, she and her mother later in the year when she was finally
discharged from hospital.

She is now over
sixteen years old and almost entirely dependent on her family. Two punishing
years have left her isolated from people of her own age, although she attends
college for a day and a half each week despite suffering panic attacks and
difficulties with concentration. She also attends three sessions a week at a
day centre, but the people she meets there are no solution to her feelings of
isolation. Her mother is her closest companion, her confidante, and
Helen’s needs have to be met within the family whatever stresses may be
created by that.

Helen’s
family meet stress with strength and face the future without self-pity, but is
this the best that can be done for young people and their families? Does
treatment have to be so punitive? And do families have to cope with so little
support? The mentally ill are always vulnerable - a young person’s life
is especially so. Nowhere in the system is there any real provision for people
like Helen, no attempt to assess the special suffering experienced by them and
their families.

Perhaps there
are countries where these things are handled differently, where there is
something on offer at weekends for instance, where parents are not expected to
assist the recovery and repair of their damaged children utterly unaided. If
so, we must learn from them fast before there are too many other Helens with a
story like this to tell.

ADOLESCENT CONTRACEPTION;
THE ROLE OF THE PAEDIATRICIAN

Ariadne
Malamitsi-Puchner MD

Department of
Obstetrics and Gynaecology

University of Athens

The following
paper was presented at the 3rd congress of the European society for
Contraception in Dublin June 1994. It is reproduced in it’s original
form.

{Editor’s comment - It should be noted that
in the United Kingdom paediatricians are not part of the ‘primary
care’ system - this role is taken by the general practitioner - and hence
young people would not be in a position to see ‘a friend coming from the
past’  in the form of a
paediatrician as described by the author.
Most teenagers would never have seen a paediatrician.}

Adolescence is
the period of development of sexual activity.

Although it is
a normal process during maturation of adolescents entering manhood or womanhood
under the strong stimulus of sexual hormones, it is not easily discussed in
many societies by parents, doctors or teachers leaving adolescents with
inadequate knowledge and occasionally leading to adverse situations (unwanted
pregnancies, rape etc.). It is evident that the problem is great. A recent
American study reports that the average age of first intercourse for American
teens is 15.2 years for girls and 15.7 years for boys. Furthermore in the USA in 1987 more than 1 million out of 9
million girls aged less than 15 up to 19 became pregnant. Of these 47%
delivered, 40% aborted and 13% miscarried. 22% of births to teens are repeat
births. Three quarters of pregnancies among unmarried women of 15 - 19 years
are unintended. In 1987 26% of all abortions were obtained by teenagers.

Although
adolescent sexuality leading to teenage pregnancy is a universal problem, the
pregnancy rate in Britain, France and Canada is half that of the reported for USA. Sweden and Holland present even lower rates, reaching 1/3
and 1/7 respectively of the American rates. Adolescent pregnancy rates in ten
European countries ranged for the years 1985-89 as follows: 12-14 years:
0-0.3,  14-16 years: 0.01-9, 16-18
years:1.2-21. In Greece, as observed by the first Department of Obstetrics and
Gynaecology of the University of Athens, adolescent pregnancy leading to
delivery increased from 5.3% to 7.2% between the years 1974-993. Creatsas et al
report that for the years 1987 and 1988 11% of all deliveries in the above
mentioned Department were by girls aged 13-19 years.

One fifth of
all premarital teen pregnancies occur within the first month after starting
sexual intercourse. Neinstein et al state that in the recent years a decreasing
trend of births to teens 15-19 years was noted.  Nevertheless, this fact is primarily due
to an increase in elective abortions and not to a substantial decrease in the
overall number of pregnancies.

But why are
adolescents so intensively involved in sexual activity?

As Neinstein
explains, among adolescents sex is justified as physical pleasure and as a new
experience. It is considered an index of maturity, reflects peer group
conformity, represents a challenge to parents and society, and offers an escape
from pressures. Moreover, the extremely powerful media which surrounds us,
radio, movies, television, advertisements, constantly promote sex based usually
on violence. The situation becomes more serious if the adolescent’s
parents on the other hand view sex among their offspring as a crime, a sin or
even a sickness, instead of discussing with them about the normal development
of sexuality and the family values in which sexuality is embedded. This problem
is even worse in single parent families, who mostly rely on school to deliver
the adequate education and fill the sexuality information gap with a dry
scientific description of the anatomy and physiology of reproduction. Trapped
among these various controversial aspects, adolescents are confused and
frequently pushed to impulsive action - to sexual intercourse without being
prepared and aware of it consequences.

Who must help
in preventing and managing this situation?

“A friend
coming from the past” - the paediatrician.

His or her role
is sometimes difficult but always gratifying. Paediatricians have the advantage
of knowing the family conditions and particularly adolescents since their birth
and childhood. They usually have a good relationship with them, they are aware
of somatic illness and have following the psychosocial development of the
youngsters. Nevertheless, paediatricians occasionally encounter some
difficulties in their efforts to cope with adolescents and especially when the
subject concerned is sexuality. Paediatricians have  worked closely with the
adolescents’ parents for many years and teens are afraid of lack of
confidentiality. On the other hand, adolescents consider themselves grown ups,
because of physical maturity, and feel their ties to their “first
doctor” to loosen. In spite of this , paediatricians consider themselves
better prepared for the care of adolescents than internists, and teenagers feel
more comfortable communicating with the former.

When and how
should a paediatrician intervene?

It is crucial
that the physician has started a confidential and trusting relationship with
the youngster prior to puberty.  It
should continue with frequent honest talks and a thorough examination, each
step of which is explained. This should take place without the presence of
parents, unless the child is reluctant. This attitude strengthens the
independent identity of the young person and forces him or her to take
responsibility for his or her health. A clear and honest statement by the
paediatrician as “I have to know more about you, your life, your
behaviour, like sex, so I can take care of you and help you if needed” is
usually appreciated by teens. Then the paediatrician must be willing and
prepared to answer all sorts of questions. The information given must be always
simple, factual and straightforward. Nevertheless, emotions should not be left
apart and the physician should not hide his or her own moral values underlining
responsibility, caring and trust. “Value free”, pure education
concerning the anatomic and physiological aspects of reproduction and
counselling stressing only prevention of unintended pregnancy and sexually
transmitted diseases very seldom provide the environment in which the
adolescent feels comfortable to ask questions and solve problems.

What should the
paediatrician counsel?

Abstinence is
considered the most effective method of birth control and prevention of
sexually transmitted diseases (STD). In the 1970s abstinence among adolescents
was the norm. Only 4.7% of 15 year old girls were reported as having sexual
intercourse in the USA. By the late 1980s that number was five
times as high. Peer pressure and media influence are responsible for this
tremendous increase. The paediatrician advising the adolescent to postpone
sexual activity until the gap between physical and mental maturity decreases
should stress that even by age 19, 20-25% of adolescents have not had
intercourse. He or she should reassure teenagers that virginity is normal and
not a disease and that the alternatives of petting and mutual masturbation can
be explored.The counselling objectives should also include the limitation of
sexual partners as STD, hepatitis, chlamydia, trachomatis and especially devastating
AIDS are nowadays of great concern. A caring and interested paediatrician
having won the adolescent’s trust is the  person who can persuade the youngster to
delay coitus until eventually a monogamous relationship can be established.

The
paediatrician discussing with the adolescent the various methods and techniques
of contraception should not omit to point out that:

a)   the risk of pregnancy is
considerably lower if two contraceptive methods are used together consistently

b)   many pregnancies are due to method
failure and not to inappropriate or     inconsistent
method use

c)   failure rates are in adolescents
higher than ones reported for each contraceptive method due to ignorance or
lack of experience

d)   birth control should always be
combined with prevention of STDs. Thus oral contraception
does not protect against STDs As most adolescent girls are not compliant with
the pill and intercourse is mostly sporadic in the majority of teens condoms
and foams are usually better contraceptive choices.

A further role
of the paediatrician is to help his chronically ill or disabled patient to cope
with contraception. He is the one who knows better than anyone else the
torturing problem of the young person who enters puberty and develops sexual
drive. Many chronic diseases are prohibitory for oral contraceptives and
barrier methods such as condoms, spermicides, diaphragms and sponges are
preferable.  Nevertheless, physical
disability may prevent an adolescent from correct use.

The most
important contra-indication for oral contraceptive use is cardiac disease.
Epilepsy is not an absolute contra-indication, in contrast to migraine, while
oral contraceptives do not pose an increased risk to patients with multiple
sclerosis. Asthma attacks are not exacerbated with oral contraceptives which
are absolutely contra-indicated in patients with cystic fibrosis.

With caution
and only in stable cases of Crohn’s Disease could oral contraceptives be
used but never in active liver disease or cirrhosis. Although diabetes mellitus
is also prohibitory for oral contraceptive use, as the latter causes a decrease
in glucose tolerance and exacerbates diabetic complications, paediatric
diabetologists tend to favour oral contraception fearing that a teenage
unscheduled pregnancy of a diabetic mother is more harmful than the controlled
use of contraceptives. On the other hand, thyroid disease is not influenced by
its use.

Adolescents
with iron deficiency anaemia due to heavy menstrual flow often benefit from
oral contraceptives. Also, cases with factor X deficiency or Willebrand’s
Disease claim lessening of bleeding tendencies. Sickle cell haemoglobinopathy
is in general a contra-indication.

No evidence
exists that oral contraceptives have an adverse effect on non-hormonal
dependent tumours. Adolescents with depression or on anti-depressants might
deteriorate with their use. Oral contraceptives should be avoided in teenagers
with systemic lupus erythematosus. No data against them exists in cases of
rheumatoid arthritis.

Young patients
in haemodialysis may suffer from hypertension or thrombo-embolic complications,
thus oral contraceptives should not be used. The same applies to teens with
renal transplants.

How should the
paediatrician cope with the adolescent found by chance pregnant?

Young girls
visiting the paediatrician complaining of various symptoms and not aware of
their pregnancy pose a difficult problem for the physician who must have high
index of suspicion and sensitivity to reveal reality. The young person needs
support to express her feelings, to explore all options and make the right
decision about the continuation or termination of the pregnancy. The
paediatrician should provide her with specific information concerning abortion
procedures, perinatal health carer, adoption or foster carer possibilities for
her offspring.

The counsellor
should suggest the participation of the adolescent’s parents and maybe of
the putative father to a discussion, before any decision is made.  Paediatricians especially have increased
responsibilities towards parents of minors. Abortion counselling should refer
to the procedure and its risks, which are less compared to those associated
with birth giving. If the adolescent chooses continuation of pregnancy she
should be promptly referred to gynaecologists for prenatal care. As the hard
task of caring for the newborn will fall on the grandparents the counsellor
should advise unmarried adolescents to involve their parents.The paediatrician
should not forget to explain to the young pregnant girl child rearing as babies
have been often unintentionally abused by their teenage mothers. Reintegration
of the young mother to school and adaptation to the new situation is another
field where the paediatrician should offer his help. Last but not least, the
importance of contraception in order to prevent a repeat pregnancy should be
explained and stressed.

Finally - do
paediatricians feel competent for all these tasks?

Although the
American and many European Academies of Paediatrics formally have recognised
adolescents belonging to the practice, “boundaries of paediatrics since
over 20 years” a study published in 1984 states that 66% of graduates
from paediatric residency programmes in the States feel inadequately trained in
adolescent medicine, especially in gynaecological counselling and contraceptive
services. Therefore the help, advice and medical care from the gynaecologist
specialising in adolescent medicine is invaluable. But as adolescents feel
easier communicating with physicians they know from their early years than with
internists or gynaecologists who they meet for the first time it is urgent for
paediatricians to learn more about teenagers and their problems rising from
sexual activity.

With the
collaboration and active participation of the adolescent gynaecologist,
physical and psychological support will provided to adolescents aiming at a
better health carer for conscious individuals.

THE LUNCHEON CLUB

My name is
Daniel Anderson. I am a student at Kingston University, in my first year of the Diploma in
Social Work. Youth Support House has been my placement for a three month
period.

During my
placement I have been actively involved in running “The Luncheon
Club”. This activity involves staff and residents preparing a two course
meal for older members of the local community. Residents develop their life
skills in such areas as cooking, communication skills and self achievement.
These factors contribute to the promotion of self esteem and value as an
individual.

The Luncheon
Club was established as part of a philosophy to provide residents and their
children with a “surrogate grandparent” figure. Many residents have
not had the opportunity to be encompassed within this healthy family dynamic,
as many have lacked a positive parent figure within their lives. The three
tier, transgenerational aspect provides residents with a good model and
positive framework of the dimensions of family life of which they can be part
within this context.  This activity
provides an avenue for conversation and interaction between residents and local
members of the community.

The integration
of local members of the community and residents is an important aspect. The
setting is within a safe and unthreatening environment where active interaction
can promote a “bridging” with reference to some residents thoughts
and anxieties of isolation and segregation from the surrounding community.

The underlying
format acts as a useful therapeutic function instilling within residents a
notion of self worth and value, in terms of residents engaging fully and on an
equal basis with staff to produce a finished product (the meal) To give
something to others and receive appreciation for this is a positive form of
interaction which may not have been in existence in their previous home environments.

The programme
is run on an informal basis, it offers staff a good chance to talk to residents
regarding problems they are facing or experiencing without the structure of a
formal therapeutic session. This informal setting can provide a good foundation
for relation building and the development of trust.

The Luncheon
Club has been running for some time now, and continues to draw upon the need
for resident participation. The development of life skills, communication
skills, self esteem and value are all contributory elements of the Luncheon
Club in respect of the whole therapeutic timetable.

Daniel Anderson

(Social Work
Student)

A Window
of Opportunity.

?

Adolescence can very much be regarded as a ‘window
of opportunity’ allowing us a chance not only to see some of the ‘early’
emotional and psychological mechanisms in action - but also a chance to work
with , treat and modify some of these early traumas.

This was the basis of the philosophy of the IRC
workshop in Washington March 1996.

The ‘Youth Support’ contribution centred
on three cases. A young girl  Ann  who had been a street child after a
number of difficulties at home, who had been sexually abused and who found it
difficult to separate and understand her feelings of love and hate for her step
father.  Barb who had such a level
of undealt with pathology that she had reached a position where her ‘object
relations were so disturbed that she was beyond help. And Carol who was at an
earlier stage in her progression, had been sexually abused by her father but showed
signs of being reachable and ‘treatable’ - a hope for the future.

The  initial
presentations were as follows -

ANN

Initial
presentation as a pregnant schoolgirl

Abusive
relationships

?possible sexual
abuse

Eventual Outcome
?

Child protection
issues

BARB

Initial
presentation as a pregnant schoolgirl

promiscuous -
First sex at 10

?possible abuse

Eventual Outcome
- ‘Murder Trial’. Psychopathic personality.

On-going child
protection issues.

CAROL

Initial
presentation - sexual abuse

Eventual Outcome?

ANN

At 12yrs Ann accused
her stepfather of abuse. This followed a long period of acting out and being ‘out
of parental control’ at home. Her natural father had left home some years
earlier and Ann resented his leaving and despised her mother for taking on
another man. Mother threw her out.
There then followed a period of drug abuse, vagrancy, ‘street
child’.

At  13yrs she met Billy her boyfriend in a police
station and immediately struck up a close relationship - seeing themselves as
kindred spirits. he too was vagrant, had been abused, was  using drugs, into crime and involved in
considerable violence and she describes how - she alone can see what a
beautiful person he really is inside.

Eventually Ann
was taken into care although this was not a happy experience - she was sexually
abused on a regular basis by an older man who lived near the children’s
home and who supplied drugs to all the girls in the home. Ann continually
absconded to be with Billy on the streets. When she became pregnant she was  transferred to YSH where her therapy
programme began and at 14yrs Robert was  born

The family
dynamic for Ann was very much based on competition with Ann at the centre of a
wheel of jealousy and family members scoring points off each other. Ann was
jealous of her sister, they had children at the same time, organised
christenings at the same time. Sister was older and Ann perceived her mother as
loving sister more - so when she seemed to get attention directed at her baby -
Ann had a baby too - to get mother back. Unfortunately most of Ann’s
attempts to make them ‘love me too’ ended in failure and thus her
return to an unsatisfactory and harmful relationship with Billy - who would
never find anyone else. Their relationship was totally dependant and manipulative
for example, would self harm and cut himself if she did not abscond to see him.   After the birth of her child , the
question was how would Robert fit into this dynamic - would there be any space
for him?

CONFLICTS
AND COMPETITION

SISTER                                            STEP-FATHER

ANN

MOTHER                                               BILLY

? ROBERT ?

Ann’s
dilemma was in confusion of roles -
in discussing the mechanism whereby this confusion arose we need to consider
what the dynamics are of relationships -

Ann / Mother

Ann
/ Stepfather

Ann
/ Boyfriend

Leading to
influence on ....

Ann  / Baby

Ann  / ‘Carers’

This is very
much an exercise in ‘object relations’  - in that the manner in which Ann was
treated as a young infant - the way she perceived her world and the people
around her - the way she developed her ‘object relations’ was
fundamental in shaping the relationship with mother - and this relationship
formed the basis for all future relationships. Hence there were parallels
between the relationship Ann had with step father and other men including Billy
- ‘expecting’ abuse, responding to manipulation, trying hard to please
others, not really having her own needs met.  We could see this pattern ‘mirrored’
in her relationship with staff in the unit. Hence we had clues as to how this ‘transference’
operated, how Ann related to people and how we might proceed to help her modify
some of her responses. It also gave clues with regard to the way she might
relate to her son.

Only time will
tell whether her world will have ‘space’ for Robert. For some time
the future looked bleak - Billy’s influence was negative to the extreme -
he had no room for a child in his life and he saw the child as usurping his
position - hence Ann was manipulated into another ‘power struggle’
of jealousy - which baby would she care for? At the moment things look better.
Ann is responding to therapy and appears to have chosen her son Robert over
Billy his father and Billy is currently off the scene - but for how long?

BARB

Barb could have
had a similar life course and outcome to Ann but she was more damaged at an
early age and had very deep disturbance of her ‘object relations’.  What the trauma was at that early stage
is impossible to tell. Her family know of nothing specific and in some ways she
has ‘always been like this’.  ‘This’ is cold , cruel and
uncaring of others.

She began her
sexual history at 8 or 10 yrs and was highly promiscuous. Barb could not be
confined, she ran off to meet men and even put a ladder up to her bedroom
window to let men in to have sex with her. Pregnancies began at 12 and she had
four pregnancies before the age of 16 having given birth to three children by
the age of 17. When Andrew was born she handed him over to her parents and was
unconcerned with him thereafter.

Pregnancies -   13 yrs    (1)   Andrew

14 yrs    (2)   TOP

15 yrs    (3)   Matthew

17yrs     (4)   Tricia

Soon after her
eighteenth birthday  - within the
short  space of 8 weeks - the
following had transpired -    marriage
ended - new partner -  Matthew DIED,
Tricia removed for neglect and possible abuse.  Matthew died in horrific circumstances which
were gorily reported in the national press at the time but although found
guilty of the lesser charge of wilful neglect and imprisoned for 6 months, Barb
never acknowledged any part in neglect or harming her children. She never
accepts any responsibility for her actions or their effect on others.

Her history
continued with  - 20yrs - Trial -
Prison - Pregnant (5) Baby removed at birth.   23 yrs pregnant (6) David - After his
birth she was sent to YSH for assessment and treatment. 25yrs(7)  TOP.

Consideration
of Barb’s object relations reveal a depth of psychopathology. A deep
splitting between the ‘good’ and the ‘bad’ and a total
lack of any coming together of these elements. Within the unit we could see the
‘transference’ aspects of this - she would adore (usually
inappropriately) or hate (very frequently and intensely) the same person at
different times and have no perception whatever that this was one and the same
person - or that the individual might be harmed in any way by her ‘murderous
attack’ - she would have no expectation that there would be any consequence
whatever of any of her actions and no capacity whatever for remorse.

Sadly Barb was
beyond therapy -all that could be done was to an extent to ‘contain’
some of her destructive potential. What happened early on to cause this? What
would it take for an Ann or a Carol to have turned out this way? What
protective mechanisms did they have which safeguarded them from such extremes?

CAROL

Carol when
first seen was the least ‘deviant’ of our three cases. She had been
abused but had not yet fallen prey to drugs, self harming or serious acting
out. Her history was that at 11yrs her Mother became seriously ill - with heart
disease. At 12yrs mother died. Thereafter she and father had difficulty coming
to terms with their grief and between
12-13 yrs Carol suffered sexual abuse by her father.

After disclosure
of this abuse  at 14yrs she was
removed to foster care and a year later at 15yrs referred to YSH.   Carol made good progress in
therapy which was initially on a ‘psychodynamic’ basis with time
spent in our ‘animal therapy’. She warmed to the animals and
developed trust in the unit. Carol had a very difficult stage following the
disclosure by a social worker of her address to her father - she went through a
period of acting out and attempted to prostitute herself to mini cab drivers -
fortunately she was picked up and brought back home.

Eventually
Carol’s therapy came to a focus when ‘story telling’ therapy
allowed her to write a tale about the animals with which she subconsciously
identified.  Her story of a hurt
kitten brought out her own hurt, anger and need for protection and was a turning
point in her progress.  Hopefully
Carol will be able to maintain her positive growth and leave her abuse behind.

“The Child That
Rocks the Cradle”

A fifteen year LONGITUDINAL
study of school age mothers and their children.

Dr Diana M.L. Birch

This book, although standing
alone as a comprehensive account of
early parenting, is also the sequel to “Are you my sister,
Mummy?” and depicts the next phase along the road of parenthood.  These are the same mothers, fathers and
children fifteen years on. How did life turn out for them? - What kind of
families did they create? - What is going on for their teenage children?

The findings of a fifteen
year longitudinal study of 200 young families in which the mother gave birth
under the age of 16 years has provided information which refutes many of the
stereotypic views regarding young parents.
It illustrates how the presence of a supportive family leads to an
improved prognosis for young mothers and their children and gives insights into
positive and negative predictive factors. Some unexpected outcomes and their
possible aetiology are discussed.

Consideration is given to
approaches which may enable professionals to confront the ‘cultural
trap’ in which many young people are caught - in that those suffering the
worst deprivation in early childhood, those raised in the ‘care’
system and children’s homes are those young parents most likely to
perpetuate the cycle of deprivation for their offspring. ISBN:  1
870717 08 2

The Journal of
Adolescent Health and Welfare

is published by:-

Youth Support

13, Crescent
Road, London BR3 2NF

Charity No 296080

Tel No 0181 650
6296

Fax No 0181 659
3309