"Special Reports - The Health Status of  Adolescents in Europe"

Author - Dr Diana Birch

Title -     Director Youth Support

Address -        Youth Support House

13 Crescent Road

London BR3 2NF

England

Introduction

Adolescents throughout the world are confronted by similar problems and tasks involving psychosocial development, emerging sexuality and the challenges of risk taking behaviours. However the impact of these developmental stages on the health of the adolescent will vary tremendously depending on the cultural environment , accepted mores and socio economic status; still important, but on a lower key, are the variables introduced by health care and the professional input into preventive and educational medicine. On all these parameters Europe differs from the transatlantic scene and even within the continent there are large cross cultural variations.

Professional Care Providers

Firstly let us consider who works with Adolescents. In Europe as in the USA there has been a debate regarding the appropriateness of paediatric versus adult physicians caring for adolescents and traditionally the trend has been for paediatric services to raise their upper age limits to encroach further on the 'teenage' market.

A questionnaire delivered to the paediatric societies in most of the European states (Burgio; Ottolenghi 1994) demonstrated wide differences in adolescent care and guidelines. The authors were able to compare data from a similar enquiry made in 1975 which revealed that the upper age for remaining on a paediatric ward varied from 14 to 18 years (with the exception of Portugal where it was 10 years). France, Netherlands, Poland, Sweden and the United Kingdom had upper limits of 18 years although not long before the limit in England was 14. (Burgio GR, Lorini R, 1975) Cynics could argue that the increased range related more to the rise in the number of paediatricians who needed consultant positions rather than the increase in concern over the provision of adolescent services.

Twenty years on only 10 of the 29 respondent countries considered adolescent medicine to be the province of the paediatrician and the authors concluded that   "... It is often claimed that adolescent care and assistance should be assigned to paediatricians who have followed children during their growth, are prepared to deal with growth and puberty problems, and are used to discussing with parents problems related to school, sports and habits. There is serious doubt as to the extent to which this actually occurs."

The situation in Europe has parallelled the US arguments - the American Academy of paediatrics made a statement in 1972 that "The purview of Paediatrics usually terminates by 21 years of age"  (American Academy of Paediatrics 1972) but five years later did recognise Adolescent medicine as a speciality.  In most European countries we have no recognised speciality of Adolescent Medicine - Austria differs in recognising adolescent medicine skills since 1989.  The arguments in Britain have circled several times around whether or not there should be a subspecialty and the British Paediatric association has held out firmly for the role of general paediatricians while acknowledging that  "adolescents in hospital should be treated in adolescent wards." (BPA 1991)  Many who actually work with young people would argue that differing skills are required and I am reminded of the comment made by a past president of  the Society for Adolescent medicine  that  ".. The time has come to either 'paint or get off the ladder" (Sanders JM Jnr 1988).

The argument for an Adolescent Medical speciality has been explored by several states including Norway (Noess PO. 1993) which has a very good record in terms of health education and preventive work with young people. Similar arguments are put forward by the Germans who note that most adolescents do not wish  to be treated by a pediatrician,  nor do they seek treatment by "doctors for the elderly". .(Kurz ;  Borkenstein. 1991).  ".. Most of the complications or problems are specific for that age period; they are not well known to all medical doctors. Because of these reasons, specialists in adolescent medicine are mandatory for proper treatment".

Services for Adolescents

The German view epitomises the general outlook of those working with youth -in that general services are insufficient  " ...  a small proportion of adolescents actually consult general practitioners. Inadequate cooperation between medical and  mental health care services as well as insufficient links between these  services and the life world of adolescents have led to a situation in which  the use of professional assistance meets with barriers. As a result, adolescents continue to avoid visiting a physician even when they have already become ill." (Palentien C.  Hurrelmann K 1994)

There is a growing consensus that adolescents require services in their own right and that we are doing them a disservice if we feel that we can enter this field without specific training and without tailoring our services to the needs of young people.  In Spain  a questionnaire delivered to the Catalan Society of Pediatrics Found that only 20% of the pediatricians had different schedules for  adolescents than for children, only 16% provided a separate waiting room and only 4.3% actually showed a preference for dealing with adolescents. (Suris;  Garcia-Tornel 1991) Major obstacles were perceived in provision of comprehensive care to teens including ".. not having different schedules or waiting rooms, confidentiality, and the  patient's perception of them as a "children's doctor."

So what services exist in Eurpoe for adolescents?  Services need to be loooked at on a variety of levels - the concept of the 'Adolescent Ward' or hospital unit is too narrow.  Adolescent medicine encompassess a wide variety of approaches from the inpatient acute services to health education and social medicine.

Traditionally, in the United Kingdom the term 'Adolescent Unit' was used to describe adolescent Psychiatric units and the problems of teenagers were regarded as 'something you grew out of' and hence was not worth treating; 'something which was your fault' such as risk taking - and thus did not deserve treatment or 'something which your parents should control'. The acute illness was treated by general physicians or paediatricians, a few child psychiatrists bravely ran adolescent psychiatric units and the school doctor did routine physical checks on children  most of which slipped through the net beyond the age of eleven.

Gradually various independant and charitable organisations began to set up teenage counselling clinics and small services in various parts of the country - all tending to work in isolation and 're inventing the wheel' and manily based on provision of contraception and sexual counselling. One of the most important of these independant organisations was the Brook advisory service which for the last three decades has been opening young people's sexual advice centres throughout the UK and has been a major influence on sexual education.  Another has been Youth Support, now ten years old, which is a charity providing services for teenagers and abuse victims but which also runs a 'Forum' on Adolescent Health and Welfare which arose out of the need for a professional peer group, coordination of ideas and support.

There is now developing a better understanding for adolescent care, the community health and school health services are responding to the need for more psychological and emotional input and there has been wider recognition of the need for a multidisciplinary approach.

In France the first in patient adolescent unit was created in 1982 as part of the Department of paediatrics of the Hopital de Bicetre in Paris. (Alvin;  Courtecuisse 1991) This was based on the American and Canadian experience and a multidisciplinary appraoch was used with a good community network.  Also in the eighties the Comite Francais pour l'Adolescence was formed. This took up the brief of  working in the wider community and focussed on health education and promotion producing an excellent "Guide Sante" in 1987 under the leadership of Dr Sauveur Boukris. This health guide was widely distributed free of charge to adolescents.

The multidisciplinary approach has also been emphasised in 'The Cholet Experience' (Jacquet; Mabrut 1991) where a three tiered service was provided including the adolescent ward (5 beds) of a  pediatric unit (38 beds; 1,691 admissions). Follow-up was carried out in a  specialized out-patient clinic (660 patients) held in an ordinary  local apartment lent by the town-hall. And a day hospital (12 beds) was reserved for those patients presenting with more severe psychological problems. In fact two thirds of patients presented with  psychological problems, of which 40% were suicide attempts. This approach allowed the team to function in a multifocal and multidisciplinary way while responding to local needs and providing a more global management and a better follow-up of adolescents with difficulties. ‘Creative’ approaches such as these provide acceptable environments for young people whose access to traditional clinics can be limited by stereotyped views and roles.

Specific Presentations

There is a sense in which those professionals who look for a problem will find it, and thus the type of presentation at youth clinics and counselling centres will fall in with the special interests and expertise of the workers. Hence clinics whose personell have an interest in eating disorder will not only recognise and diagnose more, but also patients will be referred and tend to ‘gravitate’ in that direction.  It is thus diffcult to accurately estimate which ‘problems’ are of most interest and importance to youth themselves and which presentations are most honed in on by the professionals. There is also a danger that  a type of problem will be ‘legitimised’ by providing the sort of specialist centres which we often see in Europe ie Brook for sexuality;; Samaritans for suicidal feelings; drug advice centres etc rather than general counselling. This may lead to the situation for instance when a young girl hears the message that she needs to be seen to be sexually active, or suicidal  to be counselled, rather than just unhappy or confused.   Nevertheless two broad areas would seem to be responsible for the majority of consultations across centres - emotional problems including suicide attempts; and the area of sexual health. These deserve special mention.

Mental Health and Suicide

Suicide has now become the second most important cause of adolescent deaths in most of Europe. Rates have been gradually increasing and the UK has about the worst record in Europe with regard to young men. It has been suggested that this correlates with young male unemployment (Pritchard 1992).

In Britain about 1 in 20,000 young people actually die while 1 in 200 make a serious self injuring attempt. These numbers hide the real depth of unhappiness since as many as 1 in 20 will admit to serious suicidal thoughts.  These rises in youth suicide and parasuicide have occurred at a time when adult rates were falling  indicating that our support services for depressed and hurt young people have been sadly lacking. Many have been victims of abuse and have been through part of the ‘care system’ hence early identification and intervention could have been a possibility, often the stigma and fear of suicide obstructs management of treatment.

The French experience is similar   “.. most come from troubled or abusive environments, most did not clearly intend to die and are asking for some help. Only a minority  appear to be mentally ill and need inpatient psychiatric care. These patients are best approached when hospitalized like any other adolescent  and offered a thorough health screening, within an integrated and  multidisciplinary framework which allows working with both the patient and his family” (Alvin 1993)

Sexual health and Education

Europe has a mixed reputation so far as sexual education and teenage pregnancies are concerned. Generally speaking northern Europe has a better track record than the southern states; the Scandinavian countries have had a succesful approach to sexuality and have kept their teenage pregancy rates low while Denmark and Holland have the lowest conception rates linked to a very open and frank approach to health education. The Dutch lesson has been admired in Britain but sadly we have had a considerable opposition to the provision of good sex education programmes and contraceptive services for youth which led to decreased contraceptive use and increased pregnancies in the eighties. Our conception rate is thus the highest in Europe although trends in the nineties have been encouraging. Conception rates for the under sixteen year olds were 10.1 in 1990; 9.3 in 1991 and 8.5 in 1992 the lowest rate since 1983.

Sadly the youngest age groups are least affected by contraceptive availablility and thus a significant number of 14 year olds and younger give birth each year. The under 14s have the worst prognosis in terms of personal outcomes and child rearing. The remaining girls have abortions and although 60% of under 14 year olds abort their pregnancies many do so at a dangerously late stage. Only 23% of abortions to under 16s are performed before 10 weeks and   5% are performed after 20 weeks. These girls often present late for care due to lack of sexual education and advice (Birch 1992).

Europe’s demography and political geography has changed radically over the last decade - states have merged (the Germanies); others have split (the former Yugoslavia and Czeckoslovakia) and the ‘new Europe’ includes areas of the former USSR. Sexual education is in it’s infancy here and there are enormous difficulties in acheiving 'modern' standards.  “The  availability and use of modern contraceptives is low; ....  traditional methods predominate ..  it is clear that the level of induced abortion is  higher in the USSR than in any other country in the world." (Popov 1991).

A generation of youth is attempting to enter the twenty first century at break neck speed without the protection of  health education and the levels of preventive medicine which most of us take very much for granted.

References -

1.    Burgio GR.  Ottolenghi A. "Adolescence and paediatrics in Europe." European Journal of Pediatrics.  153(10):706-11, 1994 Oct.

2.    Burgio GR, Lorini R, 1975  "Sauver l'Unite' de la Pediatrie. Une enquete sur l'hospitalisation et l'enseignement en Europe" Archives Francoises Paediatrie 32: 893-900

3.    American Academy of Paediatrics, Council on Child and Adolescent health ,  "Age limits of Paediatrics" Paediatrics 1972: 49:463

4.    Welfare of Children and Young People in Hospital, Department of Health 1991 British Paediatric Association HMSO London  pp 21-23

5.    Sanders JM Jnr "Health Care delivery to adolescents and young adults by paediatricians" Paediatrics 1988;82:516-517

6.    Noess PO. "Do we need a specialty of adolescent medicine in Norway?" Tidsskrift for Den Norske Laegeforening.  113(2):169-70, 1993 Jan 20.

7.    Kurz R.  Borkenstein M.  "The responsibility of medicine in adolescence" Padiatrie und Padologie.  26(3):121-4, 1991.

8.    Palentien C.  Hurrelmann K. "Adaptation of medical care to the changing disease spectrum of  adolescents". Gesundheitswesen.  56(10):537-42, 1994 Oct.

9.    Suris Granell JC.  Garcia-Tornel S. " Adolescent medicine among pediatricians in Catalonia."  Journal of Adolescent Health.  12(6):430-3, 1991 Sep.

10.Alvin P.  Courtecuisse V. "Adolescent medicine. Development and prospects".  Archives Francaises de Pediatrie.  48(2):137-41, 1991 Feb.

11.Boukris S. "Guide Sante" Comite Francais pour l'Adolescence Rue de la Chapelle Paris 1987

12.Jacquet Y.  Mabrut JP. "Multi-disciplinary approach to adolescents with problems. The Cholet  experience" Archives Francaises de Pediatrie.  48(3):179-83, 1991 Mar.

13.Pritchard C. “Is there a link between suicide in young men and unemployment? A comparison of the UK with other European Community Countries.”  British Journal of Psychiatry.  160:750-6, 1992 Jun.

14.Alvin P."Suicidal adolescents: lessons to be learned from early intervention." Journal of Paediatrics & Child Health.  29 Suppl 1:S20-4, 1993.

15.Birch DML “Are You My Sister, Mummy?” Youth Support Publications ISBN 1 870717 02 3 Second Edition 1992 (first published 1987)

16.Popov AA." Family planning and induced abortion in the USSR: basic health and  demographic characteristics."  Studies in Family Planning.  22(6):368-77, 1991 Nov-Dec.