There was a time, which I remember very well, when a pediatrician's primary effort was to diagnose and combat infections. All of us saw (not infrequently) among our patients such conditions as mastoiditis, retropharyngeal abscesses, erysipelas, streptococcus throats, rheumatic fever, acute nephritis, and numerous contagious diseases - especially the dreaded poliomyelitis.
Then, almost suddenly, came the advent of antibiotic therapy and the new immunizations, and most of these conditions disappeared almost entirely. The practicing pediatricians now had extra time and many of them, during the 1940s, began to develop a deep interest in the emotional problems of boys and girls under their care. Soon parents turned to the child's physician as their first source in solving emotional as well as medical problems, many of which involved their teenagers.
Adolescence is, without doubt, the most difficult period in the lives of children. It is a period when boys and girls start resisting their parents' authority and look instead to their peers for their way of life. Many of these teenagers are alienated and become runaways. There are hundreds of thousands of these boys and girls roaming the streets today. Some become prostitutes in an effort to find a means of support. The problem is far from solved. One interesting approach is through an organization in Chicago called "MetrO'Help," a service where parents and runaways can keep in touch with one another by telephone. They also have a referral service.
Many adolescents become depressed during this most difficult period; some become withdrawn, many take drugs, and some even attempt suicide. At times these suicides become contagious. Once there is a suicide in a high school it is often followed by other suicides. In one instance recently, where such an occurrence was publicized in the local papers, there were scattered suicides in the high school of the area.
But aside from family difficulties there are other concerns disturbing teenagers. There are so often wide differences in physical and sexual development; concerns over personal appearance, especially the size and shape of the nose; the problem of acne; and in those boys and girls slow to develop heterosexual interests, worry over possible homosexuality.
In the face of all these various problems, often withheld by teenagers, what is the pediatrician to do? There is no doubt that he or she can be of the greatest influence if the problems can be detected, and if the adolescent boy or girl can talk freely to the physician knowing that the conversations will be confidential.
This second issue of Pediatric Annals devoted to adolescence answers many of these questions. It deals largely with emotional problems, and as in the previous issue, comes from institutions selected by the Federal Division of Maternal and Child Health because of their superb organization in the study of adolescent health care.
The first paper, on "Recognizing and Dealing with Alienated Youth in Clinical Practice," comes from the Department of Pediatrics of the University of Washington, Seattle.
It is written by Dr. Robert W. Deisher, Professor Emeritus and Dr. James A. Farrow, Assistant Professor, both of the Division of Adolescent Medicine. The authors start by presenting some staggering statistics: approximately 1,250,000 youths run away from home each year; 25% of all high school students drop out of school; and half a million youths are held in juvenile detention facilities each year.
Most of these teenagers, it is noted, seek no help and do not trust adults in general. Then what is the pediatrician to do to detect the potentially depressed and alienated youths? The authors advise on the approach to take, that is, assuring confidentiality; also, the pediatrician must be aware of specialized resources in the community if such help is found to be a necessity.
This is not an easy problem for the physician to solve, for it takes time and the full cooperation of the parents as well as the teenager. But in a great many cases, it can be accomplished successfully.
The second article relates to "Intra-Family Sexual Abuse of Adolescents" and is authored by Carolina M. Endert, MSW, Assistant Professor of Social Work, of the Department of Pediatrics, Division of Adolescent Medicine, and Dr. William A. Daniel, Jr., Professor of Pediatrics and Director of the Division of Adolescent Medicine, both at the University of Alabama, Birmingham, Alabama.
Studies show that this is not an uncommon occurrence in families of all cultures and all economic and social backgrounds. As I wrote in this column a few years ago, I was following a welfare family, in a study for the New York City Department of Health on childhood exposure to tuberculosis. I followed a lovely, warm family with five children. They would sing together, eat their meals together with great joy, they always seemed happy - this was, to my mind, a perfect family. And then, one day, the 15-year-old daughter became pregnant - and the family blamed an uncle who they told me lived several blocks away. I did not know the uncle, but hated him in absentia.
The next thing I learned was that the family was being taken to court for improper care of the children. The State wanted to break up the family. I couldn't let this happen and went to court and testified that in my estimation this was an ideal family. The judge responded to my appeal and discharged the case.
A few minutes later while I was walking down the block, pleased with my success, a social worker grabbed my arm. "Doctor," she said severely, "we investigated the case. There was no uncle. The girl's father made her pregnant." I was stunned and suddenly realized that I was deplorably naive.
This excellent article brings out both the physical and psychological indicators of sexual abuse. The pediatrician must, through his or her sensitive and perceptive inquiry, gain the confidence of the adolescent who will relate and confide the details of the incestuous relationship. Methods of handling these situations are reviewed, along with resources available for assistance.
The third contribution to this symposium is especially important at the present time. It is titled "Working with Gay and Lesbian Adolescents" and has been written by Dr. Gary Remafedi, Instructor in the Department of Pediatrics, Adolescent Health Program, and by Dr. Robert Blum, Professor of Pediatrics and Director of the Adolescent Health Program of the University of Minnesota Hospitals, Minneapolis, Minnesota.
This subject has suddenly gained special importance due to the rapid increase in the number of AIDS victims. But this is only one factor that makes it most important for the pediatrician to identify this sexual orientation. As the authors state in the article, the development and acquisition of a homosexual identity is a long process beginning in early childhood.
A great many adolescents, male and female alike, have at one time or another had homosexual experiences. Most of these young people, and I can speak from the patients' experiences, turn to heterosexual feelings and desires as their lifetime identities. But there are a certain number where the homosexual feelings persist.
What is the pediatrician's place? It is much more than just to make a diagnosis. It is also to be a counselor with sympathetic understanding. For most of these boys and girls are discriminated against, and suffer isolation and often persecution by their peers.
This excellent article discusses the approaches to this very important subject. The pediatrician is a key figure in the physical and emotional development of every child under his or her care, a responsibility that should not be avoided. It is of great importance and may be a crucial factor in the life of the adolescent.
The fourth paper deals with another most important subject, "The Pediatrician's Role in Adolescent Suicide." It is distressing to note that in 1985 there were 6,000 suicides among teenagers.
The present study comes from the Division of Adolescent Medicine of the Department of Pediatrics, University of Washington, Seattle. It has been written by Dr. Albert C. Hergenroeder, Senior Fellow; Laura Kastner, PhD, Clinical Psychologist; Dr. James A. Farrow, Assistant Professor; and Dr. Robert W. Deisher, Emeritus Professor of Pediatrics and Director of the Division of Adolescent Medicine.
The authors note that the number of suicides among adolescents has been steadily increasing since 1950, and tragically, for every completed suicide there are an estimated 50 to 200 attempts.
What is the cause of this increase? Various postulations are considered, and to my mind all of them are important. Can the pediatrician have a determining role in preventing adolescent suicides? Do parents or the patients themselves come to the pediatrician with such serious emotional problems? And when physicians are contacted have they the capability and the training to handle these teenagers?
The authors delve deeply into these problems, specifically stating that pediatrie programs should emphasize training in suicide intervention. The capable pediatrician who is given the information can identify the adolescent at risk. But how many parents will relate family problems to the pediatrician, and how many adolescents will reveal their deep emotional problems? Given the opportunity, capable and dedicated pediatricians are able to detect the depression and learn the causative factors. The pediatrician, by the history and observation of the patient, knowledge of his or her family and peer relationships, by the teenager's demeanor at home and school, and by his or her school performance, can usually detect the suicidal adolescent.
The article outlines the approach of the pediatrician to a potentially suicidal patient. Also discussed are the waves of imitative suicides following the media publicity of a single suicide. Those of us who have had patients who attempted suicide in the past would have handled these cases much better if we had had this article to inform and direct us.
The next contribution to this symposium deals with a most important subject for the practicing pediatrician - "Interviewing the Adolescent." This is another paper from the Division of Adolescent Medicine of the University of Alabama under the direction of Dr. William A. Daniel, Jr. , one of the outstanding authorities on adolescence. It has been written by Sue Ellen Lucas, RN, MSN, Assistant Professor of Nursing; Bonnie A. Spear, RD, MS, and Dr. Daniel.
This paper on the art of interviewing covers many of the most important approaches to employ in attempting to gain a full picture, physically, emotionally, and socially, of the teenager. The authors direct first on how to establish trust. Then what to observe, the so-called body language, while discussing the adolescent's various problems, and what to do when some subject obviously upsets the patient - one interesting aspect of this paper is the division of adolescents into three developmental stages and the difference in interviewing in each of these stages.
This is a basic paper and should be of value to all pediatricians who deal with teenagers.
The final paper is an assessment of the views of pediatricians on the changing problems for modern adolescents. It is a study conducted by a survey in Minnesota, Wisconsin, Iowa, and the Dakotas.
The results of this survey are reported by Michael D. Resnick, PhD, Assistant Professor and Research Coordinator; Linda Bearinger, MS, Research Associate, both of the Adolescent Health Program of the University of Minnesota; and by Dr. Robert Blum, Professor of Pediatrics and Director of the Adolescent Health Program of the University.
Among the negative changes noted were problems relating to sexual activity, increased daily stress, and the growing use of drugs by adolescents. This is an interesting paper with many quotes by the pediatricians interviewed.