rsm92

Co Ch= airs - Diana Birch Gustavo Girard Treasurer Aric Schichor

&= nbsp; London Buenos Aires &n= bsp; Connecticut

&= nbsp; England Argentina &= nbsp; USA

The 1= 996 SAM (Society for Adolescent Medicine) meeting- “Assuring Quality Care for Adolescents - Preparing for the 21st Century” was held at= the Crystal Gateway Marriott Hotel, Arlington Virginia March 20-24th.

Our International Chapter workshop on Thursday March 21st - dealt with “The practice of Adolescent Medicine from an International Perspective” - The theme was the management of ‘difficult cases’ with the emph= asis on clinical presentation and practical solutions. This was the subject that= had been asked for by the membership at the previous year’s Chapter meeti= ng. It was thus disappointing that not only was attendance very poor - but those who had asked for this title on the basis that they wanted to present cases= - did not turn up and do so. Without wishing to winge too loudly - I would implore members in future to put their committment behind their suggestions= !

=

There= are always many conflicting interests at the SAM meeting and it is hard sometimes to choose which workshop to go to. It is worth noting though that the last few workshops have been excellent for those who have turned up and hopefully we= can attract a larger participation next year in San Francisco. Actually the tim= ing of this year’s workshop could hardly have been worse (4-6pm) and we a= re looking for a different slot next time.

=

The p= lan which was discussed at the Chapter Breakfast meeting was that we would have a ses= sion on the day before the main SAM meeting so that there would be not so much competition and conflicting timetabling. We are going to hold an ‘Institute’ on the Wednesday which will have a morning and afternoon slot with a separate theme for each section. We hope that PAHO ma= y be involved in the programme and Bob Blum has consented to join us for the day= .

=

The s= uggested theme is ‘Poverty and Neglect - Deprived Youth in varied societies’. Presentations will highlight the presence of deprivation = in all aspects of youth culture - from street children, starvation in so called ‘developing’ countries - to poverty in inner city Europe and no= rth America for example. The last part of the day will be devoted to ‘free papers’ on a variety of subjects - Semi Snajderman has agreed to pres= ent on eating disorder and Danny Hardoff has a paper on attitudes of non adoles= cent health trained paediatricians to adolescent health.Write or fax with suggestions you might have and also any contributions you wish to make.

I wou= ld also like to suggest that we all bring examples of our work in our countries - leaflets or display material which could be displayed in our meeting room a= nd give members a better feel of the work we are separately involved in back in our own countries.

=

The International Chapter of SAM is an important part of the society and this v= iew has been endorsed by this year’s president Gail Slap. The enthusiasm = of the members is reflected in the large numbers who do attend the - International Dinner - which onc= e more was a roaring success! This time the Restaurant had a ‘Cheers’ = look about it and was owned by a retired famous Football player (I apologise to = fans of Joe Theissiger for thinking he played baseball!).

=

We ar= e trying to get E mail on line for the International Chapter - not as easy as it mig= ht first appear for those of us outside the US - but Aric has been working ver= y hard on the SAM technology committee and on the SAM home page of the World Wide Webb.

&nbs= p;

Society f= or Adolescent Medicine

San Franc= isco March 5-9 1997

The Inter= national Regional Chapter (IRC)SAM

‘In= stitute’

&nbs= p;

&nbs= p;

‘Poverty and Neglect - Deprived youth in varied societies’.

Contributions and ‘free papers’ welcome.

Also - for your diary - note that we will be having the following ‘events’ at the IRC.

Institute - Scientific session - as above - probably on Wednesday 5= th March

Dinner - Social event - probably on Thursday evening 6th March=

Chapter Breakfast - discussions and recruitment of members. Saturday 8th. am.<= /span>

‘Board meeting’ - active members - ‘housekeeping’ TBA.

Dates to be confirmed after SAM programme decided upon.

Qualitative Research

One of the very welcome aspects of the recent SAM (Society for Adol= escent medicine) meetings has been the inclusion of a special interest group on ‘Qualitative research’ under the leadership of Richard Brown - (San Francisco). It was thus thought appropriate to= include the following article which appears in slightly different format in the book ‘The Child that Rocks the Cradle’ describing the fifteen year follow up of pregnant schoolgirls and their families.

Over the centuries the character and image of medicine has changed. ‘Doctors’, in other words Physicians, as opposed to surgeons who were called ‘Mister’ and identified with the ‘Barber surgeons’ - were not strictly thought of as scientists. Medicine was = an art.

With the advent of the ‘Scientific method’, new treatme= nts and investigations, new ways of ‘evaluating’ patients, Medicine= has become a science ... but patients are still people!

It is important that the ‘old skills’, the ‘art’ of medicine is not forgotten in the search for scientific correctness. This statement can be no more important than in the field of social medicine and the emotional territory of psychology, psychiatry and psychotherapy. In fact at a r= ecent meeting celebrating the centenary of the paediatrician and psychoanalyst Do= nald Winnicott considerable time was given to debating whether the great man was= a scientist or a poet and we were reminded that ‘The art of Medicine is= not always scientifically analysable’. Hence the need for qualitativ= e as well as quantitative research models.

Much of the schoolgirl pregnancy study described in ‘Are you = my sister, Mummy?’ and ‘The Child that Rocks the Cradle’ falls into the realm of qualitative research. This is a field which has to a large extent been neglected in the past, in the search for quantitative studies which often require large numbers relying heavily on the statistical approach and thus inevitably missing a great deal of valuable anecdotal information.

The word anecdotal was often regarded almost in a derogatory manner= ; to say that something is anecdotal means that it is not quite good enough to be regarded as scientific research or a valid finding in a research study. However, when the content of the anecdotal information is looked at and moreover when different incidences of anecdotal reporting are put together they can make a whole picture which is extremely revealing and valuable.

This is certainly the case when one comes to researching matters concerning outcomes and success rates for example, in work with teenagers a= nd adolescents, and certainly when one looks at anything to do with emotional responses, therapy and intervention. With regard to this present study, qualitative research gives us a way to estimate coping skills in girls and families, and to see why certain things happen and certain results ensue.

In many studies, particularly some coming from North Am= erica where te= enage pregnancy rates are much higher than in Europe, and stu= dy samples tend therefore to be large, a lot of data has been collected by mea= ns of questionnaires. The data has thus been quantified numerically, often computerised and statistical analyses are read off at intervals according to the need of the researcher. Thus the information ultimately derived is in a mathematical format.

Unfortunately people do not behave like numbers, and although maths= can give some answers and allow us to produce some of the graphs and tables in = this book they nevertheless mask the true picture. By knowing girls over a long period time on a personal basis one is not restricted just to looking at fi= nal numbers, but one derives a sense of knowing ‘why’ and a better understanding of what those numbers mean.

For instance - looking at number of pregnancies, or the average num= ber per girl, at various intervals after the first birth or at various ages, is just precisely that -= a statistical figure of number of pregnancies. But why are the girls having this number of pregnancies, and what = is actually meant by the ‘average’? =

Looking beneath the crude numbers and knowing why certain particular girls got pregnant reveals another picture - the fact that the group is not homogenous, there are different factors operating which tend to draw some girls towards having one child only and others towards repeated pregnancies. Without actually knowing their individual stories it is difficult to come to valid suppositions and conclusions on such a matter.

In qualitative research, the interaction between the researcher and= the client or patient and the emotional or psychotherapy input of that interview are very important. With the self-esteem studies, particularly, it was important to look at the psychodynamics of each individual and the assessme= nt made in the psychotherapy interview was, if anything, more important than t= he actual numerical estimate of self-esteem which is derived from the questionnaire.

Another example here - a mother might be seen as having a matter-of-fact attitude towards her injured child. The casual observer might regard this as callous, lacking feeling, denial etc. whereas a closer study= of the mother / child interaction or family situation might actually discover = that this is an effective coping strategy employed by the young mother who had experienced a lot of pain; has perhaps been abused, and who has to cut off = some of her feelings when dealing with her injured child, taking the child to hospital, being interviewed by medical staff etc.

If she allows her feelings through they could overwhelm her and she would then break down and not be able to cope with the situation or caring = for her child. The same reaction could be seen in a positive or negative light, depending on the depth of interview and the depth of understanding of the totality of her situation.

The difficulty sometimes with entirely quantitative research is that interviews tend to be too limited - perhaps confined to questionnaires alone. Not only does this limit the actu= al information elicited but the questionnaire itself can be an enormous barrier between the interviewer and the subject.

Some researchers will actually opt for using a questionnaire like t= his because it provides a protective barrier for themselves - they do not actually engage closely with the patie= nt and do not want to because getting too close to some of the pain and diffic= ulty in the patient, or being exposed perhaps to the aggression and anger of the patient, is something they cannot cope with. Perhaps they do not really wan= t to be involved with the ongoing care of the patient or taking responsibility f= or any outcome of the interview. They just want to dip in, take their informat= ion, and run.

Saying it this way might appear rather harsh and in a way condemning the researcher. There are obviously a large number of researchers who would= no way wish to harm or use their patients. However, it must be acknowledged th= at there are a number of researchers who are just using patients in order to obtain inform= ation for a research paper which may further their career but perhaps not actuall= y in the end help the patient.

Throughout all the contacts with&n= bsp; teenage mothers and their families we very much endeavoured to provi= de support and service, hand in hand with the research project. To do otherwis= e is unfair to families.

It is of course possible to look at the esoteric gains in terms of telling the girls that by helping in the research model they would actually= be helping to make life easier for other girls who come into the same situatio= n as themselves.

They deserve more than that.

Putting patients into an esoteric group like that is playing into t= heir guilt and low self-esteem. It is like saying “Well - we don’t c= are enough about you to try and make you feel better during this process, but y= ou could make a difference in helping others”. Many of the girls we deal with, who may have low self-esteem are already into this mode of caring for others, and not having their own needs met.

As I have said elsewhere, teenage mothers are often criticised for = not being able to place the needs of their children above their own, and this is grossly unfair. Until they can fulfil their own needs it is impossible for = them to be able to fully love and care for their children. An empty vessel cannot have the resources to care for others.&nbs= p; Thus one has to take p= ains to ensure the research model presented to young mothers does not feed into this dynamic.

They need to be offered help and support at each stage in their own right, and not merely as an esoteric gain. Practical help needs to be provi= ded, help with housing, nursery place for the child, counselling in the widest s= ense of the word.

Adole= scence is the period of development of sexual activity.

Altho= ugh it is a normal process during maturation of adolescents entering manhood or woman= hood under the strong stimulus of sexual hormones, it is not easily discussed in many societies by parents, doctors or teachers leaving adolescents with inadequate knowledge and occasionally leading to adverse situations (unwant= ed pregnancies, rape etc.). It is evident that the problem is great. A recent American study reports that the average age of first intercourse for Americ= an teens is 15.2 years for girls and 15.7 years for boys. Furthermore in the <= /span>USA in 1987 more than 1 million out= of 9 million girls aged less than 15 up to 19 became pregnant. Of these 47% delivered, 40% aborted and 13% miscarried. 22% of births to teens are repeat births. Three quarters of pregnancies among unmarried women of 15 - 19 years are unintended. In 1987 26% of all abortions were obtained by teenagers.

Altho= ugh adolescent sexuality leading to teenage pregnancy is a universal problem, t= he pregnancy rate in Britain, France and = Canada is half that of the reported fo= r USA. Sweden and Holland present even lower rates, reach= ing 1/3 and 1/7 respectively of the American rates. Adolescent pregnancy rates in t= en European countries ranged for the years 1985-89 as follows: 12-14 years: 0-0.3, 14-16 years: 0.01-9, 1= 6-18 years:1.2-21. In Greece, as observed by the first Department of Obstetrics = and Gynaecology of the University of Athens, adolescent pregnancy leading to delivery increased from 5.3% to 7.2% between the years 1974-993. Creatsas e= t al report that for the years 1987 and 1988 11% of all deliveries in the above mentioned Department were by girls aged 13-19 years.

&= nbsp;

One f= ifth of all premarital teen pregnancies occur within the first month after starting sexual intercourse. Neinstein et al state that in the recent years a decrea= sing trend of births to teens 15-19 years was noted. Nevertheless, this fact is primari= ly due to an increase in elective abortions and not to a substantial decrease in t= he overall number of pregnancies.

But w= hy are adolescents so intensively involved in sexual activity?

As Ne= instein explains, among adolescents sex is justified as physical pleasure and as a = new experience. It is considered an index of maturity, reflects peer group conformity, represents a challenge to parents and society, and offers an es= cape from pressures. Moreover, the extremely powerful media which surrounds us, radio, movies, television, advertisements, constantly promote sex based usu= ally on violence. The situation becomes more serious if the adolescent’s parents on the other hand view sex among their offspring as a crime, a sin = or even a sickness, instead of discussing with them about the normal developme= nt of sexuality and the family values in which sexuality is embedded. This pro= blem is even worse in single parent families, who mostly rely on school to deliv= er the adequate education and fill the sexuality information gap with a dry scientific description of the anatomy and physiology of reproduction. Trapp= ed among these various controversial aspects, adolescents are confused and frequently pushed to impulsive action - to sexual intercourse without being prepared and aware of it consequences.

Who m= ust help in preventing and managing this situation?

̶= 0;A friend coming from the past” - the paediatrician.

His o= r her role is sometimes difficult but always gratifying. Paediatricians have the advan= tage of knowing the family conditions and particularly adolescents since their b= irth and childhood. They usually have a good relationship with them, they are aw= are of somatic illness and have following the psychosocial development of the youngsters. Nevertheless, paediatricians occasionally encounter some difficulties in their efforts to cope with adolescents and especially when = the subject concerned is sexuality. Paediatricians have worked closely with the adolescents’ parents for many years and teens are afraid of lack of confidentiality. On the other hand, adolescents consider themselves grown u= ps, because of physical maturity, and feel their ties to their “first doctor” to loosen. In spite of this , paediatricians consider themsel= ves better prepared for the care of adolescents than internists, and teenagers = feel more comfortable communicating with the former.

When = and how should a paediatrician intervene?

It is= crucial that the physician has started a confidential and trusting relationship with the youngster prior to puberty. It should continue with frequent honest talks and a thorough examination, each step of which is explained. This should take place without the presence of parents, unless the child is reluctant. This attitude strengthens the independent identity of the young person and forces him or her to take responsibility for his or her health. A clear and honest statement by the paediatrician as “I have to know more about you, your life, your behaviour, like sex, so I can take care of you and help you if needed”= ; is usually appreciated by teens. Then the paediatrician must be willing and prepared to answer all sorts of questions. The information given must be al= ways simple, factual and straightforward. Nevertheless, emotions should not be l= eft apart and the physician should not hide his or her own moral values underli= ning responsibility, caring and trust. “Value free”, pure education concerning the anatomic and physiological aspects of reproduction and counselling stressing only prevention of unintended pregnancy and sexually transmitted diseases very seldom provide the environment in which the adolescent feels comfortable to ask questions and solve problems.

What = should the paediatrician counsel?

Absti= nence is considered the most effective method of birth control and prevention of sexually transmitted diseases (STD). In the 1970s abstinence among adolesce= nts was the norm. Only 4.7% of 15 year old girls were reported as having sexual intercourse in the USA= . By the late 1980s that number = was five times as high. Peer pressure and media influence are responsible for this tremendous increase. The paediatrician advising the adolescent to postpone sexual activity until the gap between physical and mental maturity decreases should stress that even by age 19, 20-25% of adolescents have not had intercourse. He or she should reassure teenagers that virginity is normal a= nd not a disease and that the alternatives of petting and mutual masturbation = can be explored.The counselling objectives should also include the limitation of sexual partners as STD, hepatitis, chlamydia, trachomatis and especially de= vastating AIDS are nowadays of great concern. A caring and interested paediatrician having won the adolescent’s trust is the person who can persuade the youngs= ter to delay coitus until eventually a monogamous relationship can be established.=

The paediatrician discussing with the adolescent the various methods and techni= ques of contraception should not omit to point out that:

a) the risk of pregnancy is considerably lower if two contraceptive methods are used together consisten= tly

b) many pregnancies are due to m= ethod failure and not to inappropriate or &n= bsp; inconsistent method use

c) failure rates are in adolesce= nts higher than ones reported for each contraceptive method due to ignorance or lack of experience

d) birth control should always be combined with prevention of STDs. Thus oral= contraception does not protect against STDs As most adolescent girls are not compliant wi= th the pill and intercourse is mostly sporadic in the majority of teens condoms and foams are usually better contraceptive choices.

A fur= ther role of the paediatrician is to help his chronically ill or disabled patient to = cope with contraception. He is the one who knows better than anyone else the torturing problem of the young person who enters puberty and develops sexual drive. Many chronic diseases are prohibitory for oral contraceptives and barrier methods such as condoms, spermicides, diaphragms and sponges are preferable. Nevertheless, phy= sical disability may prevent an adolescent from correct use.

The m= ost important contra-indication for oral contraceptive use is cardiac disease. Epilepsy is not an absolute contra-indication, in contrast to migraine, whi= le oral contraceptives do not pose an increased risk to patients with multiple sclerosis. Asthma attacks are not exacerbated with oral contraceptives which are absolutely contra-indicated in patients with cystic fibrosis.

With = caution and only in stable cases of Crohn’s Disease could oral contraceptives= be used but never in active liver disease or cirrhosis. Although diabetes mell= itus is also prohibitory for oral contraceptive use, as the latter causes a decr= ease in glucose tolerance and exacerbates diabetic complications, paediatric diabetologists tend to favour oral contraception fearing that a teenage unscheduled pregnancy of a diabetic mother is more harmful than the control= led use of contraceptives. On the other hand, thyroid disease is not influenced= by its use.

Adole= scents with iron deficiency anaemia due to heavy menstrual flow often benefit from oral contraceptives. Also, cases with factor X deficiency or WillebrandR= 17;s Disease claim lessening of bleeding tendencies. Sickle cell haemoglobinopat= hy is in general a contra-indication.

No ev= idence exists that oral contraceptives have an adverse effect on non-hormonal dependent tumours. Adolescents with depression or on anti-depressants might deteriorate with their use. Oral contraceptives should be avoided in teenag= ers with systemic lupus erythematosus. No data against them exists in cases of rheumatoid arthritis.

Young= patients in haemodialysis may suffer from hypertension or thrombo-embolic complicati= ons, thus oral contraceptives should not be used. The same applies to teens with renal transplants.

How s= hould the paediatrician cope with the adolescent found by chance pregnant?

Young= girls visiting the paediatrician complaining of various symptoms and not aware of their pregnancy pose a difficult problem for the physician who must have hi= gh index of suspicion and sensitivity to reveal reality. The young person needs support to express her feelings, to explore all options and make the right decision about the continuation or termination of the pregnancy. The paediatrician should provide her with specific information concerning abort= ion procedures, perinatal health carer, adoption or foster carer possibilities = for her offspring.

The c= ounsellor should suggest the participation of the adolescent’s parents and mayb= e of the putative father to a discussion, before any decision is made. Paediatricians especially have inc= reased responsibilities towards parents of minors. Abortion counselling should ref= er to the procedure and its risks, which are less compared to those associated with birth giving. If the adolescent chooses continuation of pregnancy she should be promptly referred to gynaecologists for prenatal care. As the hard task of caring for the newborn will fall on the grandparents the counsellor should advise unmarried adolescents to involve their parents.The paediatric= ian should not forget to explain to the young pregnant girl child rearing as ba= bies have been often unintentionally abused by their teenage mothers. Reintegrat= ion of the young mother to school and adaptation to the new situation is another field where the paediatrician should offer his help. Last but not least, the importance of contraception in order to prevent a repeat pregnancy should be explained and stressed.

Final= ly - do paediatricians feel competent for all these tasks?

Altho= ugh the American and many European Academies of Paediatrics formally have recognised adolescents belonging to the practice, “boundaries of paediatrics sin= ce over 20 years” a study published in 1984 states that 66% of graduates from paediatric residency programmes in the States feel inadequately traine= d in adolescent medicine, especially in gynaecological counselling and contracep= tive services. Therefore the help, advice and medical care from the gynaecologist specialising in adolescent medicine is invaluable. But as adolescents feel easier communicating with physicians they know from their early years than = with internists or gynaecologists who they meet for the first time it is urgent = for paediatricians to learn more about teenagers and their problems rising from sexual activity.

With = the collaboration and active participation of the adolescent gynaecologist, physical and psychological support will provided to adolescents aiming at a better health carer for conscious individuals.

THE LUNCHEON CLUB<= o:p>

My na= me is Daniel Anderson. I am a student at Kingston University, in my first year of the Diplom= a in Social Work. Youth Support House has been my placement for a three month period.

Durin= g my placement I have been actively involved in running “The Luncheon Club”. This activity involves staff and residents preparing a two cou= rse meal for older members of the local community. Residents develop their life skills in such areas as cooking, communication skills and self achievement. These factors contribute to the promotion of self esteem and value as an individual.

The L= uncheon Club was established as part of a philosophy to provide residents and their children with a “surrogate grandparent” figure. Many residents = have not had the opportunity to be encompassed within this healthy family dynami= c, as many have lacked a positive parent figure within their lives. The three tier, transgenerational aspect provides residents with a good model and positive framework of the dimensions of family life of which they can be pa= rt within this context. This act= ivity provides an avenue for conversation and interaction between residents and l= ocal members of the community.

The i= ntegration of local members of the community and residents is an important aspect. The setting is within a safe and unthreatening environment where active interac= tion can promote a “bridging” with reference to some residents thoug= hts and anxieties of isolation and segregation from the surrounding community.<= o:p>

The u= nderlying format acts as a useful therapeutic function instilling within residents a notion of self worth and value, in terms of residents engaging fully and on= an equal basis with staff to produce a finished product (the meal) To give something to others and receive appreciation for this is a positive form of interaction which may not have been in existence in their previous home env= ironments.

The p= rogramme is run on an informal basis, it offers staff a good chance to talk to resid= ents regarding problems they are facing or experiencing without the structure of= a formal therapeutic session. This informal setting can provide a good founda= tion for relation building and the development of trust.

The L= uncheon Club has been running for some time now, and continues to draw upon the need for resident participation. The development of life skills, communication skills, self esteem and value are all contributory elements of the Luncheon Club in respect of the whole therapeutic timetable.

Danie= l Anderson

(Soci= al Work Student)

A = Window of Opportunity<= /st1:place>.

&nbs= p;

&= nbsp; &nbs= p; ?

Adolescence can very much be regarded as a &#= 8216;window of opportunity’ allowing us a chance not only to see some of the R= 16;early’ emotional and psychological mechanisms in action - but also a chance to work with , treat and modify some of these early traumas.

This was the basis of the philosophy of the I= RC workshop in Washington March 1996.

The ‘Youth Support’ contribution = centred on three cases. A young girl = Ann who had been a street child after a number of difficulties at home, who had been sexually abused and who found = it difficult to separate and understand her feelings of love and hate for her = step father. Barb who had such a l= evel of undealt with pathology that she had reached a position where her ‘= object relations were so disturbed that she was beyond help. And Carol who was at = an earlier stage in her progression, had been sexually abused by her father bu= t showed signs of being reachable and ‘treatable’ - a hope for the futur= e.

The initial presentations were as follows -

ANN

&nbs= p;

Initial presentation as a pregnant schoolgirl

Abusive relationships

?possible= sexual abuse

&nbs= p;

Eventual = Outcome ?

Child pro= tection issues

BARB

Initial presentation as a pregnant schoolgirl

promiscuo= us - First sex at 10

?possible= abuse

Eventual = Outcome - ‘Murder Trial’. Psychopathic personality.

On-going = child protection issues.

CAROL

&nbs= p;

Initial presentation - sexual abuse

&nbs= p;

Eventual = Outcome?

ANN

At 12= yrs Ann accused her stepfather of abuse. This followed a long period of acting out and bein= g ‘out of parental control’ at home. Her natural father had left home some y= ears earlier and Ann resented his leaving and despised her mother for taking on another man. Mother threw her out. &n= bsp; There then followed a period of drug abuse, vagrancy, ‘street child’.

At 13yrs she met Billy her boyfriend i= n a police station and immediately struck up a close relationship - seeing themselves = as kindred spirits. he too was vagrant, had been abused, was using drugs, into crime and involve= d in considerable violence and she describes how - she alone can see what a beautiful person he really is inside.

Event= ually Ann was taken into care although this was not a happy experience - she was sexu= ally abused on a regular basis by an older man who lived near the children’= ;s home and who supplied drugs to all the girls in the home. Ann continually absconded to be with Billy on the streets. When she became pregnant she was= transferred to YSH where her therapy programme began and at 14yrs Robert was born

<= /span>

The f= amily dynamic for Ann was very much based on competition with Ann at the centre o= f a wheel of jealousy and family members scoring points off each other. Ann was jealous of her sister, they had children at the same time, organised christenings at the same time. Sister was older and Ann perceived her mothe= r as loving sister more - so when she seemed to get attention directed at her ba= by - Ann had a baby too - to get mother back. Unfortunately most of Ann’s attempts to make them ‘love me too’ ended in failure and thus h= er return to an unsatisfactory and harmful relationship with Billy - who would never find anyone else. Their relationship was totally dependant and manipu= lative for example, would self harm and cut himself if she did not abscond to see = him. After the birth of her child= , the question was how would Robert fit into this dynamic - would there be any sp= ace for him?

CONFLICTS AND COMPETITION

= SISTER &nbs= p; &= nbsp; &nbs= p; &= nbsp; STEP-FATHER

&nbs= p; &= nbsp; &nbs= p; &= nbsp; &nbs= p; ANN

&nbs= p; &= nbsp; MOTHER = &nb= sp; = BILLY

= &nb= sp; = ? ROBERT ?<= span lang=3DEN-GB style=3D'font-size:14.0pt;mso-bidi-font-size:10.0pt'>

Ann&#= 8217;s dilemma was in confusion of roles - in discussing the mechanism whereby this confusion arose we need to = consider what the dynamics are of relationships -

Ann / Mother

&n= bsp; Ann / Stepfather

&n= bsp; = &nb= sp; Ann / Boyfriend

Leadi= ng to influence on ....

Ann / Baby

&n= bsp; Ann / ‘Carers’<= /span>

This = is very much an exercise in ‘object relations’ - in that the manner in which Ann w= as treated as a young infant - the way she perceived her world and the people around her - the way she developed her ‘object relations’ was fundamental in shaping the relationship with mother - and this relationship formed the basis for all future relationships. Hence there were parallels between the relationship Ann had with step father and other men including B= illy - ‘expecting’ abuse, responding to manipulation, trying hard to= please others, not really having her own needs met. We could see this pattern ‘m= irrored’ in her relationship with staff in the unit. Hence we had clues as to how th= is ‘transference’ operated, how Ann related to people and how we might proceed to help her mo= dify some of her responses. It also gave clues with regard to the way she might relate to her son.

Only = time will tell whether her world will have ‘space’ for Robert. For some t= ime the future looked bleak - Billy’s influence was negative to the extre= me - he had no room for a child in his life and he saw the child as usurping his position - hence Ann was manipulated into another ‘power struggleR= 17; of jealousy - which baby would she care for? At the moment things look bett= er. Ann is responding to therapy and appears to have chosen her son Robert over Billy his father and Billy is currently off the scene - but for how long?

<= /span>

BARB

Barb = could have had a similar life course and outcome to Ann but she was more damaged at an early age and had very deep disturbance of her ‘object relations̵= 7;. What the trauma was at that early s= tage is impossible to tell. Her family know of nothing specific and in some ways= she has ‘always been like this’. ‘This’ is cold , cruel = and uncaring of others.

She b= egan her sexual history at 8 or 10 yrs and was highly promiscuous. Barb could not be confined, she ran off to meet men and even put a ladder up to her bedroom window to let men in to have sex with her. Pregnancies began at 12 and she = had four pregnancies before the age of 16 having given birth to three children = by the age of 17. When Andrew was born she handed him over to her parents and = was unconcerned with him thereafter.

Pregn= ancies - 13 yrs (1) Andrew

&= nbsp; 14 yrs (2) TOP

&= nbsp; 15 yrs (3) Matthew

&= nbsp; 17yrs (4) Tricia

Soon = after her eighteenth birthday - within = the short space of 8 weeks - the following had transpired - marriage ended - new partner - Matthew= DIED, Tricia removed for neglect and possible abuse. Matthew died in horrific circumsta= nces which were gorily reported in the national press at the time but although found guilty of the lesser charge of wilful neglect and imprisoned for 6 months, = Barb never acknowledged any part in neglect or harming her children. She never accepts any responsibility for her actions or their effect on others.<= /o:p>

Her h= istory continued with - 20yrs - Tria= l - Prison - Pregnant (5) Baby removed at birth. 23 yrs pregnant (6) David - After h= is birth she was sent to YSH for assessment and treatment. 25yrs(7) TOP.

Consi= deration of Barb’s object relations reveal a depth of psychopathology. A deep splitting between the ‘good’ and the ‘bad’ and a to= tal lack of any coming together of these elements. Within the unit we could see= the ‘transference’ aspects of this - she would adore (usually inappropriately) or hate (very frequently and intensely) the same person at different times and have no perception whatever that this was one and the s= ame person - or that the individual might be harmed in any way by her ‘mu= rderous attack’ - she would have no expectation that there would be any conse= quence whatever of any of her actions and no capacity whatever for remorse.

Sadly= Barb was beyond therapy -all that could be done was to an extent to ‘contain&#= 8217; some of her destructive potential. What happened early on to cause this? Wh= at would it take for an Ann or a Carol to have turned out this way? What protective mechanisms did they have which safeguarded them from such extrem= es?

<= /span>

CAROL

<= /span>

Carol= when first seen was the least ‘deviant’ of our three cases. She had = been abused but had not yet fallen prey to drugs, self harming or serious acting out. Her history was that at 11yrs her Mother became seriously ill - with h= eart disease. At 12yrs mother died. Thereafter she and father had difficulty com= ing to terms with their grief and between 12-13 yrs Carol suffered sexual abuse by her father.

After= disclosure of this abuse at 14yrs she was removed to foster care and a year later at 15yrs referred to YSH. Carol made good progress in therapy which was initially on a ‘psychodynamic’ basis with time spent in our ‘animal therapy’. She warmed to the animals and developed trust in the unit. Carol had a very difficult stage following the disclosure by a social worker of her address to her father - she went throu= gh a period of acting out and attempted to prostitute herself to mini cab driver= s - fortunately she was picked up and brought back home.

Event= ually Carol’s therapy came to a focus when ‘story telling’ ther= apy allowed her to write a tale about the animals with which she subconsciously identified. Her story of a hu= rt kitten brought out her own hurt, anger and need for protection and was a tu= rning point in her progress. Hopefu= lly Carol will be able to maintain her positive growth and leave her abuse behi= nd.

“The Child T= hat Rocks the Cradle”

A fifteen year LONGITUD= INAL study of school age mothers and their children.

Dr Diana M.L. Birch

This book, although st= anding alone as a comprehensive account of early parenting, is also the sequel to “Are you my sister, Mummy?” and depicts the next phase along the road of parenthood. These are the same mothers, father= s and children fifteen years on. How did life turn out for them? - What kind of families did they create? - What is going on for their teenage children?

The findings of a fift= een year longitudinal study of 200 young families in which the mother gave birth under the age of 16 years has provided information which refutes many of the stereotypic views regarding young parents.= It illustrates how the presence of a supportive family leads to an improved prognosis for young mothers and their children and gives insights = into positive and negative predictive factors. Some unexpected outcomes and their possible aetiology are discussed.

Consideration is given= to approaches which may enable professionals to confront the ‘cultural trap’ in which many young people are caught - in that those suffering= the worst deprivation in early childhood, those raised in the ‘care’ system and children’s homes are those young parents most likely to perpetuate the cycle of deprivation for their offspring. ISBN: 1 870717 08 2

&nbs= p;

The Journ= al of Adolescent Health and Welfare

is publis= hed by:-

Youth Sup= port

13, Cresc= ent Road, London BR3 2NF<= o:p>

Charity N= o 296080

Tel No 01= 81 650 6296

Fax No 01= 81 659 3309