Journal
of Adolescent Health and Welfare

Volume 7 - No 1 -
Spring/Summer 1994

Letter from the Editor -

Dear
Colleagues,

Welcome to Volume
seven. This year we will be having our ninth annual scientific meeting at the
Royal Society of Medicine and next year (1995) will be our tenth year of
operation - time flies!

In this, the United
Nations "International Year of the Family", we have seen an enormous
growth in the family work carried out at Youth Support House. Most of this centres
on child protection. So far as Adolescents are concerned, we are seeing both
ends of the spectrum - teenage parents of both sexes referred regarding the
relationship between themselves and their young children  - and teenage 'children' referred with
problems with their own parents.

In all our work, and
particularly in child protection, we do need to remember that the young person
is part of their peer group, part of our society and part of some kind of a
family (even if for children in care and in children's homes this exists in
fantasy only). Young people cannot be treated in isolation. The content of this
journal echoes this concept.

The 1989 Children's
Act which has been in operation since October 1991, is very specific in
emphasising the need to work with families. Since the passing of the children's
act a very high proportion of our referrals have come to us via the legal
system for assessment or rehabilitation. Hence our 1994 meeting will focus on
Child protection, child abuse work and the legal issues involved. As usual we
are inviting contributions for the journal and are canvassing participation for
the annual meeting.

Next year we hope to
have a larger meeting with an International input to celebrate our Tenth
Anniversary - format is yet to be decided but it will include a dinner after
the meeting. I am hoping that we will be able to invite back some of the
excellent speakers who have contributed over the years and that the meeting
will cover a résumé of the most important topics in Adolescent
Health and Welfare. Please contact us early if you wish to be included in any
way. Presentations, suggestions for subject matter etc. will be welcome.

Best
wishes,                 Diana
Birch     Director
Youth Support

Youth Support Forum on
Adolescent Health and Welfare

Ninth Annual Meeting
1994

"Child Protection
and the Family"

At the Royal Society of
Medicine

1, Wimpole
Street London WC1

On Wednesday 19th October 1994 6-9pm

Refreshments and displays at 6pm   Opening address 6.45pm

The meeting is multidisciplinary and will include contributions from
professionals who are expert in the field including Child Psychiatry / Legal
system / Social Work. Ample time will be available for discussion and questions
to our 'panel' of experts.

.............................................................

I would like to attend the Ninth Annual Meeting of the Youth Support
Forum on Adolescent Health and Welfare at the Royal Society of Medicine on
Wednesday 19th October.............

I will bring ......... guests.

I am a Forum member ...... (attendance free + guests free)

I would like to join the forum and enclose £20 annual fee.

I am not a member and enclose fee of £5 per person for
attendance - total ......

Name ......................... Designation ...................

Address ...................... Tel no ........................

..............................
(Admission free to students and

..............................   young people under 21)

Rehabilitation
and the Family - "What do we hope to achieve?"

The following article appeared in shortened form in
the

newsletter of SAM -(Society for Adolescent
Medicine).

This year I have been reeling from
one intense court case to another - Should this mother be allowed a chance to
have her child back? - Should a child be brought up by her natural parent? Can
you achieve good bonding after prolonged separation? Is a child more harmed by
failed rehabilitation than no rehabilitation? Should a teenage mother be
encouraged to bond with her child? What is the aftermath of parental loss?
Clichéd questions coming up time after time. Nevertheless hard to answer
in the harsh glare of the court scenario when respected colleagues argue
against each other - quoting contrasting literature and research findings with
equal zeal. 'Zeal' is I feel, the right word for it - there are few areas where
passion, and subjective fervour are more apt to cloud objective judgement than
in that of child protection and separation of parent and child.

Certainly there is a difference in
perspective - social workers do not want a dead baby on their case load and
know the media will point the finger of blame in their direction; paediatricians
may see neglected children gaining weight in hospital away from their families;
child psychiatrists look at the disorganised family structure and find it hard
to see a child being able to overcome parental patterns.

I wonder sometimes quite what we are
hoping to achieve when we take the other view? What are we doing in our
rehabilitation programme? With success rates running at perhaps 50% - if you're
lucky and how do you measure success anyway? Varying criteria for selection for
rehabilitation and no consensus on long term goals. Helping disturbed mothers
parent disturbed children can seem a thankless task.

Unless you work with adolescents. That
is when you begin to see the point. What do we see as the child reaches
adolescence? And what happens when that child becomes a parent? Removal from
the family is sadly not a panacea - we see young people whose self esteem is in
their boots - crying out to know why their families did not want them, why they
failed their parents so badly - and often recreating their own family
disturbance and imagined parental traumas in an attempt to understand and
identify with their absent parents.

Mark was placed in care at the age of
four, lived in children's homes, then a 'good' foster family. He did well at
school and college, gained professional qualifications and then 'blew it all',
lost his job, on the verge of divorce and with seething rage directed at his
four year old daughter. He remembers nothing of his early life but his fantasy
is that his behaviour was so bad that his parents had to send him away. He
needs to somehow prove that his parents were good and he was bad by recreating
the scene in this generation.

A teenage mother may well prove, with
help, to be an excellent parent, able to meet her child's needs in a way that
cannot be faulted. On the other hand she may be too much a child herself,
needing love, care and attention which her child cannot supply. The same
situation could apply to a mother who is for other reasons unable to meet her
child's needs - by virtue of mental or physical illness or deprived
circumstances. It is important that such mothers (and fathers) be given the
chance to explore their own potential - to be supported and encouraged and to
be allowed to share in the decision whether to parent their own children or
give them over to the care of another.

I know how grateful fourteen year old
Kim was when I asked her if she would like me to find a foster mother for her
child.  She had wanted so much to
please us all by being a good mother - but the depression and loss of herself
showed through. At the court hearing they called her an unfit parent and
brought up all her past delinquency - several months work on self worth
destroyed in a day. But her little son will know, when he reaches his
adolescence that he was a valued child, that his mother tried her best, and
then gave him up in love.

I am constantly being told by my
paediatric colleagues that good bonding between parent and child is essential
for future mental health and that this can only occur in the first year of
life.Many authors have disputed this time limitation and even Bowlby has
revised his views. But even if this were so surely the chance of establishing a
rapport with your own mother - at whatever age is preferable to whatever bond
may be established with a stranger?

Winnicott  once wrote a paper titled
"Delinquency as a sign of hope". Rebelling, pushing out against the
injustices that you have suffered in childhood - that is indeed a sign of hope
- a sign that the spirit is not broken, that there is an individual in there
shouting out "Hey! What about ME!" The beginnings of change, of a
sense of one's own needs, of self worth.

Adolescence is regarded
traditionally as a time of 'delinquency' and rebellion, a time of  change and energy - both can be
channelled in the healing process and that is often what makes working with
young people so exciting.  However
the 'adolescent process' can be seen in many phases of change. An abused
'victim' who begins to assert himself, a 'battered wife' who gains the courage
to leave her husband, a drug addict or alcoholic who decides to opt for a
different lifestyle - all enter a new way of being - all experience the
honeymoon elation of starting on a fresh beginning - they all in their own ways
feel the exhilarating freedom of an 'Adolescence'.

Thus , just as for the adolescent, we
can make use of this energy for change in the rehabilitation process for our
damaged families.  And , just as in
adolescence, we must appreciate the stages of this process and work through
them with our patients - understanding and support is the cornerstone -
coercion and ultimata have no place in rehabilitation.

The damaged parent of whatever age,needs
to go through a stage of being allowed to be the 'needy child' - for that
indeed is what he or she is.Years of deprivation and abuse have taken their
toll in terms of the individual's needs never having been met. A young parent
often becomes a young parent partially to find a way to fill this unmet need.It
is a mistake to either disregard this need entirely, or to somehow expect it to
be dismissed at will. How often have we heard the expression that a parent is
"Unable to place the child's needs above her (his) own".As if this
were a conscious decision.OF COURSE they can't!.

The answer lies not in condemning this
need, or pushing it to one side - but in fulfilling it. A needy parent is like
an empty vessel , without caring or 'mothering' to fill the void - they have no
resources - nothing to give their children. So our first task is to accept the
needs of the patient's inner child, to allow them to be child like and to
parent them - often for the first time in their lives. Here 'dependence' is
healthy and a required stage in the treatment process - however, like all good
parents, we need to set boundaries and be consistent in our caring during this
childlike dependency stage.

As the patient grows in trust and
confidence, we also, as good parents, relinquish some control and
responsibility so that our 'children' can grow up. Having had some of their own
needs met, they can now look to their own children's needs - but gradually at
first. We take them through Bowlby's 'exploring from a safe base' , we ARE that
safe base. They go through an adolescence with us 'holding' and 'containing'
their anxieties and gradually emerge as competent adults.

Let us not forget that all parents need
a measure of 'parenting' themselves.Not just as a model, a way of building up
the 'inner parent'by example as described above. But also when giving birth, at
the time of becoming a parent, we also need to be cared for - to be 'mothered'
or cared for by a loving partner. Those who often need this most - our deprived
or damaged patients, are those least likely to get it. To make matters worse,
they have far greater traumas to bear during the early months of parenthood -
single parenthood, domestic violence,poverty, poor housing, inexperience.They
will also suffer greater stresses and assaults to their self worth and parenting
-criticism, children failing to thrive, childhood illness, professional
intervention (usually perceived as unhelpful and critical),case conferences,
child protection procedure and possibly court action or assessment.

It is too easy for assessment and
observation to become negative,destructive and almost a sneer from the
sidelines rather than a productive process. There is no value in watching a
sinking man drown.If you see he can't swim,you throw him a life raft.So there
is no value in purely observational assessment.Seeing a faltering parent damage
herself and her child holds no joy for observer or observed.  Such an observer deserves to bear the
shame of such failure and is a perpetrator of abuse to child and parent alike.

Assessment means 'working together' to
see what can be achieved and what cannot. It is only in this way that a fair
evaluation can be made of the situation and one that has a chance of being
accepted by the family. So I suppose that I have answered my initial question
"What do we hope to achieve?"- We hope to achieve a realistic
appraisal of families strengths and weaknesses;a forward plan which will best
serve the needs of each individual within that family as well as the needs of
the whole;and an appreciation of the dynamics of the situation which is not
based on blame, fault or failure,but rather on understanding, empathy and
regard.

"Working
with Families - How not to perpetuate the abuse".

Dr Diana Birch

Director Youth Support

Introduction -

The way in which we
handle families and individuals within those families, have far reaching
effects on the way that family will function afterwards.

However much we may
disapprove of or be at odds with a family's structure and functioning, we must
realise that the child has been brought up within that structure and will have
to survive within it after the 'professional' intervention is over.

In addition since this
family structure is the only one the child has known; the way that child
perceives his world is based on this blueprint - all the child's 'survival
tactics' are based on this reality.

We cannot destroy the
child's environment without replacing it with something else and without
realising and appreciating  the
'dynamics' of the situation.

Altering the structure
or dynamics can leave members 'exposed' and unearth other conflicts.

this can be   desired -> used in therapy

or
undesired -> recreating the conflict                                                   from
a different base. (false cure).

Family structure

A family is structured
around it's own ethos - it may be an emotionally distanced grouping of
individuals who constitute a 'family' in name only and where the individual
feels no support or bonding with his fellows.

Alternatively, as is
more common in many of the families coming under professional scrutiny, it may
be an enmeshed body which takes on an existence of it's own and where
individual personalities are lost in a common boundaryless ego.

So called 'normal'
families fall somewhere between the two extremes but are still prone to power
struggles between the members - who is in charge, who is the spokesperson, who
is the scapegoat? Family members assume or are pushed into a role and
interactions between family members are influenced by these roles and by the
interplay between them - striking up allegiances, involving one another in
power triangulations and using one another in indirect communication.

How often have we heard
a child used in something like - "Tell your father if he wants his dinner
he had better come home on time".

or a parent implicated
in indirect communication as in -

"Wait till your
father gets home" or "What will your mother say when .."

Families frequently
take sides - with one child siding with mother and another with father, or all
'ganging up' on the weakest member. In 'abusive' families a child frequently
appears to side with the abusing parent against the other - since this is the safest
thing to do.

It is worth while
taking a little time to consider some examples of this - think of the last two
families you worked with and how they functioned - consider also your own
family of origin - what part did you play? This topic can form the basis of an
excellent role play with colleagues in a workshop situation.

The family is a
microcosm of the outside world and of the wider environment. The way in which
we learn to function within our families, provides the 'blueprint' for how we
function in society at large.

We carry our family
'role' with us from our family of origin to school, to our workplace , to
relationships and social settings and to our eventual roles in the family we
create.

The stability of
maintenance of a role and 'place' within the world, of being secure in the
knowledge that things turn out or people behave in the way we expect them to do
- this is the most important factor in family life.

Stability and
predictability are more important than the quality of that condition. In other
words the secure knowledge that mother loves you is certainly conducive to
mental health and well being - but so, in a perverse way,  is the secure knowledge that father will
hit you every time he comes home - as opposed to the insecurity of not knowing
whether he will or not.

There is nothing so
destructive as the insecurity and unpredictability of not knowing whether for
instance dad will be drunk or sober when he comes home and thus whether he will
hit you (perhaps when you have been good) or hug you and give you a present (maybe
when you have not had such a good day).

If your behaviour has
no predictive consequence - then it has no importance. And if your behaviour
has no importance, then perhaps you do not either. The child's self worth is
destroyed because nobody cares what he does or how he acts. It is as if he does
not exist.

This is no less the
case for those unfortunate children who are raised in families where abuse -
physical, sexual or emotional has taken place.

Sarah had been sexually abused by her grandfather since the age
of 4 or 5. In common with many victims of sexual abuse, she was unable to
'disclose' what was happening. She at the same time could not believe that
people - her mother, her aunt and her grandmother could not 'see' her distress  and acted as if they did not know.

She began to act out
the anger and frustration she felt in delinquent activity - smashing windows on
her estate and minor acts of vandalism. This did not get her into trouble,
people did not seem to notice. There was no consequence to her behaviour - just
as there appeared to be no consequence to her grandfather's behaviour.

Later, as an
adolescent, Sarah's rages became more intense. She walked a long distance with
a knife in her hands , wanting to kill her grandfather. When she arrived she
saw her grandmother and could not commit the deed. She thus went home, smashed
the family home and was committed to a mental institution. She calmed down and
was released. Another example of missed communication.

In adult life during
therapy she went into an 'uncontrollable rage' one night and smashed windows in
the treatment unit. The following day she doggedly refuted that there was any
possible consequence to her behaviour. A breakthrough in therapy occurred when
she was faced with possible consequences and a code of 'acceptable behaviour'
was laid down. It was as if at last 'it mattered' what she did and therefore
'she mattered'.

Problems of the 'meddlesome ' worker

When working in child
protection - there is an intense desire to 'do something' - it is thus very
easy to take action just so that this need can be fulfilled and the
professional can be 'seen to be doing something'. Under such pressure however
there is a very real danger that the 'something' can be of no use whatsoever to
the child needing protection or to his or her family - and can at best be
useless and at worst harmful and dangerous.

Some of the aftermath
of 'meddlesome activity' in child protection is not immediately apparent due to
the flawed manner in which much child protection work is conducted - i.e. that
of crisis intervention based mainly on protection from harm without follow up
or any treatment process to 'heal the wounds' . Hence the total gamut of the
inflicted harm is not fully appreciated nor the contribution within that
wounding process which can be laid at the door of professional error or
misjudgement.

Hence , when we feel
urged to 'do something' - it is imperative that we consider for whose sake we
do that i.e. are we being helpful to the client or 'helpful' to ourselves?.

In looking at this
dilemma , it is useful to consider a concept borrowed from Transactional
Analysis (TA) - that of Karpmann's drama triangle. The 'Drama Triangle' can be
used to look at roles in any situation where a psychological 'Game; is being
played ; in other words, where two people are not being straight with each
other, not saying what they really mean.
In such 'Game play' the roles of Victim, Rescuer and Persecutor are
played and switched by the participants in a manner that can leave both feeling
uncomfortable.

A classic 'family view'
of the triangle in action is provided by the alcoholic family. A common
scenario might be - drunken husband (Persecutor) comes in late and berates wife
(Victim) for not having dinner ready; she (now Persecutor) then turns on him (Now
Victim) for being drunk again ; he then throws up and complains how ill he
feels so she 'Rescues' him by sympathy and cleaning up after him and probably
rings his boss in the morning to tell him her husband has the flu'.. thus
enabling him to continue in his behaviour pattern and Persecute her all over
again.

In our scenario of the
'meddlesome worker' one might play the game with the professional as Rescuer
turning Persecutor. In such a situation the term 'Rescuer' is not
complimentary. Such a person 'Rescues' for their own personal ends. Their
actions are generally harmful to their clients even though they might
superficially fool some of the people some of the time.

The Rescuer begins by
making the inappropriate intervention in the vein of the dentist telling the
patient that 'It won't hurt' or the old fashioned school teacher caning the
pupil with a 'This is for your own good and it hurts me more than it hurts you'
attitude.

When the client, hardly
surprisingly, fails to respond to such treatment; the Rescuer becomes
Persecutor,blaming the client for lack of response rather than seeing that his
methods might be flawed. This is akin to the Doctor blaming his patient for
failing to get better rather than stopping to consider that the 'cure' might
have been the wrong one.

Client
- Victim

(This is hurting me)

(This can't be right)

/
\

/
\

/
\

/
\

/
\

/
\

/
\

/
\

Persecutor - - - - - - - - Rescuer

(This is for your own
good)       (I'm
only trying

(I know what's best for
you)     to help you)

(I'm an expert in this
field

- you'll ruin my
reputation).

Case Histories -

The following case
histories illustrate a number of difficulties faced by workers and the
contrasting possible end points which could be brought about by insensitive or
inappropriate action. The cases are based on true facts although one end point
actually happened , and the other was fabricated. Sadly , the end point which I
would have liked to see happen is the fabricated one.

Unfortunately we work
in an age when the very words 'child abuse' can engender such subjective
response from professionals that interventions are often less than ideal and
once the hot potato of abuse has started rolling, albeit in the wrong
direction, it can acquire a momentum of it's own and be impossible to stop or
to shift onto a more appropriate course.

Hence ill thought out
actions, however well meaning can have devastating results for the child who
has been the victim of abuse and for it's family. It is thus that our
interventions can be in themselves abusive. As they say "The path to hell
is paved with good intentions".

Please read through the case histories and evaluate how
you would have acted. Discuss the two possible endpoints.

Case History 1 - Margaret, Harry and Tom.

Margaret had her first
baby when she was in her late thirties. Her husband Tom was a business man who
spent a lot of time away from home on business trips.

In the weeks after the
birth, Margaret was tired, lonely and depressed. She had not expected to have a
child at this stage in her marriage and had not imagined that her life could be
so changed.

One night,baby Harry
seemed to cry incessantly. She did not know how to pacify him. Margaret
eventually managed to get him to sleep and , just as she was dropping off
herself - he started to cry again. She picked him up roughly and shook him,
crying, "Please, please stop it" - she pushed him back down into his
cot, ran crying into the next room and shut the door on him.

The next morning,
Margaret found that Harry had two tiny bruises on his cheeks - she must have
handled him more roughly than she thought. She wrapped him up and rushed round
to her GPs surgery.

A. The GP examined the child, found light finger tip
bruising on the cheeks, and no other signs of abuse. Harry was well nourished
and developmentally up to date.

He did seem to be a
'windy' baby however and so advice was given about feeding regimes to try and
reduce his indigestion and night time colic.

The GP also diagnosed
post natal depression, which was contributing to Margaret's low threshold of
tolerance and which, combined with her excessive tiredness, was diminishing her
supply of breast milk, thus contributing to Harry's fractiousness.

It was arranged that
the health visitor call regularly on Margaret to help her build confidence in
handling her baby. He knew that this was a long awaited child and felt Margaret
may be feeling a sense of anti-climax ad failure in not being able to be the
perfect mother.He asked Tom to take some time off work to allow Margaret to
rest.

B. The GP found bruising on the baby's cheeks and
questioned Margaret about it. She was distraught, confessed that she had
handled the child roughly and shaken him.

The doctor had recently
moved into the practice and did not know the family, he was very concerned
about Harry and decided that since he was born late to a professional career
oriented couple, he was probably an unplanned and possibly unwanted child.

The child was sent to
hospital for X ray studies and Margaret was cross examined by the Casualty
officer, followed by the paediatric houseman, registrar, senior registrar and
consultant. The hospital social worker came and asked if she understood about
the child abuse procedure in their district.

The social worker
telephoned Margaret's husband, Tom who was embarrassed to be summoned out of an
important meeting because a protection order was being taken on his son.

When Tom arrived at the
hospital, he was not able to speak to his wife immediately or see his child,
first he was cross questioned about his wife's character, her history and
whether he thought she was capable of injuring her baby. Tom was devastated.
Margaret confessed, she felt like a criminal.

It was several days
before they had Harry back. They were told he was on the 'at risk register'.
Margaret's depression got worse, she could not cope. One night she took an
overdose, Tom came home to find Harry crying alone and his wife semi comatose.
What danger Harry was in!

Margaret saw a psychiatrist
who gave her tablets which made her more sleepy and less able to cope. Tom
thought it best that Harry go and stay with his parents, who knew how to look
after children.

The marriage did not
last long after that. Margaret was branded as 'unsafe' with children. Tom had
to change his job and is now less well paid.

- What of Harry?

Case History 2
Ann and Zoe

Ann had been in care
for most of her life. She did not know what family life was like, it had been
one children's home after another.

When she fell pregnant
at 17, she desperately wanted to make a go of her life, to bring up her child
herself and to learn how to be a better mother than her own mother had been.

Pregnancy was unplanned
but baby wanted. Boyfriend Dave was supportive though jobless so unable to help
much.

Ann had been abused as
a young child and had been on the social services, child abuse register. When
her child was born, her social worker thought that her child was therefore at
risk of being abused - abused children become abusing parents.

A. Baby Zoe was placed with a foster mother; Ann fought to
have her back. She was given the task of 'proving' herself. Could she be a good
mother, did she know how to handle a baby?

So every weekend Ann
was allowed to 'handle' Zoe under the supervision of a social worker. She
picked up the unfamiliar bundle and did not know what to do - criticism
followed criticism - she was set up to fail.

B. Ann and Zoe were placed in a residential unit together.
Ann was given support in caring for her daughter and was gently allowed to
assume responsibility for her care as her confidence grew.

Zoe was on the 'child
protection' register but six months later, the authorities were happy that Ann
could cope with her child and plans were made for return to a flat in the
community.

Thus what might
initially appear to be merely a subtle difference of emphasis in dealing with a
case can have far reaching and devastating consequences for the child who we
are aiming to protect and the family who we can either support and 'nurse' to
psycho social health or who we can very easily destroy.

Sexual Abuse

Consider the case of a
sexually abused child who 'discloses' to a professional.

How do we stop him or
her from being further abused by the consequences?

What are the further
possibilities for abuse?

1 - GUILT at having been the victim - it
must have been my fault somehow.

2. Being seen as accuser - accusing 'family' and mother
or carer of not protecting her enough.

3. Breaker of family -
perpetrator - father possibly - being removed from family - break up of family his or her fault.

4. Made to testify - witness of fathers or family's guilt.

5. Physical abuse - the examination itself can be 'abusing'.

6. Circumstances of
examination and disclosure can be an abusing
ordeal.

7. Court appearance and evidence giving can be traumatic.

8. Abuse in not being believed or not taken
seriously.

9. Having to 'confront' perpetrator or argue what
did or did not happen.

10. possible further
abuse in terms of what happens if child placed back in contact with abuser - revenge, blackmail, etc.

11. Professionals
involved giving covert messages -
e.g. why don't you retract and make life easier for everyone -

perhaps you
exaggerated?

12 Or covert disgust at circumstances being
'misread' as disgust for victim?

13 What of the 'stigma'
of being an abuse victim?

There are a number of
further possibilities which might arise in discussion. It is worthwhile pausing
to consider - what could have been abusive in the last case you were involved
in? Could this have been circumvented in some way?

Conclusion

All intervention both
effective and ineffective is going to produce change - either in the individual
or in the family. Change is painful - it is often easier to stay with the
status quo than to risk the uncertainty of change and 'moving on' even if we are
moving to a healthier position.

The arguments put
forward here are not intended to deter the professional from making
interventions - many of which are essential to safeguard the welfare, and
sometimes the lives of children.

It is hoped however
that the measures we take are positive and helpful to the families we work with
and that if we have to cause a measure of harm and distress in our
interventions; that we are at least aware of such injury and can act
appropriately to minimise it's long term effect.

- International
Chapter News -

We had planned to
include the International News in the next issue of the Journal - However,
since there have been a number of developments, it was thought best to include
a section in this issue also.

What
is the IRC SAM?

The
International Regional Chapter of SAM.

1995 will see the staging of
rather an unusual spring meeting - as you know the IAAH (International
Association for Adolescent Health) will be holding it's International Congress
in Vancouver in tandem with the SAM (Society for Adolescent Medicine) annual
meeting.  This will mean that there
will be the usual format of SAM activities plus a large and varied programme
laid on by the International membership of IAAH. With such a big emphasis on
the larger International scene via IAAH - it seems appropriate to define and
explain the position of the smaller IRC SAM group within the whole.

The IRC is a chapter of SAM
which has been in existence since 1987 to provide a forum for both non USA
members and US members with an interest in International affairs. In common with
other chapters, not all  participants
are full SAM members but we encourage colleagues to join SAM wherever possible.

Our principal objectives are
to :-

*   Encourage International
participation in SAM and at SAM meetings.

*   Increase awareness in
International issues among SAM members.

*   Provide a forum via our
newsletters and annual workshop for interchange of ideas and for professional
'networking'.

The IRC has to date been the
only chapter of SAM to run a workshop at the annual SAM meeting. This activity
has been a successful focus for the chapter.  We intend to hold our usual workshop (or
institute) at the 1995 meeting. In accordance with the above definition of our
chapter - this should be seen as a SAM activity as distinct from an IAAH event.

There is naturally some
overlap in membership of IRC SAM and IAAH - but this constitutes a very small
proportion of individuals and the ethos and structure of the organisations are
quite distinct.

- Report Of The 1994 Meeting - Los Angeles -

Message from Roger Tonkin -

The members of the
Chapter present in Los Angeles held a highly successful Workshop and a
well attended Breakfast meeting. Many thanks are due to Aric Schichor and Diana
Birch as well as to the presenters for what was clearly one of the best
workshops we have held in recent years.

As in the past
years we also had a lively dinner meeting outside the hotel. It produced
exciting notions about what to arrange for our next get together in Vancouver in March '95 (keep tuned to your
newsletter for further information). Once again our thanks to Diana for setting
up a Chinese feast for us within walking distance of the meeting hotel.

The Los Angeles meeting included continuing discussions on
the future of the chapters within SAM. Unfortunately there didn't seem to be
much in the way of a definitive outcome as SAM as an organisation seems to be
preoccupied with planning a fall retreat and is putting off decisions till
then. I suggest that chapter members make their views known by direct letters
to Richard Brookman (copy to Birch / Girard) soon. {See below for response}.

My impression of
the direction that SAM is taking is to reorganise it's chapters and require
more accountability of them. I see this as a good thing but there are obvious
complications for us as international members. My recommendations include
creation of an International Section within SAM and dissolution of all non USA chapters. Such a section would continue to
enjoy the JAH, receive all SAM publications, be eligible for lower membership
fees, be supported by central office services e.g. for the collection of dues,
maintenance of membership lists etc. With the help of SAMs office the section
would publish a newsletter, sponsor an annual workshop and be generally
supportive to our International colleagues.

The section would
be a formal entity within SAM and have an appointed Executive (by SAMs board).
The section members need not be full members of SAM but those who are would
also enjoy full rights including voting of SAM membership. In the meantime the
present situation wherein the cost of running the chapter mailings, collection
of dues, organising an annual event, printing a newsletter which are absorbed
by my office, Aric's hospital or Diana's Youth Support could end and be
replaced by a simpler device for supporting our activities that is created and
paid for by SAM. We lose some autonomy but gain a smoother less erratic method
of keeping a vibrant international presence within SAM. A situation that SAM
both understands and appreciates.

From Vaughan Rickert - Workshop Co-ordinator - SAM

With regard to the formal ratings that were completed
for the workshop "An International Perspective on Adolescents and the
Media" - Co directed by Diana Birch and Aric Schichor - almost all
respondents rated the workshop in the good to excellent category across the
various dimensions. The written comments were also positive.

This is a very
encouraging result - many thanks to all the presenters. It is particularly
encouraging when we consider that we are getting more USA based participants attending the workshops
- this means that we can act as a showcase for the International group.
Hopefully we can keep up the standard for the next IRC workshop in Vancouver.
A suggested title is "International Perspectives in Sexual abuse of
teenagers" - I am waiting to hear from SAM  as to the timing of the workshops for
1995 - I have asked for a half day only since there are obviously a number of
other International initiatives in the 1995 meeting- we will not know
definitely until the autumn - however in the meantime I would love to hear from
anybody who would like to present something at the workshop

An International Perspective on
Adolescents and the Media

The 1994 International Regional Chapter Workshop  was held at the 26th Annual meeting of
the Society for Adolescent Medicine - Los Angeles on 16th March.

Introduction
- Youth and The Media - The scope of Media influence - an
overview by Diana Birch - Youth Support - England.

How does 'The Media' and Youth Interact?    We live in
a 'high tech' age - we live and breathe media. Youth are more 'Media wise'
than their parent's generation.

Differing
Vehicles for media impact

Written
word

Audio
messages - music - radio - tapes

Telephone,
chat lines, recorded messages

TV,
Video, Cable, Satellite

Cinema

Theatre

Computer
Games

Computer
Electronic mail, porn lines etc.

What Aspects Should We Consider?

Effect
of media on youth - good and bad - desired and undesired.

Effect
of Youth on Media - Young trends and Youth purchasing power affects advertising
and productions.

Consider
Media as part of a whole - pattern of society - it serves our needs - it does
not arise spontaneously.

Consider
hypochrisy of some of the outcry against the media - we enjoy horror, fear,
violence in films - they produce what the public wants.

Seed
and soil - Removing all media violence would not produce a peaceful world.

Difference
between real and fictitious - drama/doc.

Youth In
Media

How does appearing on Tv - being a child star - being
used by the media - or being part of the illusion affect youth?

Workshop format was divided into three sections -

The Impact of
images

The message in
the Media

Making Media
Work

- The
Impact of Images -

A youth in Belfast throws a petrol bomb,  Palestinian children hurl stones,
Freddie Kreuger's mother performs unspeakable acts of cruelty, human remains
are carried out in a dustbin from the mulitple murder scene in Gloucester,
Beavis and Butt Head stock pile weapons, some faceless men are burned alive in
a porn cinema in Smithfield,  'Yogi
' hits a target over Bosnia, a doll crushes a dustman in a refuse lorry .....
somewhere in the middle we lose track of the fact that a boatload of Sri
Lankans have drowned .. and Schwarzenegger tells us he'll be back....

Interactive Video Resposes -

The first part of
our workshop involved an interactive video presentation eliciting responses to
a variety of images which might commonly be presented to Youth.

The purpose of
this was two fold - Firstly the video compilation provided a tool by which
responses of groups of youth and professionals could be gauged - the responses
which had been elicited at Youth Support in London were discussed - and
secondly the material provided a 'warm up' exercise for the workshop - in that
rather than discussing media responses 'cold' - the audience experienced
differing reactions to varying degrees of violence and thus had an immediate
personal experience to tap while discussing research data presented by later
speakers.

The clips - each
lasting from 15 seconds to a couple of minutes wre randomly mixed examples of
screen violence - taken from popular films - 'Witness' ' Freddie's Dead'
'Child's Play Three' 'Terminator' - plus news footage of violence - plus
violent 'humour' sucha s in the Blues Brothers or Robin Hood or Crocodile
Dundee.

It was noted that
some levels of reporting news produced more impact - the same story on BBC or
CNN was very different - impact varied depending on visual imagery rather than
talking heads - scenes depicting emotion.      Use of familiar
objects in horrific guises produced reaction - dolls and toys out of context.
The War Games clips which had actually been taken off CNN news of a plane shot
down over Bosnia - looked like a computer game and the impact of death and the
horror of war was lost.

The older members
of audience (both in London and in LA) were most upset by real news items than
by films - the older generation also found the film clips more disturbing than
the ?somewhat conditioned youth.

"The Effects of Violence in the Media"   Lilli Friedland - President of
media psychology division of the American Psychological Association.

The American
Psychological Association published an important document - "Big World
Small Screen" which deals with the issues we are discussing today. We are
all concerned because the institutions which help civilise people and who help
individuals  to become functioning
healthy parts of society are all in a terrible state. The family the church or
synagogue and the school and at least in this country they all need a massive
amount of support. Typically in other generations , in other millennium if
there was a problem with one, the other two balanced it out - to the best of my
knowledge this is the first time that all three basic institutions are all so
weak that they can't compensate for the weakness in another and therefore all
the cultural messages all the values are passed on not by the traditional story
telling and sharing of values from the church family and school - but we have
the media. And that is why we are here today because we need the media's help
and to see why it is so particularly influential today and why we see the kind
of violence that we are shown - in our generation or in our parents generation
- it might not have had the same effect.

What we have now
is an increasingly vulnerable generation of adolescents that need even more
structure , more guidance and more healthy values and alternatives to be shown.
Carried to an extreme - we know how to make even health people unhealthy - we
know how to make a pretty normal kid growing up in a pretty normal home into
somebody who operates from the dark side.

There is a
wonderful movie out which was put out by a Greek Junta some time ago "My
Neighbour's Son" - it is available through Amnesty International. They pan
in on typical adolescent in a family in Greece and show how he was introduced to
terrorism and became part of the terrorist scene. How they broke down his
defences systematically - how at first he was appalled by i t and then how he
became part of it and the importance of that is that even under the best of
conditions - and the assumption of course is that this was a normal kid with
normal values etc. - could be incredibly affected by massive influences coming
at him  and now we are talking about
those who are more vulnerable feeling the effects of such influences.

I will not go into
a lot of statistics  - suffice it to
say that the average child witnesses 8,000 murders and more than 100,000 acts
of violence before he graduates from elementary school. Children spend more time
watching TV than they do going to school by the time they are in high school in
this country. Thus there is a tremendous effect of the media which we have to
look at.     The
psychological association had a
task force on Television -
There is no clear cut view - Roger Kline of Pittsburgh University  came out with information that women are
differentially affected by violence in the news than men - older people are
more disturbed by violence in the news - many concentrate on violence in films
but there is a growing body of interest in the effect of the news.

The average Us
child watches at least 3 hours TV per day - pre-school child watches 57 hours
per week that means it has more influence than anything else that the child
comes into contact with.
The elderly watch more TV than any other group and the low income groups
watch more, the Afro-American watch more than whites but well educated black
youth watch the most boys watch more than girls but women watch more than men.
We also need to look at the changes in society with more people working from
home, spending more time at home and the whole concept of cocooning.

Most ethnic
minorities are mainly portrayed negatively. Men are shown more as protagonists
of violence. Exposure to highly stereotyped images increase adolescent sexual
stereotype beliefs.       Pro social
interaction and non stereotypic portrayals can lead to co-operation, reduction
in prejudice and promote traditional sex role images and promote good
citizenship. So though we can point out the negative affects - violence
aggression etc. we can also point out the positive .  In the field of emotion and behaviour -
TV can increase or decrease emotional arousal which can lead to
desensitisation. Watching violence in a sexual context can lead to acceptance
of rape and other forms of sexual assault.     The rate of violence
in prime time TV is 5 to 6 incidents per hour  but
Children's Saturday morning programmes have 20-25 incidents per hour.
Children expect to have things going on all the time - if not its boring. What
does that boredom mean and the constant need for hype and arousal and what it
does to them psychologically as well as physically.

Two important  meta analysis studies Addison in 1977
and Herald in 1986 combined a number of studies 67 and 230 with 100,000
subjects and 300,000 subjects respectively - showing that a positive
association between televised violence exposure and aggressive behaviour over a
wide range of ages - also it lowers the prosocial behaviour. Effects on viewer
1. Increase in violence towards other people - Aggressor effect

2. Victim effect -
increases fearfulness - older people and women more

3. Bystander
effect - increased callousness towards other people.

4. Self
socialisation effect - increased
self directed  behaviour
which exposes one to further risk of violence.    The opposite happens is there
is a showing of pro social behaviour - i.e. decrease in violence towards
others.

Effects through
the different mediums - Music video men who have listened to only 17 min. of
heavy metal music express greater endorsement of  sexual stereotypes than those listening
to easy listening music. The addition of sexual images in a rock video
increased the college viewers appreciation of the music but violent images did
not.     Deleting
violence from the rock video did not affect the appreciation - they thought it
just as good.  So violence does not
increase sales.    Those
who watch violence against women in the rock videos seem to have an easier time
being desensitised and feel that women 'ask for rape' rape is a women caused
phenomena.

Cartoons - the
pre-school children were just as likely to imitate violence with a real model
as a filmed model and cartoons also imitated the aggressive behaviour -
animated characters influence as much - show no consequences for behaviours in
children's programmes so they do not think there is a consequence - children
walking in front of cars - they don't come back to life - they assume you go on
living - they perceive this from media.
Violence from video games - also effective. lot of school have video
games as rewards - these could have bad effect. Children less prosocial behaviour
if play video games with violence. Young minds incorporate this as important
influence.

In TV 90% of
aggressive facts in prime time are shown as justifiable acts - many did not
have expression of remorse or regret - hence difficult for adolescents to learn
behaviour model. 88% of aggressive behaviour is rewarded. Paying attention to
the negative aggressive behaviour is thus harmful. Again decreasing violence
does not decrease popularity of programme.

The association
between aggression and violence is more important for watching home video and
television and part of that difference is that in cable industry and how video
aggression and violence is more explicit and more connected. The importance in
connecting sex and violence and the importance it has in degrading the viewers
image of women and seeming to promote rape and aggression against women.

So what do we do
and what can we do? Critical viewing in schools - Canada does this. Rating systems - various types.
Help care givers to be better guides.

Tools and blockers
to help parents screen out certain programmes - but parents who bother with
that are those most involved with their children anyway - something is needed
for the others.  We need the help of
the industry and everyone working wit adolescents in order to counteract this
effect - but looking at the future it is even more scary - we are starting to
get involved in trying to assess the effects of various types of interactive
mediums on adolescents children and adults.  The University of Kansas is doing some work on this - educational
hardware and software as experiential learning is working well - you use more
than one sense - auditory, visual and tactile to promote learning - so as an
educational tool this is important. However there is concern because the two
directions with most influence in interactive medium comes from pornography and
aggressive games and that means an even larger problem for all of us.

Virtual reality is
also a very powerful field - exciting and scary - you come out of it not
knowing what is real and what is imaginary - if we are talking about the scope
for desensitising human beings - that is the most profound area I know -
because if you can't determine which is your experience - where did you learn
that?

Cocooning - living by yourself -  this has an important influence . Of
course there is a lot of positive in working at home but the negative
influences come from this. What we learn about the world is based on our
interactions with other people and by judging the reactions of other people -
that constructive input and feedback - both in the family and positive
relationships or in the workplace where we need feedback - the opportunity for
this is going to be reduced. So our feelings about ourselves - our grandiosity
is going to be less challenged - you are not going to have to compromise -  What we find is that those people who
are not going to their extended families or meeting friends are using networks
such as internet and groups that they find through the computer systems as ways
of connecting. Partly that could be great - for some people this could be
easier - less self revealing - young people do that a lot. There are real
problems - but there are difficulties with reality - you can make up fictitious
names and fantasy creatures can fill your time instead of real people. More and
more are cocooning - using computers to create fantasy friends. These have
consequences on a societal as well as an individual basis..

The Message
in the media

Using
media to convey a message. The contribution of soaps, storylines which have a moral
or covert message -
Examples of a number of British TV programmes and child oriented soaps
were provided in video form by British TV companies.

Manny Chigier - Youth Aliyah Israel -  presented a fascinating idea  "The
use of good movies in sexual health education in pre-adults"
So often the content of movies is criticised for giving negative
stereotypes and portraying unacceptable behaviour patterns particularly with
regard to sexuality. Dr Chigier demonstrated how by chosing the right material one
could also find plenty of positive messages in the film repertoire which can be
used as a useful instrument in working with young people.   Films can also be discussed with
youth and their content used to bring out undestanding of love and
relationships - classics such as Bonnie and Clyde - or 'The Fabulous Baker
Boys' looking at the dynamics of the relationship and the 'death' of a love
relationship between them.

Exercises such as
How would you make a sequel?

Making
Media Work

A
number of presentations followed this theme -

Dr Roger Tonkin  - took us through a progression of newspaper articles
which started out by condemning a youth health survey in British Columbia and then gradually turned round to support
the project - a wonderful example of how professionals can canvass the help of
the press in combatting prejudice against issues such as sex education. It was
seen to be important to cultivate a relationship with the media rather than
work in opposition.

George Creatsas - Greece - and Gustavo Girard -
Argentina described the
practices in their respective countries.

Nancy Okinow - Minneapolis - From the
centre for Youth and Disabilities - described collaborative projects and PR
work with disabled youth. Their newsletter is a beautifully produced piece of
PR work which is circulated widely to all IRC members.

Aric Schichor - Connecticut - Described
the use of Video skits - short PR messages produced by his young patients.
These items of 'peer advocacy' were short, pithy and to the point - Public
access TV is an effective way of reaching Youth with these short public service
announcements and video clips which will provide scope for increased work.

Ueli Buhlmann - Switzerland - Also
showed us videos made by patients and for patients - in this case to illustrate
physical illness and practical procedures - gastrostomy patients, diabetics
etc. The video education programme is short and compact and can be shown over
and over again hence increasing the degree of knowledge gained from it -
Animated cartoons were also discussed as a means of putting across a clear
message in a clear but inoffensive way and in the 'international language ' of
animation.

Interactive Media - David Paperny - Honolulu - Described
his computer games - "Ask PCs everything you wanted to know about
Sex" ....  Computers don't
blush and they don't judge!

An
Open Letter to The President of SAM

Dear Dr Brookman,

Re
The International Regional Chapter (IRC) of SAM

At the last SAM meeting we were nominated as co-chairs
of the IRC. It seemed appropriate therefore to outline the role and aims of our
chapter.            Out
of the total 1,170 SAM members, 86(7.20%) live outside the USA - only a few of them usually attend the
annual SAM meetings and thus for most of them the principal link with the
society is the Journal of Adolescent Health.

Our Chapter would wish to redress this in terms of :-

*  Encouraging  members from outside the US to attend the annual SAM meeting

*  Presenting ideas to the SAM board with a
view to strengthening participation by

members from outside the US.

*  Strengthening participation in the IRC
SAM.

*  Encouraging the growth of the
international membership of SAM.

This could be accomplished by :-

*  Continuing to hold a chapter workshop at
the annual SAM meetings as a forum

where members from outside the USA can exchange views and experiences.

*  Expanding the coverage of the chapter
newsletter.

*  Organising a special presentation of the
IRC SAM at the International Congress

in Vancouver.

*  Encouraging IRC members to be more
visible within SAM in presenting papers

or posters at  SAM meetings.

We are aware that there has been a lot of discussion
within SAM with regard to the position of SAM in the International scene and
the question of whether SAM is a US or North American or world-wide
organisation - It would appear that if SAM were to consider it's wider role and
develop an International section - the IRC should provide a focus and impetus
for this transition.

Dr Diana Birch                         Dr
Gustavo Girard

Director
Youth Support                        Buenos Aires

London
England                                  Argentina

What is Planned for The SAM 1995 meeting in Vancouver?

{There
are a number of International Initiatives at the 1995 SAM meeting - These are
in addition to the IAAH events which Roger Tonkin has outlined in the Youth
Health Assembly programme.  To
Clarify - IAAH meets 20/21/22 March : SAM meets 23/24/25 March.}

1. The International Dinner  -     This annual dinner meeting is an informal
opportunity for International members of SAM to socialise and compare notes on
matters of mutual interest. Those who do not belong to International Regional
Chapter SAM are welcome to join us. Reflecting the cultural diversity of our
membership we vary our choice of restaurant - Washington Tex/Mex - L.A. a Chinese Banquet - In Vancouver Native
American?

2.
International Lunches -  I understand that there are to be a number
of 'Meet the professor lunches' involving pairs of USA SAM members and
International members.

3. Multicultural Forum - This has been suggested under various guises - I
understand that now the suggestion is
that SAM, the IAAH and the multicultural special interest group and the
Canadian Association for
Adolescent Health are to jointly hold a 2.5 hour meeting which will be
organised by The Canadian organisation - Dr J. Frappier.

4. The IRC SAM -(International Regional Chapter)-
Workshop  Our chapter traditionally hold a workshop
each year at SAM - Gustavo Girard and I would wish to hold a workshop again in Vancouver meeting - a half day  A suggested topic is "International
perspectives in sexual abuse of teenagers".

The Youth Health Assembly - 1995

Please refer to
Roger Tonkin's Conference Programme for details of all the events - so far as
Youth Support members are concerned - we hope to put on a workshop in the IAAH
sector of the programme (first three days) - details as follows - please note
that this is a preliminary notice only and the event has not been confirmed.
Please note that this is distinct from the SAM part of the programme (last
three days) detailed above. If at this stage any Youth Support members wish to
involve themselves in the Vancouver meeting please contact Youth Support House
as soon as possible.

"Using Drama in the healing
process"

Lack of effective
communication poses one of the most important barriers in the use of
conventional therapy with young people. We have to 'break the silence"
surrounding family secrets and find common ground for empathy and
understanding.

Adolescents may
"communicate" their pain by acting out or somatisation of emotions -
by using 'active therapies' such as Drama we can explore an alternative medium
for expression and externalisation of their hurt.

This workshop will cover
basic theory and demonstrate the use of Dramatic techniques through use of
video recording and case histories. There will also be an interactive component
introducing role play, scene setting and family work.

Young people will be welcome
to join this session.

Youth Support Professional Training

- Publications and reprints -

Journal - Back copies Journal of Adolescent Health and Welfare  Back copies - (1988-1993)    £ 4.00 each

Books

"Are you my sister,
Mummy?" Study of school age pregnancy. 2nd
edition 1992                £10.00

"Retracing the
Echoes" Children of the Russian revolution -
Emotional aspects of growing up.
£ 3.95

"Inner Worlds and Outer
Challenges" Development of the personality and assaults of emotional
environment  £5.

"Mother or Child?" Tape slide presentation

Reports, Articles and
Reprints     -  £3.50 each.

1.1 "Schoolgirl Pregnancy".overview and medical aspects.

1.2 "Teenage sexuality and the Media"

1.3 "Schoolgirl pregnancy - a culture of poverty"

1.4 "That old Black Magic? - Sexual belief systems.

1.5 "Schoolage Pregnancy, the International scene"

1.6 "Sex Education - Does Mother Know Best?"

1.7 "Teenage Pregnancy - A problem for the nineties?"

1.8 "Self Esteem in early pregnancy"

2.1 "The search for the True self in adolescence - the dilemma
of  childhood handicap"

2.2 Sports Medicine - "The Training stresses for children and
Young  People""Diet &
Preparing for the Marathon"

2.3 "Healing abuse - Working with family that is not
there".

2.4 "HIV infection - AIDS and the Young" conf report.

2.5 "Providing staff support in child abuse procedures".

2.6 "Emotional Abuse - The hidden scars"

2.7 "Working with families - how not to perpetuate the
abuse"

2.8 "Reflections-Emotional development,origin of
personality"

2.9 "The invisible woman -
the hysterical personality"

2.10 "Fear is the key - the depressed adolescent"

2.12 "One Track Minds - obsessive part of our
personalities"

2.11 "Divided loyalties - the schizoid teenager".

Theses

These are avilable in limited supply and usually require two weeks
delivery time.

'Schoolgirl pregnancy in Camberwell' - A population study of
schoolgirl pregnancy, motherhood and two year follow up. London University MD
thesis, January 1986 - soft copies £50 - loan £15 for one month.

"A Study of Self Esteem measurement in Schoolgirl
Pregnancy"  soft copies
£15 - loan £5 for one month.

NEW    -    "Child Protection and The
Family"    -    NEW

ORDER NOW - AVAILABLE SHORTLY

The Journal
of Adolescent Health and Welfare is published by :-

Youth Support Publications,

13, Crescent Road, London BR3 2NF
Charity No 296080