Journal of Adolescent Health and Welfare

Contents

Letter From The Editor

Conference Round up

Proceedings of our conference 1996 

Proceedings of our International conference October 1998

European meeting October 1999

Interventions, cost-effectiveness and can we answer the criticism

International Chapter News

San Diego March 2001

International SAM

“When is a family dysfunctional? - A cross cultural view.”

Letter From The Editor

Dear Colleagues,

Hello again –  We are half way through the year already and have almost reached the deadline for abstracts for the October 2000 conference. If anyone still has something they want to contribute – send in soon! Late entries will be considered but there’s no guarantee we can fit them in – the timetable looks pretty crowded already. 

Our April conference in Italy went very well with a really good contingent of young people who soon warmed to the occasion and impressed us all with their role playing skills and candour. There are some pictures on the conference website at www.youthsupport.com/confitalia.htm  but the full proceedings will be available soon in a book on traumatic stress to be released in time for October 2000 conference – details on publications website at http://www.youthsupport.net/YSBOOKS/traumatic_stress.htm 

The journal is now also on line at www.youthsupport.net/YSBOOKS/journal.htm

Conference details are on www.youthsupport.com Those who are interested in our assessment and treatment services and particularly our family work will find this detailed at www.familycentre.com and www.youthsupport.org

 See you in October!     Diana Birch   Director Youth Support

Our two conferences at the Royal College of Physicians in October 1996 and 1998 have both been published as proceedings books – see below. Get your personal copy now!!   Extracts will be printed in the Journal. 

SAM in Washington March 2000 - a very good SAM meeting. Further details in the International section overleaf.

Youth Support Italia - Gioventu` Duemila April 2000 - full details will be published later in the journal and also as a book on Traumatic stress.

The following paper was presented at the European meeting October 1999 at the Royal College of Physicians - Sponsored by Youth Support

Interventions, cost-effectiveness and can we answer the criticism

Muriel O’Driscoll - Devil’s Advocate

Here stands before you a 56-year old woman  who has been working with teenagers for a long long time, started off as a mid-wife, set up teenage parenting programmes, became a family nurse and a teacher, did a lot of work in schools, got funded by the lottery to do some outreach work working in collaboration with a lot of other people, and I have fingers in so many pies.  I am standing here today jaded, cynical and not at all apologetic. Probably I’ll end up after this whole thing the most unpopular person in the hall. The reason for this is, that people keep asking me, but what good does it do? And I don’t know, I haven’t got an answer. 

When we were lucky enough to get lottery funding for outreach work for young people around sexuality and lowering the teenage pregnancy rate 3 years ago, the only thing that the lottery funders wanted from us was that we saw a thousand young people during 3 years. This meant that some nights, on windy nights, cold and wet, we would drifting round streets of the estates that we’ve been allocated hopefully spying a young person that we could attack. I don’t think this did much good at all. In fact the young people on the estate where we were working in, very quickly they got to running into doorways and down out entries when they saw us coming. Our project manager, when we got back to base, said, “How many people did you see?”

 I don’t think, this is cost-effective, I don’t think, this is a good outcome. And there’s been so many bits of snippets in the newspapers recently, in our local newspaper they did a 10-year research into the Drug Harm Reduction Programmes, Methadone Programmes, the Needle Exchanges, the going out to give condoms to prostitutes and needle exchange for prostitutes. They discovered that after 10 years of highly funded and person-concentrated work in the drug unit in Liverpool less people came off methadone and heroin than if they have not attended. That worried me. These negative things keep recurring. We’ve educated, and educated around contraceptive and sex education - teenage pregnancy rate are going up. We’ve educated, and educated about responsibility and sexually transmitted infections – the rates are going up. Chlamydia now strikes one in 16 people under 24. I used to live in the middle of the city centre in Liverpool and prostitutes used to congregate outside my house. The prostitution team, the official paid workers that help the prostitutes would come round regularly giving out packets of cigarettes, lemonade in summer, hot drink in the winter and condoms. This is supposed to be a harm-reduction exercise. Anybody in Toxteth who needed a ciggy late at night knew exactly where to go late in night for free cigarettes. It has done nothing to help young women, who get drawn into prostitution to fund their drug habit or because they are afraid of their pimp.

 Let’s look at something nearer home then. Look at the job creation schemes, job clubs and the new deals. They say, figures like in our local young persons’ job initiative we’ve had 360 attendees, yipee! How many have got jobs? Oh, we haven’t followed that up. Now, that’s the sort of thing that really is beginning to get to me. And I am sure, that must get to the funders as well. If there is no correlation between the input and the outcome, except figures, then what are we doing that for?

 Another one with first offenders, there are schemes where probation officers are assigned to first offenders, and some of you in that service might know that better than me. But figures keep coming out, prove that kids will re-offend just the same whether they’ve had intensive support from the probation service as when they didn’t. Worrying, very worrying.

 I’d like to put it to you, that adolescence isn’t a pathological condition, it’s natural, it’s wonderful, it’s physiological, it’s traumatic, it’s emotional and it’s a metamorphosis. Everyone here was once an adolescent and you’ve not done so bad, have you? Interventions may only be one kind word or one harsh word, interventions may be one good role model or one bad role model. I am beginning to feel that this is over-funded, job-creating roundabout that we are all on, and I include myself in that. There is a lot of work of satisfaction in this game. Survey asking people what they thought of interventions, are usually done to the people who’ve attended them. What about the ones who didn’t? How do we reach the others?

Here are some quotations that I have found and I’ll see whether you agree with them or not.   “No people do so much harm than those who do you good” – oops.   “We don’t change anything unless we upset it.”  “Condemnation does not liberate.”  And I have more. I was speaking to my mother who is now 89 and she said, “Well, what you have to do is read the Bible if you’re looking for quotations”. She said, “Just remember, when Jesus said, when, Lord, have I done it to you, when have I seen you hungry, when have seen you thirsty?” And the answer is, “Of course, whenever you saw a person who was hungry and thirty and ignored them, then that’s when you’ve done it to me.” And then she said about the prodigal son and I said, “Yes, the prodigal son didn’t have a social worker ”

Adults who do not like or respect adolescents, and this is a large proportion of those whose career is working with them, badly frightened by the increasing democratic relationship between adolescents and adults  which is coming to prevail in our society. A lot of adolescents quite like mixing with adults. Not as an intervention, but simply as their natural way of things. Of course, those don’t get funded.

“Each generation is a secret society and has incommunicable enthusiasms and interests which are mystery to its predecessors and to posterity” - predecessors are us.  “Advice of elders to young men is better than a hundred best textbooks” - that’s us to them.  “Students are the most valuable natural resource”.

“My experience of the world is that things left to themselves  get right”.  I think it’s Confucius who also said, “If you don’t know what to do, don’t do anything”. However, we seem to ignore that.

“The more alternatives the more difficult is the choice” – and this is so true. If you ever driven into an empty car park, if there is only one space, it’s dead easy, you go into the space, if there are lots and lots of spaces, you dither around, I am going to be better off near the exit, or better near the shop, or better near fares, or where shall I go and you go round and round - And of course the young people have got many many alternatives to follow.

“Charity looks at the need, but not at the cause”.  I think what I am trying to say is, that we who have been educated and fortunate and survived our own adolescence, can’t possibly understand the needs of the adolescents today. That the funders who throw money at the problem instead of looking at the cause of the problem are wasting their time, that the care industry of which we are all part are having a very nice living off the problems.

How do we know, that an initiative that we take changes behaviour? Well, we’ve got to have some form of evaluation. How do we know, that it’s acceptable to whose who need it? We’ve got to ask the people who don’t actually attend and that is very difficult, for people that we don’t reach we need to ask. How do we know that the initiative is outcome-driven and not system-driven? As I said at the beginning, I haven’t got the answers today. Outcome evaluation, long-tern follow-ups, how can you long-term follow up people, especially young people, when they disperse and change, and the same group of people you look at five years later, they will not be the same that you saw within intervention five years before. There is a big danger in satisfaction surveys in that people usually say what they want you to hear. In maternity hospitals I worked in we had a lovely consultant, it was an inner city maternity hospital, and patients were not really given to writing letters. So this consultant said long and loud at many meetings, that there was absolutely nothing wrong with the service because he had never had a letter from a patient complaining. The women who were in his care probably found it very hard to write a letter to a consultant, even if they knew who he was, but you see the dichotomy, he thinks everything’s all right, because he hasn’t had a letter. Women round bingo halls are complaining and muttering, but they haven’t got a system to make their dissatisfaction known to the provider.

In most evaluations non-response is usually not considered. And I was impressed by what you said before about the spoilt or the smart-arsed comments because they are so important, so vital to take on board.

What I would like to do now is to throw the floor open to you for perhaps 10 or 15 minutes because I want your expertise to help me feel less cynical.

DB. In any kind of study or work that you are doing we need to look at, is it the needs of the young person or your patients or your clients who you are looking at, or is it the needs of the people who are running the service. I was faced with that dilemma when I was first doing our teenage pregnancy survey, because I was visiting these families weekly, then monthly, then every couple of years for a 15 year period and asking the questions, and I was always thinking, well, I’ve got to be careful not to use these people, this is a piece of research for me, I am writing it up, will they get any kind of kudos out of the fact that they were involved in it. And so what I tried to do, was each time I went to see a family I would offer them something in return, something practical, or making sure that a letter was written to housing or something like that. And then also when I published it, so with a reunion,  we tried to bring them in, bring them back, have them being able to talk, like when we had TV programmes let them speak, rather than let me speak. But it is very hard to do that, isn’t it, and I think, our whole culture is very against that. I mean so many people have to write so many papers in order to get certain positions in their jobs, so you juggle with the same group of patients, and if someone has a rare disease in this country, the chances are they’ll be subject to all sorts of research, that might not further their illness at all, but will probably further the career of their consultants quite admirably. So, could we have some comments, because I think this is a kind of danger area.

Herb Friedman  I’d like to say two things and then make some suggestions. First, to congratulate you on raising very important issues that we all should be raising, absolutely essential, that we do that. Secondly, that to defer your experience in the field, then you know what you’re talking about, if you see, what I mean, in terms of your own experience for many years, I don’t doubt of trying so many different things and so on. I would nevertheless like to counter some of the opinion but I have to preface it by saying, although I live here and have done on and off for many years, I don’t know the UK adolescent scene very well. What I do have some knowledge of is the global accumulation of information about what works, which is relatively new. But in the last 10 years there has been a cumulative body of knowledge from searching many different countries, and very often from the poorest countries, from economically deprived countries and so on. Virtually all of the research points in the same direction through a series of principles I said this morning that I thought the focus had moved regarding adolescence, because young people were seen as a threat and then as a problem, to a different posture, which is an avant-garde, but not all the way yet, as seeing young people as a resource and young people as participants and activists. When that started to happen in combination with adults one sees very positive results in all kinds of settings around the world. I am saying this to make you more optimistic and not a pessimistic. I would also add that one of the areas you are really pointing to, that is just beginning, if I can put it that way, is proper intervention research, which includes two kinds of indicators. Indicators of a much sharper look at the kind of interventions we are doing, and what’s the input, what exactly are we doing? We may say something, but exactly how are we measuring it? This is often neglected in research and therefore the conclusions can go array, so what are the inputs. And the second issue has to do of course with outputs, what are the indicators? Indicators not just of problems, how many presently have gone up and down, but human development has the adolescent change in fundamental ways that are more mature and more promising. They sound a bit vague, but it’s actually beginning to happen. The reason I am putting it that way, is because when we start to look at development changes, you do see progress even when a problems may still be there, these other things are being averted, avoided and so on.

M.D. Thank you very much, I am very glad to hear that. I knew there would be some positive answers somewhere in the world, but haven’t been able to find them, that’s the difficulty, because you don’t know where to start looking. There are so many different fields, so many different specialities, so many different professions, often ordering the same thing in the same area, and they are not talking to each other either. Thank you.

I am saying how important this is to cross-professional boundaries and non-professional boundaries as well. In some of our working in Wirral with young people, we have been working with multi-disciplinary teams, we’ve been working with community artists, we’ve been working with youth workers and the health professional as well. As soon as the projects becomes quite successful and people have enjoyed them, as the workers and the attendees, we don’t know what the outcome is, it’s very enjoyable, but what good has this done, I don’t know. One of the things last year, the last thing I had to do was to go into pretty stuffy-nosed private girls’ school, into their sixth form, six form mind you, so they are 16 to 18, and talk to the girls about ?, the sex education, and they wanted come to section, peer-ins, they knew all that, they knew it all, so I said instead of doing that, we are coming up to do just a questionnaire to find out what they want. So I put down the annual topics that I could do and then a blank at the end – anything else. The worries that these girls have were: suicide, self-harm, anorexia/ bulimia, divorce, dealing with death. We are going into talk about serious things, you know. So that was one thing, worth stressing, that if you want to know what young people want, ask them, instead of assuming that we know it.

DB: That’s something that’s quite threatening to a lot of professionals, isn’t it? You don’t want to hear the answer, you don’t want them to say, Oh I want to talk about HIV or death and so on, when you are just comfortable doing periods and something rather safe. So I think sometimes we end up in the wrong pattern of work. I was just thinking actually when you were saying about how some of these interventions didn’t work because the numbers were the same. It’s always difficult when you look at numbers, isn’t it, because how do we not know that some of the ones you would have done if you didn’t see them before, and you might be seeing different people because of what you’ve done. And also is it valid in some way to have something going on in the community which might not have necessarily a positive outcome in terms of numbers, but you are seen to be going something, because it also provides a kind of positive atmosphere rather than everybody sitting back and saying, oh, we can’t do anything, we don’t know, what we should be doing, so we won’t do anything at all. I think that’s can be quite destructive.

MD I’ll go along with that, in a circular about teenage pregnancies, in a lot of the estates I’ve been doing work in, teenage pregnancy is not a problem, teenage pregnancy is a family pattern, people have kids when they are 16, or 15, or 14, so what? What’s the problem is, that there isn’t sufficient income to support the choices that people have made, so it’s positive that the problem is not teenage pregnancy. Any amount of free condoms and sex education is not going to alter family culture in those particular areas.