ISSN 1363-8394

Journal of Adolescent Health
and Welfare

Volume
11 - No 1 - Spring 1998

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

Letter from the editor -

Dear Colleagues,

So this is the big ‘conference year’
the International conference in October is really shaping up and the number and
variety of presentations are truly amazing! Please book up early and encourage
colleagues to do so too. With such a large audience we do need to process
applications as soon as possible - both for participants and for audience. SO
apply now to avoid disappointment.

We are also accepting referrals now for our
semi-independance unit / half way house - details overleaf.

Best wishes for a prosperous 1998 and I hope you
will keep in touch with Youth Support and our activities throughout the year.

Diana
Birch

Director
Youth Support

* CONFERENCE ROUND UP *

- Personal views of  those attending recent conferences -

' Reclaiming the Black Family '

Nurturing the Black Child's Positive Self Concept
-Pat Freeman -Team leader, Youth Support House

A two day intensive course run as part
of Lewisham's Black History Month '96.The aim was to focus on black children
from an African and Asian perspective. Training aimed to provide participants
with skills and knowledge required to provide positive self awareness in black
children and to foster within them a sense of self worth and empowerment. The
group consisted of teachers and project workers who worked with children from a
multi ethnic background. Through group and individual work many of us achieved
this and more. We looked at ways to apply the work to our practice.

1. What
is in a name? Each person introduced themselves by their name and was asked
to tell the group what their name meant and why they were given that name.  A name not only identifies you but can
also be representative of culture, century even the region in the country.A
name may involve history which incorporates story telling to be passed on from
generation to generation i.e. an African child need not feel ashamed that his
name is different from the widely used English names of his peer group.  If he is true to the significance and
importance of his name with pride, self love will follow.

2.Blackness
& Invisibility Debate in small groups on how we made ourselves
invisible during our childhood,when we did not want to make ourselves noticed
due to feelings of inferiority.This gave insight into how a child feels in
minority groups and ways in which they deal with it which may range from
obscurity resulting in lack of development thus not achieving their true
potential, to un-acceptable behaviour to draw attention to the fact that they
are different from everybody else and their needs are different which has not
been acknowledged by wider society. Negative images of black people have
evolved through history.  The future
of any race is largely dependant upon the care, education and nurturing of its
children.Family is the mainstay of provision here but other systems have a
share in the black child's development such as education or the care system
taking on the family role.

'Culture' is a process which gives people
a general design for living and patterns to interpret their reality. Not just
about clothes, food and music. Namonyah Soipan looks at the ways in which the
positive concept of the black child can be enhanced.The culture must
participate in educating the black child for instance using history sessions
involving story tellers from different cultures. Secondly become aware of and
respect the holidays black people celebrate. Third- Monitor what black children
watch on TV or cinema - much negativity is portrayed of black people usually
the villains, under achievers. Do not accept negativity by exposing them to
this. Raising the black child's positive self concept relates to their
blackness, emphasising positive qualities of being black rather than creating a
superior attitude.

First
International Conference on Health and Culture in Adolescence -
(continued from last edition)
‘The Israel
Experience’

Comment
by Esther Mensah, Senior Care worker Youth Support House

Having been associated with the
Christian faith all my life, the opportunity to visit Israel for an
International Conference on Health & Culture in Adolescence, November 1996
was a blessing to me. Visiting Israel has always been a dream which became a
reality. All the difficulties and sense of hopelessness, faced at the initial
preparatory stage were worth going through for the experience. The brief
glimpse of a small part of a country with so much religious history made a deep
impression on me and I am grateful to be one of the delegation of four from
Youth support who attended the conference.As my other colleagues have written
in their accounts about the conference, I have decided to write about the
"lighter" issues of the trip and my experiences in general. Our
departure from Gatwick Airport on 22 November 1996 was without problems and on
arrival in Israel we were met at Ben Gurion International Airport, Tel Aviv in
the early evening for a drive to Jerusalem.  Being the beginning of sunset on Friday,
we noticed the roads were almost empty with just a few cars around.  Our escort quickly explained to us that
it was getting to the "Sabbath"
quickly triggered a wave of thoughts in my mind and a sense of excitement
that we were actually in the biblical land.  As dusk was setting in we didn't see
much; the landscape, buildings were all hidden to unfold as a surprise the next
day. The landscape was breathtaking and it made the greatest impression on
me.  All around were hills and
valleys of white rocks and stones.Buildings particularly in Jerusalem were built
with these white stones making the built areas long stretches of uniform colour
interspersed with greenery of trees and shrubs. Jerusalem
seemed a city of "ancient and modern" merged together where one sees
very old buildings with cobbled roads and just close by very modern 20th
century buildings- the lifestyles of the people showed this diversity.  There were Bedouin communities (living
according to tradition patri-lineal patrilocal, patriarchal, endogamous and
occasionally polygamous)  There were
the very orthodox strict practising Jews and Muslims who were recognised easily
by their clothing. There were also those living liberal lifestyles who were
unorthodox in any form or shape.

Despite the busy schedule we had the
opportunity to enjoy various biblical places unique archeology the beauty of Jerusalem
as spiritual centre of three great religions existing through 3000yrs, energy
and vitality of the modern state of Israel.

The first biblical place we visited was
Bethlehem,
birthplace of King David and 1000 years later of Jesus. It was just 7 miles
south of Jerusalem
in the Israeli occupied territory
of West Jordan
(west bank). We visited the famous Church
of Nativity,
clustered together with the Grotto of Nativity,chapel of the Manger, Saint
Catherine's church and Milk
Grotto
Church
serves three major Christian confessions in the area catholics the Greek and
Syrian orthodox eastern church and the Armenians.

There were visitors from all over the
world and every group had a tour guide explaining things in different
languages. The icons in this cluster were very inspiring. The next place we
visited was the Mount of Olives
and Garden
of Gethsemane
where we saw olive trees said to be dated from biblical times. We sat on a rock
claimed to be used as a resting place by Jesus and his disciples.

Masqda, an archeological site on a high
plateau, was a famous historical place. We rode on the cable car conveying
visitors to the site where we saw one of the bases of Herod the Great, King of
the Jews. Ruins of one of his palaces showed an intricate swimming bath for the
king. Other places visited were Nazareth,
Tiberias, Capernum in the region of Galilee
with a boat ride on the famous Lake
of Galilee.
On our way back from Galilee
we went to the Dead Sea
where we had a dip in this famous sea. At the river Jordan
we saw a group of Christians being baptised by submersion and the singing and
cheering after baptism was inspiring. We drove through the Judean desert where
long stretches of rocky mountains without trees were spectacular There remained
a few interesting sites we did not see, but the experience will always be
treasured.

Saving Children from their Monsters

Priya Kanthan - Teacher and nursery
teacher at Youth Support comments on a newspaper article which has resonances
for our own practice at Youth Support House -

"Michael, you are sitting up
beautifully", "David, I love the way you put your hand up to ask a
question" and "Now Anthony, you are ready to come back to the lesson
now". Six year old Anthony had been taken from the room after throwing
himself to the floor, crying and shouting trying to disrupt the lesson.  This behaviour has always helped him to
get attention, in his old school. So Anthony would be taken out of the class
quietly and he could rejoin when he calmed down.  This is a very typical scenario when you
are a teacher dealing with some of the most disturbed and chaotic infant-aged
children.

A centre in Kingsmead in Derby,
is the only pupil referral unit for infant school children in Britain.  The Centre costs 3 million pounds per
year to run, and supports 114 children who attend regular schools around the
city.  The Kingsmead children, most
of whom have been statemented for special education behavioural needs are
supported by a team of specially trained educational and care officers.

Most of these children come to the
Centre for four afternoons each week because their behavioural problems are so
severe that they cannot cope with full-time education in an ordinary
school.  Despite their age most have
been excluded for violence in the class, throwing furniture,swearing at and
abusing teachers or other children. It can hence be seen how disruptive this
would be in a normal class. One child has never been to school because of a
history of disruptive behaviour in his nurseries.  The head of the Centre said that the
work done in this unit is vital because if children with problems at this
tender age were excluded and no other school will take them, they are referred
to a special school and it is very hard to get back into mainstream.He also
adds that these children are effectively toddlers who cannot collaborate with
other children and their play is very self-centred.  The Centre's job is to encourage them to
understand that they are real people and have true feelings and that they are
valued by us adults

Nearly all children sent to the Centre
have suffered major trauma in their short lives.  One 5 year old child had been in a 19
foster homes already. Such children cannot be expected to sit down and follow a
National Curriculum when their lives are in chaos.One of the children will
scratch herself until she bleeds, if disciplined.  The teachers in the unit have learned to
sit still with folded arms, as a response, rather than leaping forward with
tissues.  Another child may stab
himself with a pencil for attention if the teacher would praise another child,
he would then cry out "Ow, it hurts, I'm bleeding! I don't like doing this
work!”.This is a typical response and often to ‘ignore’
helps.

The Centre has a large classroom
decorated with the children's work. The room is sectioned into reading area,
play area. The work done here is very structured and the staff's aim is to
bring consistency into the children's lives. The general rule is that when
staff say something it will happen including a punishment for bad behaviour; it
happens.

The children arrive around 12 noon
and are immediately subject to a routine.
The session ends at 3pm
with a drink and a biscuit

It is vitally important to have this
early intervention. Any infant or Nursery Teacher can identify a child who is
going to have problems but if you can break the cycle of violence and
disruption at this age then you have a better chance of having a positive
effect on their educational and life chances. WE also can avoid some of the
problems that re-surge in adolescence causing disruption and teenagers excluded
from school or society. We should be more aware of the problems in very young
children and methods of tackling them. This unit works in partnership with the
regular schools and helps to avoid the devastating effect one child can have on
a general class. One little child was seen to be very quiet and withdrawn in
the unit and was building something with bricks. The child's parents had died
recently when asked what he was building, the child replied "A safe house
where monsters can't come".

We have similar children at Youth
Support House. Paul was a 4 year old boy who had a series of emotional
problems, he was a damaged child with unacceptable behavioural patterns. He had
a very unstable home and was separated from his natural mother and put into
foster care until re-united for a short period with his mother at Youth Support
House giving both mother and child help in terms of education,counselling and
therapy.  Eventually Paul returned
to foster care due to mother’s rejection.Paul lacked love, security and
above all consistency. His behaviour continued to be disruptive and abusive,
physically and verbally. Will he now continue to slide towards a disturbed and
insecure school life and adolescence?

- 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

Poverty and Neglect - Deprived Youth in varied
societies.

Continuing
the transcript of IRC institute 1997

‘Deprivation among
immigrant Youth’

Dr Manny
Chigier - Israel.

My own
experience in the last twenty five years is of working with an organisation in
Israel know as the Youth Alliah devoted entirely to the resolution of problems
and educational advancement of adolescent immigrants to Israel. We have
established what we call youth villages - that is young people living in
residential settings which provide both the education opportunities and also
social and educational advancement as such.

In the last
eleven years we had the rather unique experience of Ethiopian adolescents,
immigrants from rural Ethiopia, into the modern western technological
society of Israel and in the last 5 years we have been
working with adolescents from the former soviet union. We have to realise that
many immigrants from Russia actually come from the eastern states which have a
very distinctive cultural pattern of their own.So this has resulted in the need
particularly in my own work for me to become not only a physician partly a
psychologist or psychiatrist for which I have had the opportunity of training
but also to become knowledgeable in health anthropology. I wish to emphasise
that word because as Bob Blum indicated in his talk that is particularly
important we need toconsider ethnic minorities existing all over the world.

All over Europe,or middle east, we cannot work with ethnic minorities
without understanding their culture of the environment in which they grew
up.The subject is deprivation so let us just list what happens when a young
person moves into a different society -what deprivation occurs. The most important
one is the loss of a role model. Parents who come as adults into a new society
have difficulty coping with their own adjustment and they have great difficulty
in providing an adequate, positive role model for their young people-not the
young children, but the adolescents.

Another thing they lose is the knowledge they have of being able to do
things in their own environment.
The new system is entirely different, the language, the
experiences-imagine you are a fifteen year old Ethiopian and you have never
been to a doctor in your life.You come to Israel and after three months you
have a cough, you go to a doctor and he examines you and gives you a little
note and he indicates down a corridor to another room where someone in a white
coat summons you into a darkened room and tells you to take off your shirt, put
your arms around some metallic monster and tells you to stop breathing and then
runs out of the room!  He thinks
it’s crazy, there’s no logic in that. One of the things I emphasise
is the lack of cultural logic to fit the events.There are many obvious things
like housing and jobs and lack of food. Another important issue cultural
bereavement - the mourning for loss of culture was brought to the fore by a
Marius Isenbrook an Australian psychiatrist who had worked in Cambodia. So how do people who have lost
something react? There are three reactions - one is idealisation - we speak
well of someone who has just died and think of the marvellous things he did and
so when you are in another country and you begin to experience difficulties -
you can imagine how much better it was in your own ‘lost’ culture.
We hear how Russia and Ethiopia was so much better from these people -
idealising what they have lost.

The next reaction is denial - I can’t believe this has happened,
I can’t believe this person died and so they cannot believe that forever
they are not going to be in Russia or Ethiopia or Turkey for instance. Perhaps this is  temporary and we will go back.

The third reaction anger - what the hell are we doing here - why did I
get into this situation? A particular example comes from the work that I was
doing with sexual counselling of the disabled - one young man was accidentally
shot by a fellow soldier in the spine and developed a paraplegia and his most
immediate and intense desire was to know can I be fertile? Do I have sperm -
well we took him into the spinal injury clinic three times to check the results
of his fertility tests,eventually I told him that he had an infection following
the injury and he had practically no sperm at all - and he looked at me and
said ‘One of these days you are going to get it from me - I’ll see
that you get ‘fixed’ for what you have just told me’. Well we
all know of the bad messenger - he who brought bad tidings - they killed the
messenger in medieval times because he brought the message to the king. The
Army is destroyed - so kill the messenger. We as doctors have to relate to
people we are often the bad messengers - we tell them they have TB, that they
have malaria and so they are angry with us - we have to understand when they do
not co-operate, when they are angry - that is a kind of reaction.

Another response is to wait for miracles - wait till tomorrow and
everything will be marvellous -sure Ill get over my tuberculosis - give me a
week and I’ll be finished with that. So miraculous expectations as such.
Bob Blum has mentioned the importance of a belief system in common - which is
one of the few things that the Ethiopians and the Israelis have - a common
belief system - this can work in two ways. An example of people who were
involved in the holocaust - they can come out of such an experience completely
disillusioned with the concept of a superior being - how could there be a
superior being in care of us Jewish people and allow six million to be
destroyed - on the other hand there are those who come through the same
experience and say - how can it be that I have come through all this and
survived when so many others did not - there must be a superior being that
allowed me to survive. It can work both ways from that point of view. So what
do adolescent immigrants bring with them into the new country - the new
environment. One thing they bring is their bodies. We had a very interesting
presentation at our health and culture conference - a physician from Norway who deals with immigrants from a number
of cultures. She felt that since they bring their bodies - the development of
those bodies was a very important feature - so body building for the adolescent
males is important to them - comparing who has bigger triceps and seeing who
has the ‘better’ body. We as doctors work with their bodies - so
care of these bodies is something we should be encouraging. For an Ethiopian
girl - it is very important for the girls to braid their hair - this is part of
their body image - also one should understand that they do not consider
themselves black but dark brown - a joke in Israel is of two Ethiopian girls
who see two Yemenite girls in the street and say - gee these Scandinavian girls
are beautiful So everything is relative.

One problem with image is that whenever we have a new wave of
immigrants from one part of the world or another - many of the officials cannot
understand the names in Ethiopian or another tongue - so they give them new
names - the only thing you have with you is the name you brought with you - now
that is lost too.

They bring with them notions - certain notions about the world - for
example - there was a refusal to have blood taken for clinical investigation -
and if you look at anthropology you will see that their notion is that the
amount of blood you have is a constant and does not replace itself so why
should somebody take ten ccs of blood from you - if someone took ten dollars
out of your bank account you would object. Local therapy was given in the
villages - if you had a swollen foot you were given a poultice.Where is the
logic in putting something in your mouth to cure a swollen foot

Tradition in Ethiopia forbids marriage up to the seventh
generation. The extended family would keep a trace on who these relatives were
so you might find you cannot marry your boyfriend - though you may be 14 and
pregnant because you discover he is only three generations apart. You must
accept this tradition or be rejected by the family.

Let us go on to some clinical considerations. A very strong reaction
to a problem is psychosomatic illness - for example stomach pain from a problem
- in Iraq it was more ‘I can’t breathe’ so
a lot of asthmatic illness - others may say ‘it hurts my heart’ -
so chest pains. For Ethiopians it is the stomach - they have a saying,
‘the stomach is larger than the world’ in other words you swallow
the problem. Eventually there may be an abdominal problem. There may be pseudo
psychiatric symptoms - perhaps almost looking schizophrenic, very vague, losing
interest - we worked with an adolescent psychiatrist who did not immediately
put people on medication right away because they were in an ambulant situation.
Give them a week in the place and you discover what is called an adjustment
reaction - when people are reacting too much they need time out and everything
will settle down. They may begin to act in a confused state but medication is
not the answer. You just need someone from their own culture to come in - no
doctors, no medication, just someone who has been here a year and can identify
with what they are going through.

Of course there are psychiatric problems - but most are
pseudo-psychiatric. If you have someone in this state, you put them on
medication, they don’t cooperate, then you have to restrain them. You
have created a dreadful situation. Where can you go with them after they have
had 3 months treatment and are in this sort of state? There’s nowhere to
go- you are classified as an Ethiopian,an adolescent, a psychotic -
that’s it! Then there are problems such as suicide -taking up negative
aspects of your new society - what happens when you learn a new language? The
first things you learn are the swear words - and so they want to go into
smoking, sexual patterns - things that make them seem more Israeli.

What can we as physicians do to help these people, to improve their
health situation. First is to avoid being judgemental - we always have a
tendency to consider people from different backgrounds who are not coping as
inferior somehow.Talk about class differences - there is always that -they may
not be able to use the toilet - have come straight out of the countryside and
have never seen flush toilets. My reaction to that is that if we took you a
qualified physician and left you in an Ethiopian village and you had to find
your way through a forest or a jungle for ten kilometers - how the hell would
you cope? So they don’t know what they don’t need to know we need
to give them information. We have another example - we use young people to
teach hygiene to the older immigrants - these are sixteen year olds who have
been 2 or 3 years in the country. One of the stories that someone obviously had
quite a severe infection of the skin and this young person said, didn’t
you go to the doctor- yes I went to the doctor - and what did he do - he gave
me a little note - what did you do with it - I hung it around my neck.He
assumed it must be an amulet - nobody seemed to think he needed to be told -you
use this note to get medication and then you use the medication in this way ..
Another point is to go beyond the initial complaint - we all know an adolescent
will come with a pain in their ear when they really want to ask you about
something else.They  throw you the
question just as they go out the door - by the way I think I’m pregnant!
One could say so right at the beginning - so it’s important to have a
little check list to go through. The name - that’s important - what is
your name and what does your name mean - it only takes two seconds to ask that
question but already you have personal contact and have broken a barrier with
that young person. Doctors never have time, but it’s a question of how
you use that time where you put the priorities.

Using a few words in their own language is very powerful - Harry
Belafonte was performing for 20,000 people in the local park there and he said
‘le- itra -ot’ which means see you again , and the whole crowd went
crazy. President Kennedy walks into the 100,000 people out here in Germany and says ‘Ich bin ein
Berliner’ - nonsense! but they remember him 30 years later that he went
there and said ‘I am a Berliner’. When our prime minister was
assassinated President Clinton spoke on TV and he said ‘Shalom ha bere’
Farewell friend - three words - what did we get three thousand stickers in
Israel saying those three words - stuck on walls, on food every sort of thing -
amazing to use these words to make such a connection with somebody.

Another thing I like is to keep communication going - not close the
case -say ‘if you feel bad come back, or you can always write to
me’ something to keep the door open. It’s amazing how people
remember, come back ten years later and say - remember you said if I needed you
I could come back - I didn’t need you , but I remember you said that.

Lastly a find of way to work with other staff - multidisciplinary -
using social workers and other disciplines makes life much easier. The indirect
method can be useful - I have a friend who had this problem. Rather than -I
think you have this vaginal discharge because you had sex - one could use an
indirect approach - you know last month I had someone come in who had the same
problem as you and it turned out to be caused by having sex - do you think that
might be the case for you too? An indirect way of leading into the question.

In health education we often use movies to help - and one we often
show when looking at adjustment is called ‘Victor’about a Mexican
kid in California trying to be organised and in Israel we say -well could this
happen here? Two little stories to show what could be done.A girl of sixteen
managed a record for Israel,she gave birth at the youth village two
years running quite unexpectedly because she was wearing the voluminous type of
dress that wear and she came to medical attention because she denied having sex
at all a psycho -social problem. What was the first thing she needed?- to avoid
getting pregnant again whatever the reasons so we arranged an adolescent
gynaecologist from a private clinic to have an IUD inserted.Now she got the
message- I am now protected. First pregnancy resulted within the family the
second by a driver on the last bus station on the way home - both cases of
sexual abuse and she cannot talk about these events. She had a period of
anorexia nervosa and during treatment she had her IUD checked regularly, she
attempted suicide. Two years later she is rehabilitated working in the army

Another Ethiopian girl kept vomiting- not exactly bulimic but she was
making herself quite ill. She refused psychiatric admission she had gone with a
group of Israeli adolescents to visit some holocaust sites in Europe, where youth are taken to help them
understand something of their history. This seemed to awaken a problem for
her,the youth village would not take her - she was considered too ill and
difficult to handle. So I tried the use of metaphors- instead of vomiting out
all this food- why not vomit out your problem. That caught on with her and
every time she came she would say that she was helping to vomit out the problem
and she started to eat the food. I continued the ritual of weighing her - when
people are in bereavement it is important to continue with the ritual as a form
of therapy. Now she’s doing well in school and is very bright I use the
metaphor of the sun being out and everything rosy and happy - but then a cloud
might come and block out the sun and everything may seem dark and depressing -
but the sun is still there behind the cloud even though we can’t see it
and it will come out again. So when working with ethnic minorities I stress
again how important it is to be a medical anthropologist, speaking in terms
they understand

Marginalized
Youth in British
Columbia

Roger Tonkin, Vancouver.

I don’t know how many have been
to Vancouver
- your impression probably is that of a beautiful city in a marvellous setting
with a fair degree of affluence in the society. Even then despite those
features we have our population of young people who are less well  served by society or in greater need and
I will talk briefly about them this morning. I will share an anecdote but
indicate that material I present is population based information not about
individual patients or scenarios. It is important to recognise that adolescent
health care is based on population as well as individual cases and we cannot
focus on one to the detriment of the other. When thinking of population based
approaches we need to think how that translates into action, programmes
benefiting somebody other than ourselves to give a paper or publish in a
journal. We have just  appointed a
Children’s Commissioner under mandate from the Justice Dept. One thing
they are mandated to do is review all deaths of children & adolescents in
the province, they were only looking at deaths of young people under the care
of the state when they realised they should be looking at them all.

The case I want to talk about is of an
infant who died in foster care of sudden infant death syndrome - that case is
illustrative firstly because sudden death syndrome means the child was under
six months of age. The child was born cocaine addicted and immediately placed
in foster care and it turned out this was the second infant death to this
mother and had cocaine addiction. The first child of three is also in foster
care alive not born cocaine addicted apprehended early on for neglect. The
reason being that the youngsters mother was a hooker, an aboriginal working in
the province - remember our province if you travelled 1000 miles north you are
still in BC and the same East, only 3mill people in the province so we have
quite a spread out population. When young people leave their reserves they get
onto the streets, especially young aboriginals. This mother and baby I review
was l4 when she hit the streets, getting into all the street scene and l7 when
she killed herself. We are talking about a very young life associated with an
incredible amount of  misery which
does not come through in the population based statistics. That is why I told
you this story.

Let us look at two populations - just
under l6000 students in all regions and 110 kids who live on the streets in Vancouver.
This population is special, reviewed in December by us. The others are only
there in summer or weekends. Almost the entire street youth population is in Vancouver,
the media make it big but it is small. We divided youth into 9 groups of
population based on very simple splits - if you carried a weapon you were
violent - it didn’t mention whether you were the victim of a fight,
carried a pocket knife, if you fought once in your lifetime - simply that you
were involved in violence. You can see students in school are largely non
violent and street people are involved in violence in some way. Mostly grade
7-12, population of really young are much less so- they tend to be older
youths. Males are a little more violent than females certainly in our province,
a high proportion are Asian so you see the Asian population is high risk as are
aboriginal as opposed to others - not living at home, mother employed full
time, could have given same information for fathers but usually the families
are more well off of other groups. Interestingly the majority on the street
said they did like school and a fair number  were thinking of returning to school.
Where did their income come from? They had jobs, we did a poll in 1993 and the
Govt have just changed the welfare system so that if you did not have 3 months
proven residency you did not get welfare - some get money from families, a fair
chunk are involved in the drug scene and prostitution. That is for income, not
necessarily trading a place to live for sex. When we compared youngsters in
school with those on the street it was interesting that with the exception of
cavities both groups had the same standards of general health. When you looked
at more specific areas of healthcare giving them labels you can see a higher
incidence of TB, anaemia and more concern with acne as well as more allergies
reported in street population. This may be part of the answer of why there are
complaints of respiratory problems because almost the entire street population
are smokers and in both male and female it is a less common reported problem.

You can see from chart 95% of school
attenders have never tried cocaine whereas the street kids are more likely to
use it, and similar findings were available for marijuana etc. Sexual activity
- basically the norm, this population remember being slightly older - but
school attenders are less sexually active than the street population although
interestingly the numbers are different to those  presented earlier. When you look at
partners over six months remember only a small proportion quoted prostitution
as a way of  gaining income whereas
school attenders have no partners or one. Certainly they practice monogamy.
First of interest is self recorded levels of emotional distress during
preceding three months and you will see high proportions of both males and
females presented more as emotionally disturbed than school attenders.Perhaps
it was slightly more obvious as a gender gap in street population than school.

We believe this study is one of the few
based on population approach involving self reported physical and sexual abuse
but I am sure it is of no surprise we can confirm the biases. You can see the
females on the street have a history of physical and sexual abuse, their lives
are an experience of youth and the same applies to the males on the street
having more physical abuse than any sub group which gives a sense of a
population who are experiencing more abuse in a serious manner.  Again there is the traditional gender
gap but the street group have a higher incidence of having been involved in or
been attended to for violent or suicidal attempt so suicide is very much a
piece of their life. They tend to get good medical care but mental health
services are not so good so efforts are being made now to address this group.

Remember first overhead of various
groups of population there is another group - this is pure speculation and
small piece of methodology. When we first presented  this we left out the non violent group
which represented 5 or 6 kids but if you look at this group 100% heterosexuals
the higher proportion of groups in school 95% of them considered themselves
heterosexuals, and this was based not only on practice but of the street people
only 20% of them see themselves as heterosexuals and when we looked through we
stumbled upon what we think is a different group on the street - more likely to
be suicidal, less likely to be violent, and we are not sure what that means so
we have a project working with the gay lesbian community looking at the issue
of suicide in the gay population. Another example of statisticians throwing
this stuff out but from listening to the kids they are saying we have to look
at this. We produced a report for release to the general population on street
people in a user friendly format,data is used for looking at marginalised adolescents
to motivate programmes. My pitch is that when looking at adolescents whether
street people, gay, aboriginal or kids with chronic illness we have to look at
population comparison and at what data tells us and how to get them involved in
whatever the issue may be.

Comment
from the president of SAM

Dr Gail Slap

I am delighted to be here, one reason
enjoying SAM growing internationally and secondly because only 12 hours ago I
arrived from Asia
where I have seen first hand some issues that provide care for adolescents in
that part of the world and I am convinced that we need to keep together and
provide judicial planning for adolescent service. I think this community within
SAM has grown amazingly and you are a testimony to the effectiveness of that
testimony - an extraordinary turnout increasingly recognised. Talking to people
in the inter-national community about work with adolescents is a joy for me.

I realised for the first time what we
are talking about when we go to other parts of the world particularly the
developing world. We are probably as inter-national as most in the field of
adolescent medicine but my work has increasingly pulled me into areas like
China Russia India and parts of Malaysia
and what I see is terrifying to a western eye, hard for us to know what goes on
for youth in the rest of the world. As those problems become global we have to
learn lessons from each other. Learn why families stay together, learn how to
prevent HIV in adolescents - the only way these things are going to happen is
if we co-operate more. My own personal work is more drawn to that
inter-national arena, one of the most exciting things. We can change more the
situation of developing countries now than we can in the developed countries
because so little has been done particularly in parts of India.
I congratulate you on your work, you are the biggest institute this year, the
ideas and energy give a deal to be proud of. The lions share of leadership was
due to Diana Birch I say a big thank you to her, she pulled this group together
and produced a wonderful programme

Nutritional
issues affecting Youth

Dr Semi Sznajderman, Israel.

Nutritional issues affecting youth -
deprivation poverty and neglect and I am bringing the other side of the coin.
Numerous problems pertaining to adolescent and nutrition, nutritional needs are
greater at puberty than at any other time except infancy. Unfortunately less
attention has been given to this despite long term consequences. Nutritional
issues impinge not only on immediate need and development but lifestyle leading
to chronic disease such as cardiovascular disease, cancer and osteoporosis.

In developing countries malnutrition is
the major problem faced by adolescents and I would like to concentrate on the
nutritional problems related to the disease of affluence, obesity, eating
disorders and specific nutritional deficiency resulting from unbalanced diet.
These problems once seen only in the so called developed countries and
increasingly is prevalent in developing countries due to the widespread
adoption of western values and lifestyles. Although this issue is not so
prevalent in developing countries as affluent countries, long term implications
and the likelihood of their increase may lead to serious implications and
merits effort in prevention. Unfortunately most doctors in nutrition are from
USA or Europe and little has been done on diet styles of teenagers in
developing countries however much may be learned by studying the surveys done
in developed countries especially in low socio economic groups.

Nutritional requirements in adolescence
-The major issues are relatively high fat and saturated fats recommended level
is 30% Recommended dietary allowance for adolescence in terms of energy
requirements in females 47% before puberty and 40% after but few attain these
levels. All nutritional needs are increasing during this period, and the main
deficiencies in this period are of calcium iron and Vit A.

Understanding current diet habits of
adolescents is important in order to identify problem areas and suggest
correction. In Western society adolescents have greater freedom and increasing
buying power for snacks and beverages. They can do that without parents help.
With decreasing parental supervision of nutrition and diet the path is set for unhealthy
eating pattern which contribute to disorders, skipping meals, breakfast,
snacking is common and reported in 80% of adolescents. Junk food tends to be
high in saturated fats, cholesterol and sodium.

TV and computer games account for a
substantial amount of daily routine of teenagers. This sedentary activity
coupled with snacking in response to advertising leads to a cycle of poor
nutrition setting a lifetime habit leading to long term problems detrimental to
health. Slimming is the ultimate
response to glamorous multi million dollar advertising programme of
weight loss products and globalisation of communication  internet and western ideas is likely to
be adopted by non western society with similar results. Our research study
included a study of the report by Susan McNab “Report on the Dietary
practice of black and white girls 9-10 years old over a 5 year period”
They took 5379 kids, finding skipping meals, snack food, use of fast foods were
common. Black girls were most likely to report any of those behaviours. The
reason was unclear. May have been related to behaviour and differing perception
of weight by the different social and ethnic groups. This study highlighted the
difficulty in generalising about diet practices of socio economic and ethnic
groups without taking into consideration cultural differences.

Little is known of eating habits of
developing countries and because of lack of information it would be useful to
assume that habits are related to adolescents in poor socioeconomic groups in
developed countries rather than high socioeconomic groups. It is revealing to
look at changes in morbidity in cardiovascular disease among African American
populations over the past decade, relating diet to atheroschlerosis  which has risen dramatically.

Recently Johnson studied the intake of
diet of adolescents between 11-18.
Deficiency in calcium, Vit A & B were common as well as over use of
saturated fats and sodium. African American from poor socioeconomic groups were
most at risk. This is not confined to the USA, in England 80% of children aged
12-13 in a poor area of London were in excess of ll% of total dietary intake,
25% of the girl’s calcium
intake was below recommended level and 30% ate no vegetables.

A report from Korea
gives an insight into dietary trends in developing countries. Population of Seoul
rose from 2.5 mill 1960 to 10 mill 1990, economic change created a gap between
low and high income groups in dietary practice. Meat fish and dairy produce
increased six fold in high income group compared with low income, more than 30%
of calorie intake coming from fats and 20% in poor group. Also lower income
group suffer from anaemia and malnutrition. In the higher income groups
cardiovascular problems have increased in Korea
accentuating the potential danger of adopting western diets and creating new
problems of over-nutrition of wealthy in parallel with malnutrition of the
poor.

In developing countries diet practice
means insufficient calorie intake - for example a study done in street food by
Nigerians in 1995 showed that all major food groups were represented in street
food - 50% of mineral and vitamin needs and 25% of daily energy needs
indicating that contrary to the situation with snack and fast food in
developing countries street food has good nutritional content and contributes
to good dietary intake by teenagers in Nigeria. Unfortunately the study did not
analyse fat content.

Obesity and anorexia - eating disorders
where calorie ingested is in discord with amount needed resulting in energy
imbalance. Reports from US National Health & Nutritional Examination
Service showed 22% prevalence of obesity in 12-17yr olds between 1963 and 1991.
In 95 cases there is no medical aetiology and 75% persist to adulthood. Several
factors are relevant- increased availability of high calorie foods out of home
leading to decreased levels of activity in front of computers leads to
increasing obesity, leading to medical and psycho social complications leading
to bulimia and hypertension causing cardiac disease and ill health. Long term
morbidity and mortality of obese adolescents was studied in a 55year follow up
of 550 students at Harvard showing increased mortality in all types of
cardiovascular disease. The same group in 1993 studied social problems showed a
lower academic achievement in overweight adolescents, lower income and
decreased likelihood of marriage in male and females. Obese adolescents fared
less well than adolescents with chronic medical conditions.Contribution of
genes & parental size is unclear.

Data is available for developing
countries from a study of a poor neighbourhood in San Paolo Brazil
investigating prevalence of obesity and malnutrition found a rate of 21%
obesity in girls and 8.8% in boys whilst malnutrition was 12.6% in girls and
15.5 in boys in the poorest society. It is difficult to assess the social
implications in developing countries but it is clear that cultural differences
will affect the way that people react to differences in weight - in parts of
the black community in America slight overweight in girls is preferred to
underweight for ulterior reasons - it may give the appearance of strength and
the idea of beauty in the subculture. In a 1994 study British and Uganda
students were compared with their rating of the female figure ranging from
anorectic to obese. The most striking difference was the fact that whilst
British students found the slimmer figure more attractive, Ugandans found
under-weight less attractive and rated the obese figure most attractive. Such
data may hinder preventive measures in anorexia and bulimia and obesity.
Conditions thought to be extinct in developing countries are becoming more
prevalent with increasing awareness of the medical community and also secondary
to the influence of western culture on adolescent societies with exposure to
international media.

In 1994 an Egyptian screening for
eating disorders in secondary schoolgirls in Cairo
-11.4% scored positive for abnormal eating patterns and 1.7% were victims of
bulimia. In Israel
a screening of girls in Jerusalem
found a 1.10% rate of abnormal eating disorders, much higher than expected from
an earlier study and similar to the levels expected of a western country.
Attitude towards eating and diet was dependant on country of origin of
immigrants. Mothers emigrating from Europe
rated as having greater weight concerns than those from the east Asia or Africa
- this shows the effect of acculturation on eating disorders -adapting to
western values and eating habits girls exposed themselves to obesity, eating
disorders.Similar problems were appearing in developing countries

Calcium deficiency - Calcium is
essential for bone formation about 40% of the bone mass is laid down during
adolescence.Long term consequence of low intake during this period include
osteoporosis and low bone mass. Replacing milk as a source of calcium and
increased use of carbonated drinks aggravates this deficiency.Calcium
phosphorous balance is also adversely affected. Normally milk and milk products
account for 50% of the calcium intake at this age - studies have shown that 40%
of adolescents may be deficient in calcium intake and intake decreases with
time. Girls suffering from anorexia have a high risk of osteoporosis. Iron
deficiency is most likely to occur during peak growth and be made worse by
blood loss during menstruation.Daily need increases from 12mg to 15mg during
peak growth and up to 30 mg during pregnancy. Iron deficiency is one of the
most important dietary problems in developing countries -as well as developed -
it is worse in pregnant and vegetarians In Rajistan India 74% of 10-14yr girls
had iron deficiency anaemia and a high level of malnutrition. These problems
are compounded by the high needs of pregnancy.

Despite importance of dietary needs in
adolescence only recently have deficiencies in this area been researched and
recommendations formulated.Less is known about the nutritional status of
teenagers in developing countries. We are seeing diseases of affluence in
developed countries becoming prevalent in developing countries and poorer
communities hand in hand with adoption of western diet and values. We are
seeing the spread of obesity, anorexia and bulimia and poor eating habits of
the west becoming prevalent in developing countries thus aggravating deficiency
diseases such as iron deficiency anaemia and diseases of malnutrition found
previously in the poor.

Deprivation
in Latin America - How are Youth Affected?

Dr Gustavo Girard - Argentina

The Simon International English-Spanish
Dictionary gives these definitions for the following words: deprivation:
privacion (privation); carencia (lack); perdida (loss)  deprive:  privar (to dispose of); despojar (to
divest) despojar: to strip; to
rob.Something has been taken away something has been robbed. It keeps being
taken away and robbed  The same
thing happens with the word neglect, translated into Spanish as despamparo.
Lack of protection. The second version of deprive refers to dignity.

This the basis on which I will make the
following consideration about youth in Latin
America. Let us study what neglect consists of, by going through
different situations that are closely connected with each other.

POVERTYlevels
of poverty in Latin America
are those of a Third World Country -or a developing
country, whichever you prefer. Adjustment policies and ill-distribution of
public expenses and wealth, tend to increase the irritating social
inequalities, showing no signs of a reversion of this process.  The information provided by the most
wide-ranging sources only confirm what is already known to all.The prospect is
even gloomier when we analyse the lack of functional, well-grounded
alternatives to modify the system. The "death" of the ideologies, although liable to be argued about,
leads to a certain quiet and passivity, which forecasts no good for the future.

Together with material poverty, it is
possible to observe the settling in of an affective
poverty. Endeavours made to overcome
the economical problem have their inevitable side effects upon the family,
whose members must multiply their work efforts. The number of families capable
of subsistence based upon the income of only one member is steadily decreasing.
This is an important unbalancing factor in the structure of the traditional
family tipping into crisis.

NUTRITION  Malnutrition levels are continuously and
permanently increasing. Those concerned the most are the children, origin and
end-point of the already typical vicious cycle of poverty. Forty thousand
deaths per day due to malnutrition and illness that are avoidable.  This fact, by itself, is
significant.  It comes from the Cumbre Mundial de la Infancia (World Summit for Infancy).

EDUCATION One of
the main characteristics of present society is the high degree of competitiveness. Education performs here
an essential role.  Education means
knowledge, and knowledge means power.
As an antithesis, we can state that lack of education in itself leads to
marginal situations.

We would be facing what has been called
cultural malnutrition.   In three Latin American
countries we have found that:-

*
In Argentina
88 % of the population complete the primary education; 26 % of this group
complete the secondary education while 2 % of this last group finish studies at
the University.

*
In Costa Rica
the same thing happens with the 34.4 %; 21.3 % and 9 % respectively. While in Brazil
only 17 % complete the primary education; 8 % of this group finish secondary
education, and only 1.8% of this small group accomplish University studies.

These figures provide partial
information, since they refer to quantity and not quality. What is profitable
is high technology, and it goes without saying that our countries can only have
access to borrowed technology, if and
when it is allowed to them.

100 MILLION CHILDREN aged 6-11 are
without school education Another figure provided by the (World Summit for Infancy).

HEALTH
Latin America is a
replica of what happens world-wide in other developing countries.  Comprehensive medicine is preventive and
interdisciplinary, and that is not easy to achieve in areas which lack
resources.  The share of the already
scant budgets intended for Health turn out insufficient, and the requirements
of a society with educational and nutritional deficiencies are greater.

Reproductive
health: unwanted pregnancy, abortion and AIDS; the inappropriate
use of drugs, accidents and/or violence.
Pathologies that go beyond merely biological facts, due to their highly
psychological and social implications.
All social groups are affected, but each with characteristics of its
own.

Unwanted
pregnancy: and its consequence, abortion, imply a
higher death rate in areas of fewer resources.

AIDS: as
it is correctly said, affects poorer,
younger and more female subjects every day.

And as to drugs, Latin American countries were traditionally considered as
producers, or countries in which drugs were "in transit".Nowadays, unfortunately, drugs have reached our
countries to stay.  The decrease in
the price of many substances has extended the use of drugs to the most varied
circles.    When
considering the topic of drugs, several regional, social and cultural
connotations must be taken into consideration and respected, since they bring
forth consequences on health quite different to those expected, when regarded
from another point of view. Accidents,
formerly patrimony of developed countries, show an important increase in Latin
America. Argentina
reaches the sad number of 30 deaths per day, due to traffic accidents, over a
total population of thirty five million.
The higher speeds of modern vehicles do not match deficient road
infrastructure.  The connection
accidents-alcohol is the same here as in other societies.  Teenagers and youths are a large
proportion of injured

Latin America
bears an important share in another report of the Summit World. 150 MILLION
children in the world suffer from deficient health conditions.

THE
TRANSCULTURAL PROCESS The problem brought about by the transcultural process has an
important impact upon the health of our teenagers and youths.  The migration in search of sources of employment,
both towards the interior of the countries as to neighbouring countries, is
greater every day.  The migration
from outer rural areas to the city originates belts of poverty: slums (villas
miserias), favelas.

The communication media encourage a
desire to acquire  consumer goods
and life styles unattainable for the majority of the population.  The "American Dream" is also
exported into Latin America,
and if it can be considered frustrating in North American society itself,
little can be said of what happens "South of the border".

VIOLENCE
From all I have said so far derives one the main problems in the health of
teenagers and youths: VIOLENCE.
Our societies are more and more violent every day.  As paediatrician I deal with recurring
consultations from kindergartens.
The reason, the child does not know how to defend himself. Children that
have been brought up with affection in moderating homes (containing homes) face
from the beginning of their socialisation violent components for which they are
not prepared.  It is as if there
were no room for a healthy, non-aggressive child in the present society.  Violence reveals itself in many ways:
right from handling a gun, down to an irresponsible practice of sexuality, or
high-speed driving.

CHALLENGES
FOR THIRD MILLENNIUM On the threshold of the third
millennium, it is right to consider the various challenges that our Latin
American society is due to face.
Whereas human life upon this earth is computed in "thousands of years", machines as we
know them hardly date back two hundred
years. Development of science and the technology of the century about to
end match those of no other period in the history of humanity. Therefore, the
integration of human factors with the
progress that has been achieved is
far from being ideal.  Teenagers of
today will play the leading roles of the next millennium. Post-industrial
society is already being forged by high technology.  Automation is replacing many jobs, with
unemployment as its main outcome.
These advances, fruit of complex and costly investigations, will keep
growing.  As a paradox, our agro-exporting
countries will find their incomes relatively diminished, in terms on exchange
with technology-exporting
countries. The consumer society will not weaken its pressure; it will be
increased as a result of its necessity to place its goods.  The breach between what is offered and
the possibilities of acquiring it will grow larger, and this will lead to
logical negative consequences. Development in communication media will keep
"shrinking" the world. This takes place at dizzying speed.  Nothing happening in the world can be
ignored by the international community.
This aspect will act as an important counterpart to the differences
between rich and poor countries.
Nations will no longer be able to regard what happens in any other
country as something beyond their concern.
True leadership will be based on the ability to foresee and circum -vent
problems. Otherwise the solution will only lead to increased individual,
regional and international violence.

This world-wide tendency to go back to village kind of life will have a strong
impact on ECOLOGY.  Man is no longer
a lonely inhabitant of the planet. Large human (settlements) produce harmful effects of Nature.  The balance is in danger. The heating of
the atmosphere, the melting of the polar ice, the green-house effect, the
nuclear waste, and so on, are only some aspects of what is really happening.
Development of new vaccines will increase the preventive aspects -immunisation
against HIV is to be expected.
Health costs will be greater and greater. Who will be able to pay for
them? We can immunise against hepatitis A or B but the cost rises beyond $100.
This is what high technology offers to a population with a yearly income of
$300 per head. Genetic manipulation
will create ethical dilemmas of increasing difficulty

PREPARING
FOR THE MILENNIUM The magnitude of the facts so far may
produce a paralysis or immobility fruit of panic;or on the contrary may act as
motivator for change. The development of humanity must engender natural
optimism. Very few years ago, the planet was on the verge of destruction.
Nuclear armament had reached such an extent that it could annihilate life on
Earth completely. When the fate of mankind rested on the push of a detonator,solutions
formerly unimagined,came to mind. We professionals dealing with teens by virtue
of our closeness to youth are responsible for their future and that of humanity.
In answer our concern is to strive for:-

*comprehensive
education suited to future demands. Information
grows so fast that encyclopaedic approaches must be left aside, with the
certainty that however hard he strives, man will only be able to learn a tiny
proportion of available knowledge.Creative potential must be stimulated, in a
continuous educational process.

*adequate
NUTRITION answering the needs of young people and
their idio-syncrasies. We cannot solve the problem of malnutrition of large
populations but can achieve positive results by making better use of scarce
resources.

*
individual responsibility for own health and that of those
around him.  It is essential that
man should value himself adequately in both respect and dignity. On this basis,
all efforts should be directed to primary prevention,on individual and
community levels.

*
ECOLOGY in many communities, young
people have a stronger conscience than adults. Humbly acknowledging this
reality, we must contribute our experience and knowledge to it.

*An
important contribution to health of youth has been provided studies on RESILIENCE.In the make up of the
resilient being we find an important working tool. It is not a closed process
but is open to the reality and present of the individual and society in which
they are immersed

*
development of SPIRITUALITY Throughout history man has given
transcendental importance to spirituality. Professionals entrenched in western
philosophy (dissociation of body and soul)maybe due to over emphasis on
individuality have largely excluded the spiritual from health practice.

*
The doctor patient relationship is
essentially a human meeting, a vital encounter-as such it must not be
undervalued.Reduced to the intellectual mere transference of information,
little benefit is obtained nor behaviour modified. One of the richest,
captivating controversial personalities in our times, Teilhard de Chardin, describes the human being as not created, but in the process of being created. There
are few similarities between Stone Age cavemen and Modern Man. Today we would
be ashamed of our ancestor. What characteristics will future man possess? If we
work hard with dedication and passion for youth, we will have contributed
without even knowing it, to take a step forward in human development.

Living
on the streets - Health concerns of street Youth in Brazil

Irene Adams - Brazil.

We need to consider basic definitions. What
we are talking about,how do we get information, to what use do we put that
information What can we do for street children who are not just deprived, they
are marginalised and not just marginalised but criminalised. You have no right
to go out there and collect any information at all about them unless you ask
yourself the question what do street children get out of this research? I have
worked for the last ten years in Bello Horizonte where I have the clinica amor-for
street children. Brazil
has 140 million people. The state of Sao
Paulo has 25 million and the city 13 million
-its very modern and up to date any western business man would feel completely
at home there - but there is another Brazil
- a Brazil
more like the Ethiopia
we have heard about - from which Manny’s immigrants come from.

My clients,the children of Brazil
are those who live love and sleep on the streets. My clientelle - they go
around in bands together. There are children on the streets and children of the
streets. Children on the streets have a family of sorts to go back to at night
- may spend the day on the street selling chewing gum-but he has a reference
point, someone he might listen to who he respects. He is not my client, my
clients are of the street. How many children? Any statistics you are given, figures
are probably wrong - it is a dynamic situation -there are those coming into the
pool and those going out- we do not know how many are on the streets at any
given time.They come from poor neighbourhoods but they may bounce back and
forth going back to another area or to a family when the police are putting on
pressure. Some have come from rural areas with their family and some may come
on their own having left their family in the countryside. The longer they stay
on the street the harder it is to go back they lose reference and become part
of the street. They may come from another city - from Rio the death squads are
more active in Rio -our town is safer -drugs are more in evidence in Rio and
cheaper and so when they find it more expensive here they will go back to Rio.
The only people who care in general for these kids are church groups - many
have no help from official sources. Until 1989 a child on the street would be
taken from the street to a government
institution, by virtue of the fact that he was on the street but now they have
the same rights as adults so technically are allowed to be on the street -
however if they are on the street and steal they can be arrested just like an
adult can. This is a radical change - you won’t find as many street kids
in the government
institutions now. Their role is being redefined.

When do you count the kids if you want
to find out how many - the best time is at night- but you will have trouble
finding them - they are so well hidden, huddled together you can’t tell
how many are there or differentiate adults from children - if you count in the
day they can get from one end of town to the other so fast- you can count them
two, three four times. A survey found that 400 children were on the street -
but workers were giving them meal tickets and many attended several times,had 3
or 4 meal tickets at least 60 of 400 had been through the survey three times.

How about their health - speaking in
the physical, emotional and psychosocial sense. There are massive queues for
health care - people sleep in the queues-health care is very poor for these
people in Brazil.
With regard to health care for the street kids - I bring the clinic half way to
them - but they have to come half way to me.There are many projects working
with street chidlren - we work in Bello Horizonte together - there are more
than 25 projects church projects, national street kids movement,city government
projects and we all work together in an integrated way to deliver health care as
part of this integration. We have different goals for different kids and
different goals for different steps this child is taking. The model is like the
twelve steps of Alcoholics anonymous - the first step is on the street. The
goal when he is on the street- the Rua is simply - make friends with him see
what his reality is like establish a trusting relationship -don’t make
demands of him - you have no right to - you can’t set limits at this
stage. But if he will come to my open house then I can offer him more - we can set
some limits at that stage - to come to the open house he has to abide by our
opening hours - has to arrive without being under the influence of drugs and if
he’s stolen something he’s not allowed to bring it in - these rules
were made with the kids themselves. With regard to my medical care,on the
street I could offer just first aid but in the open house I can offer a broader
range of medical interventions and work on medical needs - convincing him that they
are of importance.

When he has been able to come to the
open house - we hope he will be able to step up to a residential project -
there he will have to accept even more limits. In addition to stopping drugs,
he will have to keep regular hours, will have to study to prepare for a
profession or job and medical care will have to change also - he will have to
learn to use the government
system. He’s no longer on the street,he has to go to the health post and learn
to exercise rights of using the government
system from which they were excluded when they were on the street.

Finally once they leave a residential
project where they have daily supervision they move on to a hostel -a bit like
a boarding house where they all have jobs and they share the rent and household
duties and the function of the clinica amor is to refer them on- whatever their
health needs are. Our motto is educating for life through health The clinic is
behind the open house. At the clinic they need to learn to wait-wait their turn
and not need instant gratification - like when they need something on the
street and they will steal a watch - their records are also something which
they can ‘own’ and they will be encouraged to be interested in
their weight, height and share the information with the staff. Much of the
information on the kids comes in their ‘check ups’ - they are
pleased to be able to make an appointment, and attend for ‘their’
‘check up’ - which is a sharing experience between the staff and
the kids. The open house is run by the church - the church have no problem with
the legitimate use of condoms - they support AIDS prevention - the open house
has broken glass in the windows because these kids have very short fuses, a
problem can easily cause them to flare, break glass - hit your friend over the
head with a chair - and many of the girls have babies. Body image is important
to them - but they have no way of seeing their bodies - we have a mirror in the
open house which they love to stand in front of - it has never been
cracked!  We do courses with the
girls and sessions devoted to looking at being a girl on the street, being
pregnant and being a mother.We teach hairdressing,sewing making things to sell
in the market as an alternative to stealing. Success for me means that a girl
can get off the street have antenatal care and then come and see me with the
baby. Another street boy became a street educator - he went round in a van and
made friends and encourage them to come in for care to a project. Street
problems vary - in other cities prostitution is the norm, in our town the girls
do not - it is not acceptable - they do not want to. In Rio
the kids go hungry - the police is a heavy presence - in our town they are not
hungry. Health care can be a bridge to these children - so that in the end it
is the kids themselves who benefit from our intervention.

Attitudes
and Practices of physicians in Israel regarding Adolescent Medicine

Dr Daniel Hardoff, Israel.

OBJECTIVE: To study perceived skills,
practices and desire for training in adolescent medicine among paediatricians,
family physicians and internal medicine specialists, as a basis for further
developing the discipline

of adolescent medicine in Israel.

DESIGN: A random sample of physicians
completed a self-administered questionnaire sent by mail. It included
demographic data and 17 items regarding attitudes and practices relating to
specific topics in adolescent medicine.
A total score (ranging between 0 to 51) as well as 4 sub-scores for
medical, sexuality risk behaviour, and psychosocial issues were calculated.

RESULTS:  306 questionnaires were completed.  42.2% of respondents were
paediatricians, 34.6% were family physicians and 23.2% internists.  Their mean age was 45.2±9.6
years.  86.6% of all respondents
treated adolescents.  Family
physicians perceived themselves better trained for treating adolescents (mean
score 42.0±9.9) than paediatricians (37.9±10.2) and internists
(35.1±8.8) p<0.0001.  98%
of paediatricians, 97% of family physicians and 94% of internists desired
further training in at least one topic in adolescent medicine.

CONCLUSION:  Although the majority of the above
specialists treat adolescents, they perceive their training insufficient and
request further training in adolescent medicine. The national health
authorities should therefore develop appropriate programmes to cater for the
demands of Israeli physicians caring for adolescents.

The Journal of
Adolescent Health and Welfare

is published
by:-   Youth Support,   13, Crescent Road,   London BR3 2NF

Tel No 0181 650
6296
Charity No 296080
Fax No 0181 659 3309