rsm92

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

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

&= nbsp; England Argentina &= nbsp; USA

We ha= ve just had our SAM meeting in San Francisco. As usual a very f= ull meeting which seems more crammed with material every year.

Our i= nstitute was the most adventurous project we have undertaken to date with a number of chapter members, new faces and prominent SAM members giving of their time a= nd joining in - quite a heartening milestone for us all - and hopefully someth= ing for the chapter to grow on.

It do= es seem that after a somewhat difficult period of ‘role confusion’ duri= ng the birth pains of the IAAH, the Chapter has emerged with a distinct identi= ty - a fully fledged part of SAM. While at the same time IAAH has forged it’s own identity outside of SAM - even though t= here is a considerable overlap in membership. This healthy parallel growth feels much more comfortable than what could have been perceived as competition for the same ‘market’. Gustavo and I defined the IRC in our ‘= 94 newsletter - this definition is reiterated below for the benefit of new members.

The w= rite up of the institute will feature in the next journal - however this edition does include articles by chapter members Daniel Hardoff (Israel) and Onno Sijper= da (Netherlands).

What is the IRC SAM= ?

The International Regional Chapter of SAM.

The IRC (International Regional Chapter) is a c= hapter of SAM (The Society for Adolescent Medicine) which has been in existence si= nce 1987 to provide a forum for both non USA members and US members with an interest in International affairs. In common with other chapters, not all chapter participants are full SAM members - but we encourage colleagues to = join SAM wherever possible.

Our principal objectives are to :-

Encourage International participation in SAM and= at SAM meetings.

Increase awareness in International issues among= SAM members.

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

The IRC has to date been the only chapter of SAM= to run a workshop at the annual SAM meeting and this activity has been a successful focu= s for the chapter.

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

At ou= r chapter business meeting - We decided that we should collect chapter dues from memb= ers since the cost of keeping in touch, producing the newsletter and postage is high for a chapter so widely dispersed geographically. Aric will be contact= ing members to request chapter dues of a minimum of 10 US dollars (reduced from= 20) and a suggestion of a donation to boost chapter coffers which are currently= in the red.

One o= f the reasons - in fact the main reason for this deficit - is the fact that this = year a number of SAM members signed up for our international dinner and then did= not show up. Since the dinner was on a Friday night and had to be booked at sho= rt notice - we had to prepay for the set number of meals - and this money was = lost when the ‘no showers’ did not contribute. For all other SAM din= ners a sum of $40 is paid up front at booking - so you would think that people w= ould realise that signing up for an event does bear some responsibility to pay f= or it. Aric is contacting these individuals to exact payment.

Next = years meeting will also hopefully include an international institute and we will = be working on the theme of exploitation of youth - particularly via sexual exploitation , pornography, prostitution of young girls and boys and ‘sexual tourism’. We will also include child labour. Please get= in touch if you would like to present on this theme.

Eating Disorder= s - Cultural and Religious Considerations

Daniel Hardoff - D= ivision of Adolescent Medicine

Bnai Zion Medical Centre Haifa Israel.

The d= efinitions of both anorexia nervosa, bulimia and also of the eating disorders not otherwise specified include the fear of being fat ⁽¹⁾. This inte= nse feeling is involved in the development of the pathological eating behaviour However, beside internal factors that influence the adolescent to achieve weight control, cultural aspects have a significant contribution to eating patterns and weight control of teenagers in particular and need to be considered in the evaluation of persons with suspected eating disorders. Th= e role of culture in eating disorders is of interest to physicians and psychologis= ts as well as to sociologists and anthropologists.

There= is an extensive literature dating back to Darwin ⁽²⁾ on cross-cultural differences in the idea of beauty and within a given culture a consensus of opinion and taste prevails regardless of age,socio-economic status, ethnic differences and standards ⁽³⁾. Throughout history, ideals of feminine beauty have changed in accordance with aesthetic standar= ds of the particular time and women have attempted to alter themselves to match the current societal demands ⁽⁴⁾. The societal pressure to stay = slim in western countries increases with the socio-economic status and the overa= ll wealth of the country ^(5,6) whereas i= n the less affluent countries there is a direct positive correlation between body weight and socioeconomic status ⁽⁷⁾ The perception of body shapes and aesthetic values of overw= eight are culturally related so that the stigma of fatness as ugly is far from a universal value ⁽⁸⁾. Indeed in some cultures obesity is valued a= s a symbol of success and economic security ⁽⁷⁾. It has been shown t= hat Kenyan Asian females tended to perceive thin female shapes more negatively = and fat female shapes more positively compared to British females ^{(9) However both Kenyan British and UK females ratings
demonstrated a linear relationship between increase in obesity and increase=
in
negative evaluation ⁽⁹⁾. In a recent study of Ugandan and British
males and females in England who had to rate health and attractiveness of figures, the
Ugandan subjects of both sexes tended to rate the more heavy obese figures =
as
much more attractive and healthy than did the British subjects⁽⁸⁾
Still, that study showed that there is a pan-cultural preference for midran=
ge
body shapes.}

Adole= scent girls in North America have perception of attractiveness that does not conf= orm to biologic reality⁽¹⁰⁾ A = survey of adolescents of both sexes in the US showed a striking disparity between self-perception of obesity and actual weight for height in girls but not in boys⁽¹¹⁾ A literature review of children’s attitudes toward thinness and fatness ⁽¹⁰⁾ revealed that at age 7 years and possi= bly earlier children have acquired adult cultural perceptions of attractiveness= . By 6 to 9 years of age children already express dislike to the obese body build and the role of television in obtaining such attitudes has been suggested since, a message is delivered through TV programs and advertisements equati= ng thinness to beauty and good life. These cultural predispositions may be regarded as contributing factors to the development of eating disorders in pre-adolescent children who are now more frequently diagnosed compared to t= he previous decade⁽¹²⁾

Cultu= ral factors in development of eating disorders have mainly been studied in West= ern civilizations.Despite recognition that socio-cultural factors influence disordered eating, the important sociocultural factor of ethnicity has been previously overlooked⁽¹³⁾. Within the United States white adolescents were more likely to exhibit buli= mic behaviours than were Black, Hispanic or Asian adolescents^(14,15)= In a recent study comparing Greek Australian and Anglo Australian adolescent g= irls regarding risk factors for the development of eating disorder no difference= was found in body image variables indicating dissatisfaction ⁽¹⁶⁾ Si= nce previous studies have shown low levels of eating disorders in Greek girls living in Greece⁽¹⁷⁾ and similar risk levels of Australian compa= red to US girls⁽¹⁸⁾ it was hypothesised that first generation Greek Australian girls had assimilated Australian attitudes regarding ideal body = size and eating behaviours ⁽¹⁶⁾ When Turkish & Greek adolescents = in their native countries were compared to Greek females in Western Germany a higher rate of anorexia nervosa in the offspring of migrated families was f= ound⁽¹⁷⁾ suggesting migration to Western culture as a risk factor for the developmen= t of eating disorders. Cultural changes that include identification with Western ideals of slimness are therefore followed by an increase in weight and shape consciousness leading to the development of eating disorders⁽¹⁹⁾ This hypothesis of over-identification was supported when a transcultural comparison of eating disorders was performed in the former East and West Be= rlin ⁽²⁰⁾ A cross-cultural study of the prevalence of eating disorder= s in Central Europe before the political changes of the 90’s, has shown th= at eating disorders represented at least as a common problem in Eastern as in Western Europe⁽²¹⁾. It has been suggested that the process of identification with Western values existed before the political changes thr= ough the mass media, and that further increase in eating disorders in these countries might be possible following the recent change= s⁽²¹⁾

Confl= icting data exists in regard to the relative prevalence of eating psychopathology among Asian women compared to Caucasian women in the US and in the UK. Whil= e in British studies women⁽²²⁾ and school girls⁽²³⁾ with an Asian background (from the Indian subcontinent) had more abnormal eating attitudes, American Asian women not from the subcontinent had lower levels = of eating psychopathology ⁽²⁾ Other surveys have demonstrated differences within the same ethnic group across nations^(25,26).R= ecent study⁽²⁷⁾ shows that perceived control by family members is not important in determining the relatively unhealthy eating attitudes of Asian adolescents of Indian origin 14-15 years old.When girls of a broader age range(12-16 yrs) were studied the effect of perceived parental control was particularly strong among the older girls ⁽²⁸⁾.Parents are likel= y to attempt to ensure that their children conform to the values that the parents themselves hold as important. These efforts may conflict with the childR= 17;s attempt to identify with Western cultural influences causing the child to gain internal control manifesting = as disturbed eating patterns and eating disorders⁽²⁹⁾.Interestingly, with parental control excluded it turned out that the Asian girls were more satisfied with their bodies than the Caucasian girls⁽²⁷⁾

While= cultural factors may change eating behaviours of migrating adolescents, religious traditions regarding food restrictions have prevailed thoughout generations= in different cultures. Fasting days in the Jewish tradition such as Yom Kippur= and food avoidance during the day in Ramadan month in the Moslem tradition are typical examples. There is no place for individual variations within these traditions and the time limit for food restrictions is clear and precise. T= he paucity of literature describing anorexia nervosa in the Jewish context suggests orthodox Judaism may protect against the illness ⁽³⁰⁾ Judaism does not consider aesceticism very highly, and strongly refuses to = see God-pleasing act in self inflicted abstention from the permitted pleasure of life⁽³⁰⁾. There is a long-standing connection between Christian aesceticism and food refusal, where the human body was considered secondary= to the human will and spirit⁽^{31) In
medieval times self starvation was sometimes considered as a heroic behavio=
ur
inspired by God and Christendom’s patriarchy defined it as a saintly
sacrifice⁽³²⁾ But in the thirteenth and fourteenth centuries holy
anorexia became a positive expression of self by a woman in response to the
world that attempted to dominate her⁽³²⁾. Anorexia nervosa emerg=
ed
as a new and distinct medical entity in the late 1800s when food refusal was
considered a disease symptom rather than an act of personal piety⁽³¹⁾.
In modern times ascetic behaviour involves a wish to make radical statements
such as hunger strikes for political purposes or for personal protect. Howe=
ver
“fasting girls” at the turn of the twentieth century sometimes
reacted against antimodernist impulses by joining traditions of Spiritualism which is a religious
movement stressing transcendence of spirit over body and flesh^{(33)
Contemporary fundamentalist
tradition extends an asceticism about secularity to control of the appetite=
and
consumption of food. Many diet books published by fundamentalist
church-affiliated presses equate the spiritual realm and God’s Kingdom
with bodily thinness and lack of fat⁽=
³¹⁾
Although there has been little actual research on religiosity in contempora=
ry
anorexia some published reports suggest that religion does play a role in t=
he
lives of present time anorectics. Thus in ancient times socio-cultural issu=
es
including religious affiliations were the sole influencing factors in
determining restrictive eating behaviour. In our times these factors still
contribute to the development of eating disorders. Therefore, migration, fa=
mily
tradition, religious affiliation and beliefs should be included in the
assessment of eating disorder before finalising the clinical diagnosis.}}

References

1.= 217; Diagnostic and Statistical Manual of Mental Diseases’, Fourth Edition= (DSM IV),= American Psychiatric Association, Washington, DC, 1994, 539-550.

2. Da= rwin C. ‘The descent of man’. London: John Murky, 1874.

3. Ca= lico S. ‘Toward an interdisciplinary psychology of appearance’. Psychia= try 1978, 41: 243-253.

4. Heinberg LJ, Thompson JK, Stormer S. ‘Development and validation of t= he socio-cultural attitudes towards appearance questionnaire’. Int J Eat Disord 1995, 17: 81-89.

5. Go= ldblatt PB, Moore ME, Stunkard AJ. ‘Social factors in obesity’. J Am Mec Soc 1965, 192: 1039-1044.<= /o:p>

6. Silverstone JT, Gordon RAP, Stunkard AJ. ‘Social factors in= obesity in London’. The practitioner 1969, 202; 68= 2-688.

7. Po= wers PS.‘Obesity: The regulation of weight’. Whilliams&Wilkins, Baltimore,1980=

8. Fu= rnham A, Baguma P. ‘Cross-cultural differences in the evaluation of male and <= o:p>

female body shapes’. Int J Eat D= isord 1994, 15: 81-89.

9. Fu= rnham A, Alibhai N. ‘Cross-cultural differences in the perception of female bo= dy shapes’. Psychol Med 1983, 13:829-837.

10. F= eldman W, Feldman E, Goodman JT. ‘Culture versus biology: Children&= #8217;s attitudes toward thinness a= nd fatness’. Paediatrics 1988, 81: 190-194.

11. F= eldman W, McGrath P, O’Shaughnessy M. ‘Adolescents’ pursuit of thinness’. Am J&= nbsp; Dis Child 1986, 140: 294.

12. <= span class=3DSpellE>Lask B, Bryant- waugh ‘Childho= od onset anorexia nervosa and related disorders’. La= wrence Erlbaum ass. Publishers, Hove (UK) 1993.=

13. D= olan B. ‘Cross-cultural eating disorders’. Int J Eat Disord 1991, 10: 67-78.

14. <= span class=3DSpellE>Howat PM, Saxton AM. ̵= 6;The incident of bulimic behavior in a secondary and university school population.’ J Youth Adolsc 1988, 17: 221-231.

15. <= span class=3DSpellE>GrossJ, Rosen JC. ‘Bulimia in adolescents: Prev= alence and psychosocial correlates’. &= nbsp; Int J Eat Disord 1988, 7: 51-61.

16. Mildred H. Paxton SJ, Wertheim Eh. ‘Risk= factors for eating disorders in Greek- and Anglo- Australian adolescent girls’= ;. Int J Eat Disord 19= 95, 17:91-96.

17. <= span class=3DSpellE>Fichter MM, Elton M, Sourdi L, Weyerer S, Koptagel-ilal = G. ‘Anorexia nervosa in Gr= eek and Turkish adolescents’. Eur arch Psychiat Neurol Sci 1988, 237: 200--208.

18. P= axton SJ, Wertheim EH, Gibbons K, Szmukler= GI, Hillier L, Petrovich J= L.‘Body image satisfac= tion, dieting beliefs and weight loss behaviors in adolescent girls and boys’. J Youth Adols= c 1991, 20: 361-379.

19. N= asser M. ‘Eating disorders: the cultural dimension’. Soc Psychiat Psychiat Epidemiol 1988, 23: 184-187.

20. <= span class=3DSpellE>Steinhausen HC, Neumaerker KJ Vollrath M, Dudeck U, Neumaerker U. A ‘Transc= ultural comparison of the Eating Disorder Inventory in former East and West Berlin’. Int J Eat D= isord 1992, 12: 407-416.

21. <= span class=3DSpellE>Rathner G, Tury F, Szabo P, Geyer M, Rumpold= G, Forgacs A, Soellner W, Ploettner G. ‘Prevalence of eating disorders and minor psychiatric morbidity in Central Europe before the political changes = in 1989: a cross-cultural study’. Psychol Med 1995, 25: 1027-1035.

22. D= olan B, Lacey JH, Evans C. ‘Eating behaviour and attitu= des to weight and shape in British women from three ethnic groups’. Brit J <= span class=3DSpellE>Psychiat 1990, 157: 523-528.

23. <= span class=3DSpellE>Mumford DB, Whitehouse AM, Platt= s M. ‘Sociocultural correlates of eating disorders among Asian schoolgirls in Bradford’. Brit J Psychiat 1991, 158: 222-228.

24. L= ucero K, Hicks RA, Bramlette J, Bra= ssington GS, Welter MG.’Frequency of eating proble= ms among Asian and Caucasian college women’. Psycho= l Rep 1992, 71: 255-258.

25. <= span class=3DSpellE>Choudry IY, Mumford DB. &= #8216;A pilot study of eating disorders in Mirpur (Paki= stan)using the Urdu version of the Eating Attitude Test= 217;. Int J Eat Disord 1992, 11= : 243- 251.

26. <= span class=3DSpellE>Mumford DB, Whitehouse AM, Choud= ry IY. ‘Survey of eating disorders in English-medium schools in Lahore, Pakistan’ .Int J Eat Disord 1992, 11: 173-174.

27. A= hmad S, Waller G, Verduyn C. ‘Eating attitudes among Asian schoolgirls: The role of perceived parental control’. Int J Eat = Disord 1995, 15: 91-97.

28. <= span class=3DSpellE>McCourt J, Waller G. ‘Developmental role of per= ceived parental control in eating psycho-pathology of Asian and Caucasian schoolgirls’. Int J Disord 1995, 17: 277- 282.

29. <= span class=3DSpellE>Resek PJ, Leary MR. ‘Perceived control, drive f= or thinness, and food consumption anorectic tendencies as displaced reactance’. J Personality 1991, 59: 129-142.

30. Rampling D. ‘The asceticism of anorexia nervosa’. In: Hardoff D, Chigier E: ‘Eating disorders in adolescents and young adults’. Editor. Freund Publishing House L= td.London 1988, 47-54

31. B= anks CG ‘‘Culture’ in culture-bound syndromes: The case of anorex= ia nervosa’. Soc Sci Med 1992, 34: 867-884

32. B= ell RM ‘Self-portraits of holy anorexia’. In: Har= doff D. Chigier E: Eating disorders in adolescents a= nd young adults. Editor. Freund Publishing House Lt= d, London 1988, 35-46

33. <= span class=3DSpellE>Brumberg J. ‘Fasting girls = The emergence of anorexia nervosa as a modern disease’. Harvard Univ Press,C= ambridge MA 1988

34. W= oodman M. ‘The owl was a baker’s daughter: Obe= sity, anorexia nervosa and the repressed feminine’. Inner City Books, Toron= to 1980

I am = a school doctor in the Youth Department of the Regional Health Service in Zwolle, Netherlands. I shall try to inform you about a new approach in our Health Service in which co operation with our direct clients, schools and local authorities is essential. I shall show you how epidemi= ologic inquiries can make this part of the whole policy cycle for schools and local authorities. I am in charge of the health care for about 10,000 children and adolescents from four to about 20 years old. It is our duty to achieve opti= mal health of young people through periodical examinations and consultation hou= rs for adolescents but also by stimulating network activities and co operation= of various disciplines and professionals and by Health Education activities, sometimes in specific projects. Interdisciplinary co operation is necessary= to cope with the often complicated problems young people have to deal with tod= ay. Especially in the small, mostly rural towns in the eastern part of our coun= try there has been a relatively fast increase of behaviour problems amongst adolescents in the past ten years as reported by many authorities and confi= rmed by epidemiological inquiries in various fields of health. For many years in our region the l= ocal alcohol abuse problems among young people have been significantly higher th= an in the rest of Holland (‘87 Regional Health Service Inquiry). Traffic accidents and casualties are more common. Juvenile delinquency has grown fa= st, gambling problems have become very common and especially the use of drugs h= as increased from about 1-2% among adolescents in 1987 to 15% now! It seems th= at this process has been accelerated considerably by, on the one hand, the los= s of traditional firm family-ties, the decrease of the role of the church in the community and the loss of social control in this rural society, and on the other hand the denial of the real problem and lack of professional infrastructure in the region (police, social work, etc.) In the past years = we have developed three projects to approach this problem:

· a regional project for young dropouts, in which collaboration links= are being established with the secondary schools, especially in the fields of school dropouts and absence-administration and abuse and addiction problems= .

· A local addiction prevention project for drugs, gambling and alcohol which started six months ago; and finally

· A project on bullying and social competence in the whole area of the Health Service

Commu= nities and schools show interest in establishing a more integrated way of approaching these problems thus Health Services are forced automatically to start new procedures and processes. In the field of Public Health we developed two ma= in approaches in the past four years. An important basis for these new approac= hes is a more systematic way of collecting data (youth) health profiles, the inquiry with 2000 adolescents. The two approaches are:

1.School Health Policy In the past few years the co-operation between schools on the one = hand and the Youth Department and youth assistance services on the other has been concentrated on four areas:

· signalling and assistance of problem youths

· health education and health promotion

· network activities / co-operation of professionals

· care of a healthy environment

It tu= rned out that schools were very satisfied with the more structured co-operation with= the Health Service and also that projects such as the “bullying̶= 1; project and the “addition” project were much more effective when these four areas were taken as starting point. A variety of organisations i= n Holland (Health education, Health servi= ces) at this moment try to conceptualise this overall vision on school health polic= y. The European Association of Health promoting Schools is a good ambassador in this field.

Until= now a broad implementation project for elementary schools has been carried out by some thirty regional Health Services in co-operation with the Institute for Applied Social Sciences of the University of Nijmegen in the past five years. Recentl= y the same institute started an implementation project for secondary schools with= our health service as a pilot institute. Both questionnaires of this enquiry and the whole school health policy cycle are an important part of this implementation project.

2. Healthy Cities Approach

In ou= r country, as in our region, it is increasingly important to develop a Health Policy f= or any community or even any part of a city. One tries to develop a local heal= th policy in this way with participation of the population, with direct lines = to the local authorities especially directed to social-economically determined health differences. Practical consequences of this approach are in general:=

· specific projects for the young (criminality/ social dropouts)

· special projects on a subject (safety,traffic security, damp housing)

speci= al investigations: in addition to the regional database centre, we made several inquiries by key figures to stimulate the local health policy.In our Health Service we already have a long history in this field (”Public Health = for young drop outs” Turku 1991) Since 1994 we have tried to develop a healthy Region approach in which all 21 communities of our Health Region can participate The first activities the several communities asked us to cooper= ate in are “accident prevention” for the aged, drugs prevention and so= cial isolation. The whole local health policy cycle in this respect will start n= ext year so the communities are already looking anxiously forward to the first results of our inquiry

The investigation; its origin

1 cardiovascular ri= sks

From t= he available national data our health service tried to establish some prelimin= ary communal health profiles, which were the first basis for the Regional Data = Bank to develop in the years to come. It soon turned out that cardiovascular diseases both in morbidity and mortality were more prevalent in our region Therefore in 1993 we started a cardiovascular epidemiological project for t= he whole population in which participated about 3200 inhabitants aged 20 to 70. For the young we wanted to start an inquiry on life style to be carried out= in 1994.

2. Socio-economically determined health differences

For m= any years there has been a good co-operation with the department of Social Medicine of the University of Groningen. Some investigations have been = carried out together so when we were asked to participate in the longitudinal study= of 2000 adolescents in the northern part of the Netherlands, similar to the twenty-07 inquiry in Glasgow (Patrick West et al.) in which socio-economica= lly determined health differences were the main target (cf also Black Report 19= 84) we were happy to do so. We decided to use the same questionnaires as Groningen for both their study and our li= fe style study and completed the questionnaire this way. Finally we added 1500 to the existing 500 students who already participated in our region in the = Groningen investigation and thus made our= own inquiry with this 2000 students population<= /o:p>

3 School health poli= cy

The H= ealth Promoting Schools Approach is growing very fast in Holland and since our service is involv= ed in the implementation project for secondary schools it was very natural to incorporate the questionnaires and the whole investigation in this project.= It can be one of the instruments in the information stage of the school health policy. Moreover the projects based on this approach (bullying, drugs and stimulants use) needed a baseline measurement

The investigation, the method<= u>

Procedure

Eight= een schools were approached in 1994-995 to co-operate in the investigation. Aft= er an explanatory meeting with the management and interested teachers within school an invitation for joining the inquiry was sent to the form IV students (15= -16 years of age) of the four types of secondary school education in our countr= y. On the day of the inquiry a team of epidemiologists, a school nurse and med= ical assistant introduced the questionnaire in the class and where necessary assisted the students in filling it in during one period of 50 minutes. Res= ults were collected and were analysed with the help of SPSS

The questionnaire

The questionnaire consists of the following categories:

A personal factors (family structure parents education and profession)

B Hea= lth determinants; life style (stimulants, food, sports)

cultural factors; social network /social support; coping behaviour and coping style

C Sta= te of health ; somatic experience complaints; psycho-social well-being (loneliness, self esteem etc.); medical consumption

The population

For t= he Groningen investigation there were three = schools in Zwolle. For the health service investi= gation the schools were in Zwolle (100,000 inhabitants) and in th= e other cities in the neighbourhood Kampen, Hattem, Steenwijk, Dedemsvaart,Ommen and Hardenberg (all about 20,000 to 30,000 inha= bitants)

General results

The n= umber of male and female students was nearly equal

The a= verage age was 16.6 years

The m= ajority of the young came from traditional family structures (89%).<= /p>

Lifestyle - Lifestyle and general behaviour influence sho= rt term and long term health. In the next table the results for tobacco, alcoh= ol and drug use are given as well as the results for sports and breakfast=

Li= festyle results for the whole region:

&= nbsp; number %

Smoki= ng (now) No &= nbsp; 1256 &n= bsp; 63

&= nbsp; Yes 732= 37

Alcoh= ol use No 327 19

(last 4 weeks)

1-5 times 1036 &n= bsp; 52

6-19 431 22

20 or more 137 7

Drugs= never 1345 75

1-5 times 271 &nb= sp; 14

6 or more 360 11

Sport= s No 572 &n= bsp; 29

&= nbsp; Yes 1416<= span style=3D'mso-tab-count:1'> &n= bsp; 71

Break= fast 0-2 days&= nbsp; 353 18

&= nbsp; 3-4 days 162 8

&= nbsp; 5 days 1470 &n= bsp; 74

The r= esults for smoking (yes or not) are very much the same as those of the NIAD survey of = 1992 which concerned the whole Dutch youth population. Looking at the same age in this inquiry one can see that the group of non e= ver drug users has diminished from about 85% in 1992 to 75% now. That means that more children are willing to experiment with a so called soft drug like cannabis, a good reason for a prevention programme. Alcohol use is rapidly increasing from 72% drinking in the last 4 weeks as mentioned in 1992 to 81= % in this inquiry. As for sports and eating habits the results are more hopeful. More important seems the difference in substance use for the l7 schools. Dr= ugs use for instance ranges from 7.5 to 15.4%

General health Only 57% of the students felt health= y.

% Complaints in the last 4 weeks

Heada= che &= nbsp; 68

Stoma= ch aches &= nbsp; 51

Nause= a &= nbsp; 41<= /span>

Sore = throat &= nbsp; 43

Cold<= span style=3D'mso-tab-count:5'> &= nbsp; 75=

difficulty concentrating 43

learning new things 30

Sleep= lessness &= nbsp; 52

Truan= cy &= nbsp; 28=

Probl= ems menstruation 70

Altho= ugh all complaints score reasonably high differentiating the results for the differ= ent schools and education types is very important in setting up prevention activities. As for the degree of cheerfulness 89% felt more or less cheerful and 11% did not. For this part as also for the General Health Questionnaire (GHQ) there are only slight differences between the various schools and reg= ions but there is an interesting difference between boys and girls.

I mus= t admit that I showed here only some results of the whole inquiry. Other results wi= ll have to be worked out and analysed further but I think it is enough for the purpose of this lecture the use of these data for school health policy and local health policy

Health policy - what next?

In or= der to give a better basis to both the school health policy and the local health policy it is very useful to collect health data more systematically on vari= ous levels and from different sources. We call this systematic health profiles.= For both fields these profiles will yield a different policy cycle.<= /span>

Sc= hool health policy

In the Implementation project for high schools (ITS Nijmegen) four main instruments for data collection about school health have to be developed:

· one instrument on the student level; this questionnaire, adequately modified and shortened, can be a good one

· one questionnaire for the sociology, biology and health care teachers about the health education programmes they are using

· one questionnaire for mentors and counsellors about the student probl= ems they come across in their work.

· finally a checklist on safety and hygiene within the school

All t= he instruments have to be evaluated and validated in the years to come but they can already serve to initiate the policy cycle we are going to start with t= he schools. Standardised interviews will be carried out with all the 17 schools involved in the enquiry. A specific report with the first data about the students in the school compared with the regional and if possible national averages for each type of education will already have been presented to the school. At this meeting we can discuss the results, collect special demands= for further analysis and make further suggestions for intervention, programmes = and projects for the school. In November 1995 a contract with each school will = be made with a specific program for the next years. Possible interventions hav= e to be as standardised as possible. National projects on a certain subject (bullying criminality stimulants etc.) are preferred but specific intervent= ions for the school are possible, if required. The programmes will run in 1996 a= nd at the end of 1997 a&n= bsp; final evaluation will be made in which both the interventions= and the co-operation between school and health service can be discussed in orde= r to make a new contract for the years after that. This way the whole Policy Cyc= le can start again.

Lo= cal health policy-Only aft= er the consent of the schools about using their data can we start the policy cycle= for the local health policy. In the healthy region project we have the next activities for the years to come. Three pilot communities will have their f= irst interview about their specific problems and needs and demands; they will be able to decide about the specific approach in their community in December. = The first results of the interviews with these pilot communities can be used to make a specific scenario for these interviews in general. Results refer to communities where students attend school further analyses will be made star= ting from the town, village or quarter where the students are living if communities for= specific results. Consequently for the whole population just as for the you= ng people a local health policy cycle can start which will be evaluated every = two years

Conclusion In this presentation I have tried to inform y= ou about a new approach in our health service in which co-operation with our direct clients, schools and local authorities is essential. I told you about epidemiology as a very important part of the whole policy cycle. I showed y= ou some results of our adolescent investigation. Further analyses will be made from the results and I hope to present them more comprehensively in due course.

Worki= ng within the field of child protection and vulnerable adolescents, sexual abuse is o= ften a predominant factor, where clients have suffered, and continue to be emotionally scarred throughout their lives. It is therefore essential for those professionals working within this area to have an understanding of both vic= tim and victimiser, where an understanding of offender behaviour and related therapies can aid and enhance a more knowledgeable and effective approach to work with the victims of such abuse.

This = essay will attempt to address some common profiles of the offender, a psychological analysis of offending behaviour, and provide the reader with an outline of treatment models.

The m= ajor focus of this essay will deal with the child sexual offender, within the framewor= k of paedophilia, incest and child molestation.

Such psychological factors as ‘social isolation’, ‘role reversal’, ‘marital discord’, ‘the seductive child’, ‘unsatisfactory marital sexual relationship’, ‘alcoholism’, ‘sex punitive mother’ and ‘fami= ly dysfunction’, have all been well researched in determining offender characteristics. Transference= of non sexual problems into sexual behaviour, is an= other key psychological patter in relation to the profile of the offender. IN the argument of a quest for ‘immediate gratification’, a Freudian analysis sees the offende= r as ‘continuing into adult life with infantile sexual desire’. with the likes of ‘unresolved oedipal conflicts,= castration anxiety and repression of the oedipal wishes’. These conflicts all act as contrib= utory factors of regression states of psychosexual development stemming from childhood, thus leaving the adult in a state of ‘neuroses / life crises’, which can then develop into a state of ‘perversion’. It = has been argued that socialisation is a further element adding to the make up of the sexual offender. With exp= osure to pornography and being the recipient of molestation, deviant sexual behav= iour as a child can be evidenced within research / practice findings, the result= of being inappropriate sexualised behaviour instilled within the child. With these primary external stimuli modelling the child’s behaviour, a framework of ‘generalisation’ can result in a transferen= ce of promiscuous behaviour to all who the child interacts with, (imitation).<= span style=3D'mso-spacerun:yes'> In relation to interfamilial sexual abuse, incest has been defined as an ‘erotic form of hatred’. Offenders characteristics are key pointed on the whole toward a member of the family unit, and encompass such antecedents as ‘depression, low self esteem,= and difficulties in maintaining sexual relationship with adult women’. These contributory factors can thus result in ‘recreational, tactical and physiological forms of abuse’. A modern recogn= ition in relation to sexual offender profiles brings gender into the argument and dispels the myth that males abuse and females do not abuse. This next section dealing with maj= or patterns of offending behaviour will address the psychological explanations= of behaviour, incorporating gender issues.

Sexua= l offender behaviour is steeped in ‘Freudian regression’, ‘Kleinian metaphor’s’, and behaviourist theories in trying to understand = such behavioural traits. Freud, as mentioned earlier, titles ‘perversion’ as a possible result of regression. The regressed off= ender has developed an age appropriate sexual and interpersonal orientation, yet under certain circumstances may regress to sexual involvement with children= . The fixated offender has never dev= eloped psychosexually beyond a primary sexual interest in children. Weldon, developing a Kleinian perspective brings gender into patterns of offending behaviour. As a penis is a projecting organ, = sexual gratification is inevitable in that the penis projects outwards in active search of its sexual goal, (this provides an explanation for non familial sexual abuse). In terms of the female, the womb is no passive organ, but rather has a strong quest to engu= lf sperm and therefore has an active need to draw things in through the medium= of the vagina. Weldon then argue= s that as the baby / child is an extension of the mother, abus= e will often occur as an introspection, in terms of an abusiveness of the self. thi= s can be further argued by ‘punishment of the self’ evidenced by = such things as self mutilation and bulemia.&nbs= p; Elliot has stated that the severity of abuse shows no differentiatio= n in relation to gender and male / female perpetrators. ‘Oral se= x, forced mutual masturbation, penetration and object sex were all predominant’, regardless of gender. Upon discovery, denial is a key behavioural patter, common in the majority of offenders. Freud states that ‘distortio= n of the past can often be subtle and unintentional’. However, Kennedy and Grubin in the= ir study entitled ‘Patterns of denial in sex offenders’ state that= one half of their sample of one hundred and sixty two men were unwilling to acc= ept full responsibility of the offence. Projection and transference towards an external stimulus is often reported, such as placing the blame upon the victim, (the seductive child),= the partner, depression, stress and alcohol.&n= bsp; Perhaps patterns of denial are best summed up by Salter, who outlines six characteristics of offender denial within a psychological framework:-

a) Denial of the acts themselves (external conflict)

b) Denial of fantasy and planning (internal conflict)

c) Denial of responsibility (cau= se factor, external stimulus)

d) Denial of seriousness (distor= ted perception)

e) Denial of internal guilt (ego conflict)<= /o:p>

f) Denial of the difficulty of changing abusive behaviour (behaviour modification)

̵= 6;Psychosexual regression’, ‘behaviourism’, in the form of ‘conditioning’, ‘child aggression theories’, ‘socialisation’, ‘non-affliation’, ‘internali= sed conflict’, ‘conflicting mental apparatus states’, and ‘opportunity’, are all fundamental issues in relation to explai= ning sexual offender behaviour, based on a psychological perspective. One can see that from the above, treatment will predominantly lie with a clinical, psychological framework.<= o:p>

Much = of the treatment plans operating within England and the USA centre around ‘behaviour, attitude, relationships, emotions, physical conditions, cognition and sexual interests’. These categ= ories are often implemented within a therapeutic and controlling framework of behaviour modification looking at ‘antecedents, behaviour and consequences’. Penile plethysmographs are sometimes used to determine the level of deviant arousal patterns in offenders. the sexual offender is subjected to a variety of visua= l and audio material, whilst the connections to the penis, and other parts of the anatomy, produces readings of arousal.&nbs= p; This sexual offender is subjected to a variety of visual and audio material, whilst the connections to the penis, and other parts of the anato= my, produces readings of arousal. This psycho-physiological method helps to assess the arousal level and thus determine the behavioural approaches needed in relation to offender rehabilitation. Aversion ther= apy, developed originally from ‘classical conditioning principles’, includes stimuli such as video, audio and slide material, whereby the avers= ive stimuli will include electric shocks and unpleasant smells. This therapy portrays a classic ex= ample of ‘negative punishment’, and is used primarily within secure settings. covert sensitisation, helps to instil within the sexual offender the relationship between antecedent and consequence of an offence, by means of linking the former with negative thoughts of the latter, hence emphasising a bypass of = the behaviour. A popular model of treatment is group therapy which can take many forms. Psychotherapy,= whereby sexual offenders engage in group discussion about their offending, in order= to ‘enhance insight and self control’. Salter argues that groups should be mixed, e.g. paedophile, rapist and molester, whereas Wyre states that groups should be constructed to the main themes in individuals offending behaviour, such as sex education and attitudes towards women, reconditioning, whereby deviant arousal fantasies are replaced by non deviant fantasies through the notion of operant conditioning ‘Cognitive distortions’, provides another area of concern needing a psychological model of treatment. Cognitive distortions are a predominant characteristic within sexual offenders, e.g. ‘If he does what I tell him, he must want it’. Group work where peers challenge rationalisations about such distortions in relation to cognitive developmen= t is often successful in cognitive restructuring. Perhaps the most controversial for= m of modifying sexual offender behaviour is that of surgical castration, (not implemented in the UK<= span lang=3DEN-GB style=3D'font-family:Courier'>). The fact that orchidectomy can solve problems by curtailing sex drive has been argued by Malcolm Alexander. However John Gunn has replied to this model of treatment by stating = that ‘guilt, problems of sexual identity and suicide could result from surgical castration, whereas the less severe chemical treatments can be reversible in these situations’.&nbs= p; It can therefore be seen that such behavioural treatments as ‘negative punishment, positive reinforcement and operant conditioning’ outweighs the practice / notion of surgical castration,= as evidence suggests that many offenders still commit offences after castratio= n.

In co= nclusive terms, it can be seen that profiles of the offender, behavioural patterns a= nd models of treatment are predominantly explained, analysed and adhered to wi= thin psychological framework. Psychological theory is at the forefront of working with sexual offenders. It can be noted th= at firstly, there needs to be an on going development of integrated models of sexual abuse, both explanatory and therapeutic, and secondly an attempt to = relate sexual abuse to general psychological theories.

This = essay has provided a brief analysis of sexual offenders behaviour and characteristics based around a psychological framework, as we= ll as outlining a descriptive and analytical element focusing upon behaviourist and cognitive theory in relation to treatment. The essay acts as an overview, whe= re interested parties will need to look further afield for a more variable and in-depth knowledge of the psychology of the sexual offender and related mod= els of treatment.

Bibli= ography -

1) Fi= nkelhor D. ‘Sexually Victimised Children’, New York Free Press 1979

2) He= rman J, ‘Father daughter incest’ (Cambridge) Harvard University Press 1981<= o:p>

3) Al= exander P.C. ‘A systems theory conceptualisation of incest’. Family

process 224, page 79-87, 1985

4) Bi= rch D.M.L ‘Bonds and Boundaries. Child protection and the family.’ YSH publishing 1994

5) Sa= lter A.C. ‘Treating child sex offenders and their victims’ Sage publicati= ons page 52, 1988

6) Ty= son and Tyson. ‘Psychoanalytic theories of development= 217;. Yale University Press page 44-46, = 1988

7) Stoller R. ‘Incest, the erotic form of hatred&#= 8217;, Korma publishing, 1988

8) Conte J.R.’The nature of sexual offences against children’. Wiley and Sons Ltd page l6, 1991

9) Sc= ully D. ‘Understanding sexual violence’. A study of convicted rapists. Unwin Hyman 1990

10) W= est D.J., Roy C. Nichols F., ‘Understanding attacks’, London Heinemann 19= 89

Letter= from the Editor	2=	&= nbsp;	Procee= dings conference 1996 &= nbsp; Intern= ational Conference 1998	12 &= nbsp; 13
Twelft= h Forum Meeting - Self Harming Behaviour &= nbsp;	3=	&= nbsp;	&= nbsp; Youth = Health Profiles - OnnoSijperda &= nbsp;	&= nbsp; 17
Confer= ence Round up - ‘Youth - Our Res= ource for the Future’ &= nbsp;	4=	&= nbsp;	A brief psychological analysis of= some common sex offender profiles, behaviour patterns and models of treatment. Daniel Anderson	22
Rita&#= 8217;s visit to Brighton &= nbsp;	5=	&= nbsp;	&= nbsp; The Ch= ild That Rocks The Cradle	&= nbsp; 26
Intern= ational Chapter News	6= &= nbsp;	&= nbsp;	&= nbsp; The Gr= eat Pancake Race	&= nbsp; 27
Eating= Disorders - Cultural and Religious Considerations Daniel Hardoff<= /p>	8=	&= nbsp;	&= nbsp; Semi-<= span class=3DSpellE>Independance Unit , Penge Projects	&= nbsp; 28