ISSN 1363-8394

Journal of Adolescent Health and Welfare

The Journal of the Youth Support

British Society for Adolescent

Health and Welfare

Volume 14 - No 1 – Spring 2001

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

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Dear Colleagues,

This is the first edition of the new ‘real millennium’ and we are beginning to plan a ‘new look’ conference for October 2002. Even though it may be some time away time passes fast so get your applications, suggestions and abstracts in soon.  After a long period at the Royal College of Physicians  we are moving to the Barbican which reflects the new age and gives us more scope for youth involvement and new developments in the programme.  We feel sure that you will be impressed by the Barbican which bridges the space between true ‘old London’ The ‘City’ of Dick Whittington ( legendary Mayor) and modern architecture, an artificial lake and state of the art design.  The arts are well represented at the Barbican where again old meets new with the home of the Royal Shakespeare Company – the ‘Pit’ theatre rubbing shoulders with presentations of new plays and concerts. The museum of London, St Pauls, The Old Bailey, and The ‘Old lady of Threadneedle street’ ie the Bank of England are a stone’s throw away and visitors have the chance to join walking tours of the area. The programme is already looking exciting with special sessions involving young fathers, youth creativity and the arts, substance abuse and sexuality ….. etc etc

Returning to past conferences – the proceedings of October 2000 are in preparation – orders being accepted and the book on traumatic stress which includes the proceedings of our very successful April conference in Italy is available. When ordering please specify which language version you would like. Also copies of the 1998 and 1996 International conference proceedings are available. The proceedings books together are forming quite a textbook on adolescent health and are a useful reference source.

Check out our websites publications www.youthsupport.net/YSBOOKS

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

Conference details are on www.youthsupport.com

Best wishes -           Diana Birch

Director Youth Support

Contents

Letter from the Editor

Herb Friedman –

Traumatic stress

2

3

3

International Chapter News

International Chapter Workshop

‘Strengths of Youth – Protective Factors’ - International Regional Chapter Workshop at SAM 2001

19

19

Books Books Books

4

Adolescent Medicine in the United Kingdom – Russell Viner

20

Conference round up

5

The British Society for Adolescent Health and Welfare

27

The Italian Earthquake Study

6

Conference 2002

28

Herbert Friedman

Sadly Herb Friedman passed away on 20th December 2000 – this is not an obituary – I do not feel I can do him justice – but we will all miss him greatly and he was one of the best friends that adolescent health ever had. His talk “Global perspectives in Adolescent Health” which he gave at our 1999 meeting was printed in the last issue of the Journal and his speech at the October 2000 International conference was the last presentation prior to his death – hence we will be dedicating the conference proceedings book to Herb and if anyone wishes to contribute a message in that publication – please do send it in to us.

Herb's funeral took place on 5th January 2001 at Keyhaven in Dorset. It was a burial at sea but the weather was bad so the actual committal could not take place it was performed later by the funeral directors. We sailed up the Solent and then had a service on the key by Hurst Castle (A battlement / Medioeval castle and fortress in the centre of the channel near the Isle of Wight)  Then refreshments in the castle and we sailed back a couple of hours later. About thirty people attended - from all different areas of Herb's life which echoed his versatility. His niece represented the family and Jane Fergusson and some of the WHO people were there and some of the therapists from Barnet where he was working laterly. A rabbi gave the service and then there were tributes from his niece and a poem by another lady. There were about a dozen floral tributes and they will be cast into the sea with the coffin (they had to be biodegradable). It was a lovely setting and peaceful - although FREEZING! Herb had planned it and chose a piece of music - twenties sounding dance music - typical of his humour. I was cold and tired after the drive and sea journey - but I'm very glad I went and paid my respects. Herb deserved that from all of us in adolescent health.

Advert for traumatic stress book

* CONFERENCE ROUND UP *

Our conferences at the Royal College of Physicians in October 1996 and 1998 have now both been published as proceedings books which are available – see below. Get your personal copy now!!

Proceedings of our conference 1996

Youth - Our Resource for the Future

Now available from Youth Support -£5 by mail order –

13 High Street Penge SE20 7HJ

FAX 44 181 325 8647 or

E mail us at [email-masked]

Proceedings of our International conference October 1998

Youth – Conserving Our Resource for the Future

Available now from above address - £8

Proceedings of our International conference October 2000

Youth – The Promise of a new Millennium?

Available now from above address - £8

A Survey of the Psychological and Emotional Consequences of Earthquakes

The Italian Earthquake study – Youth Support Italia

Part One - The Survey and Results

{This section of the paper was first presented by Sonia Lucia in our preliminary presentation at our European meeting at the Royal College of Physicians London October 1999 }

What was the outcome of the earthquake which struck the Apennine region of Umbria / Marche in September 1997? We were moved by the words of a young school child from Gualdo who said ‘We are shaking in our dreams’ Lisa (not really her name) felt the earth move beneath her night  after night as a series of earthquakes destroyed her home. What is the psychological effect of feeling the earth move in that way and of realising that it is not perhaps the stable bedrock that we believed and hoped it to be.?  How do young people and children respond to the trauma and stress of such events?

The Earthquake began suddenly on 26th September 1997 and there were repeated smaller quakes and aftershocks from September 97 until the new year 1998.  This is an important point – the quake was not of great intensity or severity measured on a global scale or against say the Turkey or Greek quakes but it was long drawn out and as we will see this is a significant point in psychological terms. The survey in the schools took place in the first week of June 1999 – so 18 months after the first quake. The epicentre of the quake was near Fabriano – although here in fact the worst damage was in Cupo and that was where YS centred it’s relief work.

We used two schools in our study group. Liceo classico Stelluti and liceo scientifico Volterra both  local secondary schools. The liceo classico had been destroyed in the quake and the pupils had been moved to another building. So we should note here that these pupils had been directly affected in school even if they were not physically affected at home. The control group was supplied by pupils in equivalent schools in Ancona and Falconara. Two pupils from Ancona had moved there from Fabriano after their houses were destroyed in the quake - so they were transferred to the study group.

Study method

The study method was a self administered questionnaire which was given to the young people in class groups in their schools. An explanation by their teachers or by one of us preceded the questionnaire. They were encouraged to be frank in their responses. The questionnaire was confidential but they were asked to give their names if they wished and were offered feedback if they wanted it. The questionnaire was divided into three main areas. Feelings and thoughts about the actual quake. Long term reactions and feelings after the quake and a self esteem questionnaire.  The questionnaire dealt with whether they were affected personally, materially and what problems they experienced at three stages – at the time of the quake; since the quake; and at the present time.

The self esteem questionnaire is a multi cultural instrument based on the Canadian ‘Battle self esteem inventory’  which has been widely used in all youth support research and is thus tried and tested and gives good levels of comparison to control groups and other populations.  One useful part of this is a ‘lie’ and defensiveness scale. This was useful in deciding whether ‘untrue’ responses were false, deliberate sabotage or mistakes.

Survey Sample

The average age of the pupils in the study was 16.75 years with a range of 14 to 18 years. The average age of  youth with problems was 16.5 – slightly lower – this was not significant. Controls and study group had the same average age and characteristics.  This means that they were just over 14 on average at the time of the quake.

Sample Size

Fabriano

Female     305

Male  196        total 501

Control       Female   130

Male  46         total  176

Spoiled                                      42

total 719

The sample size was 501 in the study group which were 305 girls and 196 boys. The controls were 176 which were also more girls – 130 – than boys – 46.  42 papers were spoiled – and we have some comments about that. In total 719 pupils were involved in the study.

Spoiled Papers

Mistakes    Smart Arse        All

Controls                       4                   8             12

Study            Stelluti     5                   5             10

Volterra   8                 12             20

Total study                 13                 17             30

Total                          17                 25             42

Analysis of the spoiled papers revealed some interesting features.  From a statistician’s point of view spoiled papers are a nuisance. Papers that have to be discarded and which reduce your final numbers.  From a psychotherapists view point however they were also quite revealing.  In all there were 42 spoiled papers  which gave an overall percentage of 5.8%  there was not much difference between controls and study group in this respect. The controls had 6.8% spoiled of which 33% were mistakes and 66% deliberate spoiling. The study group had an overall level of 6% with 43% mistakes and 57% deliberate spoiling. In summary a slightly higher rate in the control group which could easily be explained by the fact that having not been directly affected by the earthquake, they did not take the survey so seriously. If we look a bit more closely at these figures we can see that most of the deliberate spoiling – which we have referred to as ‘Smart Arse’ remarks – are coming from the boys. In Fact nearly 8% incidence in boys and only 0.66% in females – more than a hundred-fold in males. This of course reflects the nature of young men – however the exact content of the response was also  interesting. We will return to that later.

Damage versus non damaged

The study sample divided up into young people who had not been directly influenced by the quake in that they had not sustained personal injury or loss of property but were nevertheless affected indirectly – these numbered 300 of whom only 39 did not have an emotional problem in consequence of the quake.  A group of 125 had mild damage to their homes; 39 had severe damage and only 7 sustained injury. Thus 171 were directly affected by the quake. Controls and study sample showed similar gender differences.

Stelluti            Volterra         Totals

male    female     male  female

no problems         3          5             27       4        39

probs no dam     10      119           66       66     261

damage mild        8         41            42       34     125

damage severe    1         10           16       12      39

injury                     0                  3             1         3        7

spoiled mistake     3          2             4         4      13

spoiled smart A     3          2           12         0      17

tTTTt

otals             28      182         168     123   501

As we have seen, 164 students had their houses damaged of which 39 suffered severe damage.  Housing consisted of staying with family 60%; friends 25%, a second (holiday) home 20%, containers 2% , Caravans 3%. The numbers add up to more than 100% because there were several moves – which of course were also disruptive and destabilizing for an already traumatized group.  Only  7% suffered any physical injury and this was generally mild.

A 17 year old girl  When the earthquake started we had to run out of the house. In the morning when the shocks became more intense, shortly afterwards I returned home. It was a complete mess. The church bell tower was almost falling down and everyone at Borgo were scared to go home. I had never been through such an experience but I count myself lucky to have found another house. It worried me to think that others might find themselves in difficulty and I was anxious because of the number of times we had to go out in the open as the house was crumbling.

Responses

Let us now go on to look at the responses. I must remind you that we are looking at the individuals own perceived problems.   In the study group 296 girls – that is 97% felt that they had problems resulting from the earthquake. In contrast only 166 boys which is 85% of males felt they had problems.

Percentages        study         control          total

M    F         M    F

no problems     15     3      78   48        100 (139 )

problems           85    97     22   51        100 (538 )

total                 100 100  100         100         100 (677

)

Note also that quite a high number of controls also had problems   -  however it should be stated that there were no cases in the study group who had been directly affected by the quake who did not report problems - not even the boys! The percentages show that 51% of control females and only 22% of control males also reported problems. This shows well in the graph. There is as you see an enormous gender difference.

Looking at the number of problems experienced. Some experienced a high number of problems but as would be expected the number decreased with time. The  same pattern is followed by males and females although the males experience fewer problems. The average number of problems experienced by girls were 3.6 at the time of the quake, falling to 2.7 afterwards and 0.3 at the time of the survey – ie 18 months duration.  For males the comparable figures were 2.2 ; 1.2 and 0.1.

Self Esteem

Self esteem was not a significant factor in distinguishing between the various age or gender groups or between schools etc.  However the self esteem measure was lower in those with multiple problems and particularly when problems were long standing. Here we have an example of low self esteem in a girl who lost her home.

Girl 18 years old Low self worth The earthquake influenced my life a great deal because my house was badly damaged and so I was out of home for a year. Apart from the fear of the earthquake I suffered a lot of problems because my routine was completely turned upside down. I was afraid of being injured and of not knowing  what had happened to other family members. Seeing the way objects shook made me anxious.

Main Problems

The main problems at the time of the quake were – insomnia in a fifth of pupils; tiredness in a quarter, weakness 11%, Anxiety in a third, fear in over half (59%) palpitations in 13% and fear of being alone at home again in nearly half (46%).

Main Problems – at time of Quake

•Insomnia 20%

•Tiredness 24%

•Weakness 11%

•Anxiety 33%

•Fear 59%

•Palpitations 13%

•Fear of being in home alone 46%

Of course a lot of these problems relate directly to the physical conditions that the young people found themselves in. It was difficult to sleep and many were scared of being at home when there were aftershocks.

After the quake the problems remained to some degree but lessened in frequency. It should be stated here that it was hard to define the cut off point between ‘at time of quake’ and  ‘after quake’ when there were so many after shocks and this was a drawn out event.   However we decided to count symptoms occurring in the first week as ‘at the time’  The important thing to note here is the emergence of new symptoms as the pattern shifts into a chronic situation.  We thus see that 13% now have difficulty concentrating.

Main Problems – After Quake

•Insomnia   19%

•Tiredness   15%

•Difficulty concentrating  13%

•Anxiety      24%

•Fear            47%

•Palpitations  9%

•Fear of being in home alone 39%

We asked the pupils if they were worried about themselves, their friends and their families. As one might expect, the girls worried more than the boys. Interestingly the pupils who were not directly affected – ie had not had their houses damaged or experienced injury, worried more than those who had been directly affected. This was most noticeable with regard to worry about oneself. In fact affected males worried least about themselves 40% at the time of the quake.

Worry about Self and Others – Immediate
Pupils unaffected : Directly affected

Looking at the same factors in the period after the quake. The effect is even more marked.   Only 25% of affected males worry about themselves as opposed to 55% of unaffected males.  The highest rate of worry is in unaffected girls who worry most about their family – over 80%. ‘ I was worried for my mother and for her state of mind’  At the time of the survey a significant number of pupils were affected by long lasting symptoms. These included depression –  with lasting symptoms in 5% of those with mild damage to their homes.  Also  44%  felt sadness for others and anxiety was persistent in 5% of those with damage to their houses.

Girl of 18  The earthquake of 26th September 97 affected my life a great deal and that of my family. Having lost overnight my home and all my possessions now I am harder with the realities around me. It is true that suffering makes you grow up.

Part Two

Comment and Discussion.

This study has shown some significant pathology in teenage school pupils who had experienced a moderately severe earthquake.

This study took place before the Turkey quake and hence the children were not affected by that. One might have expected that identification with the sufferers in that disaster could have caused a reawakening of symptoms. Individual memory and group memory of disaster is important in assessing reactions.  Hence the ‘problems’ experienced by the control groups. Communities do not live in isolation, there is a movement of people between Fabriano and Ancona for example and relatives may live in both communities. Each have experienced quakes before and the majority of parents and grandparents of Ancona and Falconara pupils will have experienced quakes and talked to their families about them. Hearing of earthquakes in the region will have awakened fears in the pupils.  We did also wonder if the control group may have been affected by the on going war in Yugoslavia just across the water - but the results do not seem to indicate this as a factor.

So now let us consider the spoiled papers, the smart replies – the smart-arse comments.  An inappropriate response like laughing at a funeral can indicate embarrassment or inability to cope with the flood of mixed emotions. This is more than that. The sort of forced bravado which results in this sense of joking in the face of danger , making light of pain and problems, and pretending not to care is a form of ‘manic defence’. It can appear as a driven form of escapism.  It may begin as a smoke screen diverting others from seeing our real feelings and weaknesses - but the pernicious nature of such a defence is that it then hides our true feelings from ourselves. It may help troubled youth to cope with emotions but is a flawed coping mechanism which brings it’s own problems in its wake.We have a good example of a manic defense in the words of one of the girls

‘The period of the earthquake was really amusing apart from the fact that my house had been declared condemned and I have been forced to sleep at my grandparents house. I spent the days in the company of my parents and friends enjoying myself a lot.  In my family, I’ve been the one less worried about the shocks. I didn’t let myself be conditioned by the events and I tended to have a good time during those unusual days. This event also had a positive side, it forged solidarity between people and it made us reflect on our life. Most likely if my house had not been destroyed I could have said that the earthquake was a completely positive experience. Now that the house is ‘destroyed’ I have to say that I would not mind feeling some more little shocks.’

Another aspect of the emotional defence also lies in the gender difference - males reporting fewer problems - for all the usual ‘macho’ reasons.  Latin races are supposed to show ‘machismo’ anglo saxons the ‘stiff upper lip’ but whatever you call it the adolescent years - which are what we are looking at here - are the time when the gender difference is at it’s most intense, when boys  are developing into young men and have not yet acquired the confidence to be able to show their emotional weaknesses.  So fewer males completing the questionnaire, fewer reporting problems and more making a joke of it. A highly defended group.

Looking a little more closely at some of the problems.

The graph shows problems for the group with no damage to their homes.  The symptoms are shown in the order of incidence as at the time of the quake. The highest incidence is for fear, fear of being alone, anxiety, tiredness and insomnia.

Looking the at the rates after the quake we see that the order has changed.  Insomnia and lack of concentration becoming more prominent. And as time goes on some  of the symptoms disappear altogether for this group. The top five remain although  lack of concentration, palpitations, weakness and fear of the dark also persist.

A 16 year old male It was a terrible experience. Every day I lived with the fear of seeing my house crumble and of losing myself or my friends fortunately this dreadful experience is now over.

The same graph for the cases with slight damage to their homes shows a different pattern. The top two symptoms are the same as for those without damage – fear and fear of being alone at home. But of the top six symptoms anxiety is very much lower. Only 7% as opposed to 29%.

In the case of the group with severe damage – the pattern is different. They are fearful, can’t sleep, are sad, school problems are a major feature coupled with lack of concentration. Weight loss , poor appetite and headaches – somatic symptoms come to notice.  However note again how anxiety is less of a feature than for those without material loss.

Concentrating on the timing shows how the different levels of direct damage influence the responses. Note lower anxiety again in those directly affected with severe damage. This relates to the feeling of once the worst has happened you don’t have to fear it any more. After the quake those without damage have a high level of anxiety related problems while in general insomnia, sadness and problems with concentration are prominent particularly for the group with damage. In fact the students responses echoed this feeling that waiting for something that might happen caused more anxiety – Several remarked that gaps between the tremors were more scary because you were waiting for the next one and that the longer gaps were more difficult to cope with because you then knew another one was imminent.

I was worried by long periods without shakes.

Girl aged 16 The earthquake marks your life and your existence because every time that there is even a small shock you are traumatised and start yelling. Even if I have not suffered any damage either to my house or to my person the fear is there and it is powerful, even now (18 months later).

In the long term (this is eighteen months later)  these are the symptoms which persist. Fear, anxiety, tiredness, insomnia, poor concentration.
The duration of symptoms is also important to note. 40% of all students had some long standing symptoms and 12% still experienced at least one symptom after 18 months.   The incidence and average duration of the most common long term symptoms – fear 4% with average of 5.5 months chronic tiredness 2% on average for 6 months and anxiety 2% lasting nearly 4 months - show that although the incidence of each symptom might be low – the actual impact on the community and the individual is significant.

16 year old female Fortunately in my village the effects of the earthquake were not very destructive and my house was not damaged Therefore the various consequences that it brought were fear, anxiety and agitation for a long period of time. I was anxious over the thought that these events are unpredictable and can happen at any moment. I was afraid of the destruction of the earthquake and of losing those I loved.

The phases of disaster impact can be seen in the progression of quotes from the students – first the survival and heroic camaraderie stage –

Fifteen year old girl In my block during the days of the quake there was a great communication even among those popele who are usually terse and don’t talk at all with anyone. They stopped under our house and talked about everything (including the earthquake). But the bad thing was that only during those days of was there a communal rapport between the inhabitants of the same building. During the shocks some people were so scared that they came out of their homes without being fully dressed!

I saw windows burst and houses crumble.

School was closed for a month

This phase gave way to a pervading sense of hopelessness and helplessness in the face of danger which was a theme in many of the students comments.

Female aged 15 At that time I was in terror specially when night came and I would have had little chance of escaping if there had been shocks.

Female aged 15 I was really worried when the walls moved back and forth. I went and slept in the car during the shocks.

Female aged 19 I’ll always remember the  earthquake because for me and my family it was a  long period of continuous chaos, of great fear and of little achievement both at school and on the work front. It is only when you are in the face of it (the earthquake) that you really understand that in the face of nature you cant do a thing, you can only hope that it will not play any ‘nasty tricks’.

At the time of our survey of the Fabriano quake the young people were one could say, in the restoration / disillusionment phases in the transition towards normality. The drama of the initial event had passed and they were beginning to face up to the long term reality of what had happened.   Initial shock and helplessness had also faded and they had gone through a phase of  anger, feeling let down and this was expressed both directly and indirectly.

Girl of 16 (SEI 10) with anxiety state and low self worth.

The thing that worried me most about this quake was that the shocks were so frequent. My nerves were in pieces and I was in a dreadful rage. I also had a great uncertainty about tomorrow because I did not know if I would have a tomorrow.

They were also angry with the authorities –  ‘they know it’s a seismic zone’ why were they not prepared. When the school building collapsed the teachers did not help the pupils during the evacuation.

16 year old boy angry with the authorities I’m afraid of Italian Beurocracy because the rebuild times are so long and my house is left just exactly as it was on that day.

The earthquake has been a real problem for me and my family. Of course life goes on but I feel better out side than indoors. It is as if when I go inside the house, which since the earthquake I share with my parents, grandparents and my brother, I feel much too sad because I remember how good it was before alone and in peace in my condemned house. However I get along very well with my parents and especially with my brother apart from the inevitable family squabbles.

Anger could well up against the family when they were cramped together –  while in other families stronger bonds were forged.

Girl 19 years used voluntary work to avoid her sense of helplessness – family issues.  After the earthquake I made closer ties with my family and my parents. During the earthquake I did voluntary work with the scouts in the ‘caravan city’ I am scared of the earthquake coming back and of being alone in the house. I’m afraid of a nocturnal quake. What worries me most is not to be able to do anything about it.

Healing the Wounds

This picture is apt – the time had come to heal the wounds. Communities want to move on and it is laudable that people do not wish to dwell on the past but move forward positively to a new future. However we must remember that the emotional scars of such experiences are forever part of us and though diminished by time can for the more vulnerable of our society prove to be a real obstacle to a healthy and happy life. So we do need to provide support services and help for young people who are caught up in such traumatic situations and take note of their emotional needs.

Our estimate is that in this event approximately 3% of school pupils suffered from a significant degree of long term post traumatic stress. Fabriano was not the only town affected – Umbrian towns sustained heavy damage. We only examined a small proportion of the school children. 3% over the whole area is a lot of children. The effects on younger children may also have been more pernicious.   This is a seismic zone and there will be more quakes. A continuing program of education coupled with a dialogue with youth to air the problems and fears is just as important as building anti-seismic houses. What we need is ‘anti-seismic’ minds.

- International Chapter News -

News of the International Regional Chapter (IRC) of SAM

(Society for Adolescent Medicine)

Co Chairs - Diana Birch   Gustavo Girard  Treasurer Aric Schichor

London          Buenos Aires                     Connecticut

England          Argentina                           USA

Workshops /  Institutes  -

San Diego March 2001

SAM meeting March 2001

Luncheon - International Regional Chapter (IRC) SAM

‘Strengths of Youth – Protective Factors?’

In this session we will consider a variety of different challenges which Young People face in growing up and entering adulthood. Rather than looking at the problems and difficulties from the common perspective of the fate of those who have ‘fallen by the wayside’ we will consider the positive attributes of those who weather the storms of childhood and adolescence and emerge as fulfilled and productive adults.

Why do teens NOT become young mothers? Why do abused children NOT follow the paths of the victim or allow themselves to be  carried along the  ‘cycle of abuse’ to harming their own kids? What factors help a young person from a deprived or abusive background to avoid the fate which statistics and professional experience would tend to commit them to.

And lastly,  but most importantly -  How can we enhance and encourage  these factors?. How can we bring them to the fore in our less fortunate kids? How can we utilise these strengths in helping youth as a whole to survive the world which we have created for them?

This session will have an International flavour with presentations from a number of countries and areas of the world, but will in the main be dealing with universal factors applicable to Youth throughout the world – albeit influenced by local cultures and values.

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

Russell Viner.

I am an adolescent physician, paediatrician by training, appointed a couple of years ago to develop an adolescent medicine service between 2 hospitals in London Great Ormond Street Children’s Hospital and the Middlesex Hospital. I went down to visit the Youth Support House a couple of years ago and was very impressed by some of the work that Diana does at Youth Support you are obviously developing quite a good service there. We’ve been developing things at a slightly different tack at the two hospitals I work at this is the first adolescent medicine service within the health services in this country that I know of.

Need for Adolescent  Medicine

What I want to do first is tell you about the need for adolescent medicine and adolescent health in this country, some of the research we’ve been doing, what’s available within the health services particularly. Then about the kind of model one can use to develop services and a little about our service. I suspect most people are surprised when they realise how many adolescents there are in this country. In England alone there are 6 million young people 10 to 19, at least 12% of the population. It’s a very large number and it’s very clear to me that there’s no way 12% of the health budgets in this country spent on young people, it’s far lower than that. The projection for the next little while is that will increase, in 2002 there will be 6.4 million, a 9% increase in a decade from 1992. It may decrease slightly after that but it’s sobering thought. Just looking at a general sense it’s very clear what we call the new morbidities, such as accidents, suicide, homicide, environmental causes have largely replaced the old morbidities: infectious diseases, congenital malformations as killers of children and young people and that’s really very dramatic.

Mental health: many of you will know, that young people, up to 20% of young people have some form of mental health problem between 16 and 19 years in the UK some 93 data: depression, anxiety, alcohol dependency, drug dependency is really quite high levels amongst their population in a way I don’t think many of us realise. Probably only 5% have a severe mental illness, but it’s very clear again that certainly far less than 5% of the mental health expenditure in this country, 5% is not very much, goes on children and young people and I suppose those like Diana who work at the coalface with working with many young people with social and mental health problems will tell you that getting money is really very difficult.  The increase in young male suicide in this country, in England and Wales, probably certainly worse in Scotland than in England and Wales, and one of the higher rates in Europe, as you will know.

Sexual health –apart from the USA Britain, England and Wales and Scotland together in the developed world have probably the highest rates maternities in young people between 15 and 19. And what’s quite fascinating is that over the last 10 years, 15 years now, this actually hasn’t changed in England and Wales, in Scotland or in the USA, where we’ve seen reductions in many other European countries and many much poorer European countries. The next generation will probably be the most infertile in the history of humanity, that’s an interesting and sobering thought. STD rates are up to 10 to 15% in many populations. The UK rate for teenage conceptions is certainly the highest in Europe. This is producing anxiety in government at the moment and producing some money, will be interesting to see whether it translates into changes in service provision.

Smoking

Smoking – many of the other morbidities as you know we fail to meet the Health of the Nation targets set by the last Conservative government. it conspicuously failed to reduce youth smoking by a third as it had intended, in fact the rates have gone up since 1986 amongst young people, 11 to 15 year olds in particular regularly smoke, now up to 15%, increased in girls as you know much more than boys. One thing that ties much of this together and much of which Diana was talking about together is poverty. Unemployment rates amongst young people has always been higher than all age unemployment but in fact has risen in the last years of the last conservative government, dropped a bit under the new labour government, but certainly not as much as one would expect.

Chronic Illness

Chronic illness is the area where we’ve seen increased morbidity, mortality amongst young people. Some figures suggest that up to a quarter of young people in England report some form of long-standing illness, much of this is not particularly severe, but much of it is. There’s been an increased incidence particularly of diabetes and asthma amongst young people, but there’s also been an increased survival for young people with chronic illness. The prevalence of young people with cystic fibrosis over 15 years of age in the UK has more than doubled between the late 70s and the early 80s and my colleagues in cystic fibrosis work tell me that it has doubled again in the last 10 years. There’s certainly some start been made in providing facilities for these young people, but it’s certainly a very sobering fact. We must remember that now over 85% of young people or children with chronic illness survive to adult life, a very different figure to 20 years ago, and one of the reasons why the health service needs to get very serious about adolescent medicine and transition from paediatric to adult care.

What is adolescent medicine? I think it’s a very difficult question to ask. What is different between adolescent health and adolescent medicine? – again another very difficult area. If you look around the world some people very much adolescent medicine exponent and some people prefer to talk about adolescent health. In the USA and certainly in some of our European colleagues adolescent health, adolescent medicine is very much a primary care based enterprise. It’s not particularly in hospitals, it’s not in tertiary centres, it’s about being there at the coalface, general practice, community health, various other issues much of it is to do with drug and alcohol work, much, as Diana has said, is to do with teenage pregnancy type work, much of it is to do with eating disorders, although it is not particularly primary care, but it’s involved in prevention and health promotion. Australia I think probably has a health service that is most like in the UK not in terms of the way it’s funded, but it terms of the way doctors and nurses and other people work. Adolescent care in Australia has much more developed within secondary care..

What exists in UK

In the UK what exists in adolescent health. In a very formal way national structures in terms of universities, in terms of the national health service, very very little, in a formal sense. But I think there is actually a lot going on in this country in primary care, in a charitable sector and outside all the medical profession as such, certainly outside the health service. Youth Support is certainly one example of that, and as I’ve gone around the country in a couple of years that I’ve been here, I’ve certainly found out that there is a huge amount going on, but it’s very fragmented, people are not working together, there’s little sense of cohesion, many people are constantly reinventing the wheel, that good practice in one area is not being translated into good practice in another area and certain communities are developing projects that have been found to fail in other communities and there is very little overall coordination. Within medicine there’re some interesting developments, the Royal Colleges of GPs has a general practice working group that’s really been quite active, Diana’s Youth Support has been around for a long time and has done good work for a very long time. There’s a very long history of cause for action within the health service itself even since the Platt report in ’59, but little action has evolved from that. I undertook a survey in 1997 of health authorities and boards in this country to see what kind of thought the commissioners of health in this country were demanding in adolescent health from those who were providing services. It’s the commissioning authorities, health authorities and boards and now primary care groups to actually push providers into providing good health care. What are they doing about adolescents, are they thinking adolescents, do they know anything at all about adolescents? This is the survey I took with a group called Caring for children within health services. We sent out a questionnaire mail order to a 124 health authorities and boards and only 10% of commissioning authorities had even thought to provide specific advice to service providers within their health authority on adolescence. 90% did not have specific advice about the special needs of adolescents. 6% mentioned young people, adolescents and young people within the child health specifications briefly, but 81% did not make any mention of adolescent health and we are talking about hospital, community health, the whole lot. Staggering. By region, there are some dramatic regional differences. The South and West region was one region where there was a lot work being done on adolescent health. If you look at South Thames, if you look at North Thames, if you look at Northern Yorkshire – absolutely zero, actually North Thames isn’t absolutely zero, but fairly poor, dramatically poor.

Mental Health

Mental health specifications I found even more scary, because the Government has been pushing very strongly for all areas to actually think about adolescent mental health. We took these figures to the Department of Health and they laughed at us, they said that in fact this cannot be true. But overall only about 40% of health authorities had specific instructions for the provision of adolescent mental health within their area. 57% of them had no specification at all. We also asked them what do you have in terms of some form of hospital services for adolescents in your area? You won’t be surprised to find out that 80% made no provision whatsoever for adolescent put into hospitals within these regions. About 8% of them had some kinds of teenage wards, that’s 14% of them seemed to have some kind of provision for adolescents and young people within children’s wards, that would usually be a bay, it might just be a small room, it may be very little at all. Pretty staggering. We also asked them what plans they had about developing adolescent health policies. One would have thought that if mailed a questionnaire on adolescent health and you’re forced to examine your naval and say that you have no specifications it would be easy to tick the box and say, yes, we have some future plans. But even 52% ticked the box and said, no, we have no future plans for developing anything in terms of adolescent health. But it seems like another quarter that felt guilty enough to say they were developing some specifications for adolescent health. We then undertook a survey of the youths of hospitals by young people in this country, something that I am particularly interested in terms of developing a service either into very specialised hospitals: in London Great Ormond Street for Children Hospital and the Middlesex Hospital. The picture of one of the young people from our ward and that’s actually a back cover of a report I produced called “Youth Methods” which is entitled “Evidence-based best practice for caring for young people in hospital”. We published that with the Nuffield Foundation last year. It’s about good practice in developing adolescent units, what young people need and what need to be provided for them.

Bed usage

There is actually quite a considerable bed usage by the young people in this country. Young men have a higher hospital need than young women early on and suspect it fits with accidents, risk-taking, risky behaviour and much of it is trauma and orthopaedics; that young women later on have a higher bed use and this is largely to do with gynaecology. These figures are by the way excluding mental health, excluding obstetrics, excluding learning disability, etc. This is excluding mental health and excluding obstetrics because that data is already well available. Each district general hospital in this country needs about 15 beds for adolescent patients which is certainly 1 ward in adolescent unit. What you are usually told when we talk to people about developing health services for adolescents is that adolescents are a healthy group, that they never see GPs, they never go to hospital, they don’t need special services because they are very healthy group. And I suppose compared to infants and compared to the very elderly, yes, they are a very healthy group, but those of us who work with adolescents know that they have very special health needs And you pull the figures together that no one else has done before, you actually realise that they do use quite a lot of hospital beds, there is quite a great need for hospital beds for adolescents, much greater that people usually assume. It’s interesting that these figures have never been pulled together before. People produce figures for paediatrics which is naught to fifteen, and they produce figures for adults, 15 to 60 and then t he elderly, 60 and upwards, and no one’s ever really thought about adolescents actually from the 12 to 19 bracket. And I am sure as Diana knows and others who tried to produce any health statistics in this country and many others, no one actually provides health statistics for young people as such, they provide them for children under 14 and up 15 and then 15 onwards. So in fact, the adolescents group gets dissipated in the middle and it appears they have no special health needs. As you probably well know both paediatric and adult services usually provide very little in a way of useful services for adolescents within hospitals. The paediatricians baby them, the adults ignore them. The average age of a paediatric ward in this country is about 3. The average age of an adult ward is 67. It’s very difficult for a young person of 15, 16, 17 with their own particular needs to be nursed in either of those.

Not all bad news

What else has been happening recently in the UK, because certainly it’s not all bad news. I am talking more specifically about the health service. I think there’s been a lot happening. I think the main reason to be optimistic in this country and as I go around the country I feel that there is a real general build-up of interest in adolescents, particularly at all levels of the Department of Health, the Department for Education, within the health services itself, people are starting to talk about adolescents a lot more. Recently the Royal Medical Colleges have got together and formed inter-collegiate working party on adolescent services.  There’s been a number of other young things going on, the Carnegie Foundation got what they call a Nuffield-Carnegie Young People’s Initiative, which is trying to give a large sum of money to thinking about innovative proposals in youth health in this country and they have funded a large number of working groups to do this, one of which I’ve been involved in. So I think that again is a very positive new development and many things should flow from that.

European Group D, which is about training in adolescent health. I’ve been recently invited by some of our colleagues in Europe to join a working party in training in adolescent medicine, which will have its first meeting later this year in Lausanne. If we can get some European-wide action or some European-wide guidelines on training doctors and other professionals in adolescent health and adolescent medicine, we can again more powerfully go to governments and say, this needs action. And this will tie in very well with inter-collegiate working party, because part of what we want to do, particularly in medicine, is to develop training programmes for doctors, which is sadly lacking in this country. Tony Blair’s government has quite a focus on young people: education, education, education seems to be the watch word of New Labour and I think that’s very useful for us. There’s a real emphasis as well on what they call at the highest levels “joined-up thinking” which is about not working just in health, just in education or just in social services, but actually about holding joined budgets and working together. And if any of you have actually tried working with really difficult young people just from within the health services you realise that this kind of joined-up thinking is incredibly important.

Where to?

Where to from now? We need to be thinking about adolescent health provision at all levels of the health services, primary care, community health, health prevention, that primary level, which has to be broadest base, which has to be where the coal face, where most of the work is going on, where people like Diana and others work. Secondary care, which is the district general hospitals, the general hospitals, where many of these young people will go to casualty, will be admitted to hospitals for various operations and look to for much of their medical care. Tertiary care, which may be tertiary children’s hospitals, it maybe adult teaching hospitals, but it’s also the universities. We also need action in training, medical schools, Royal Colleges, as I said, there is not one Royal College of Medicine in this country that has any .training requirements in adolescent health, so none of the doctors in this country that are being trained are required to have any focus whatsoever on adolescent health. The GPs are doing it best, a colleague of mine Chris Donovan that some of you may know, has been working for a long time within the General Practitioners College and they have some good training materials, but it’s certainly not a requirement. So we actually aim to make a requirement at least within the general practice colleges and least within paediatrics, that medical students and young doctors coming through should have some exposure to adolescent health in that. Within nursing training there is no requirement as I understand it for adolescent health, but again I think there’s been a lot going on within the nursing profession which has very much led the way in terms of working with adolescents and young people in this country.

Adolescent medicine is not a specialty and should not be developed as specialty in this country. When I was appointed I called myself an adolescent physician, and a lot of people said to me, what is an adolescent physician. My background and training is in paediatrics and endocrinology but I’ve done other things as well. In the States there is a speciality of adolescent medicine, a similar situation may exist in other countries. I think that would be unadvised road to follow in this country, we must not form yet another small subdivision of medicine. What we need is specialists in adolescent health, but adolescent health or adolescent medicine should not be a specialism. Medicine is already too much broken up into chimneys that don’t talk to each other.

In terms of a model; for developing adolescent health in this country, we’ve tried to think about the various tiers of the health services and try and how we can get adolescent health into them. The broadest tier of course, is this one at the bottom, primary care,  general practice, school health services, community health services and the charitable section, Adolescent specialists are never going to see the great majority of adolescents, adolescents are seen by general practitioners, by school nurses, by all sorts of other people who are not adolescent specialists. So we need to get adolescent medicine into the pre-existing structures rather than developing the new ones. Secondary care are the hospitals, we need to get them in there. And tertiary care. I feel the best way to do that is to develop regional centres of excellence in adolescent health. In secondary care each district general hospital needs to have a dedicated or named consultant/doctor with an emphasis or responsibility for adolescents and the same within the nursing sphere, and they need to be supported and have links with a regional centre. One of the messages that I have about building services is about research and scientific credibility, which is something we have to develop if we are going to put adolescent health on the map. It’s about action at all levels, not just primary care, not just secondary care, but very much at tertiary and government and national level. I think I might leave it there. Thanks.

The Journal of Adolescent Health and Welfare

is published by:-   Youth Support,

Tel No 0181 325 8162             Charity No 296080                  Fax No 0181 325 8647