Medicine discovers the teen-agers
Between 12 and 18, most people are healthier than they ever were before or will be again — but they're also overfed, underworked and easily laid low by many physical and mental complaints of their own. Are they special cases that need doctors and clinics of their own? A growing number of doctors think so: here’s what they’re doing about it
NORTH AMERICAN TEEN-AGERS are already the continent’s healthiest and most pampered citizens. Now, whether they need it or not, they are well on their way to becoming the special concern of doctors who are working out yet another department of medicine—the adolescent clinic.
“Adolescence itself isn’t a medical problem,” says Dr. J. Roswell Gallagher, a specialist who has headed a Boston clinic for adolescents for
the last ten years, "but it can aggravate so many other physical and emotional conditions that no doctor can really treat a teen-ager properly unless he takes it into account.” Many doctors and hospital boards disagree. Dr. A. L. Chute, head of the pediatrics department of the Toronto Sick Children’s Hospital, says, “Everyone likes to be pampered, and adolescents would doubtless appreciate their own clinics and hospital beds. But this is a refinement we
don't consider terribly important. Anyway, other needs arc paramount at the moment.”
Doctors generally agree, though, that teenagers, despite their noisy ebullience, aren’t in as good physical shape today as they were thirty years ago. “They are heavier and taller, probably because of better nutrition and fewer longterm childhood diseases,” says Dr. Gallagher. “But many of them eat too much and don’t get enough exercise.”
Sex concerns them more than it once did, Gallagher believes, principally because youngsters today are made aware of it earlier, have more opportunity to get into trouble, yet still find no socially acceptable outlet for their urges. Although it’s difficult to get figures for comparison, specialists also believe that emotional illnesses, which increase both in number and severity as youngsters grow into their teens, are taking a higher toll today. Some doctors estimate about ten percent of all adolescents will
have some kind of serious emotional upset in their teens, although many will go untreated. A small group — who drink to excess, or are under the influence of drugs, or show suicidal tendencies — need help gravely. (In the U. S. about three youngsters in every 100.000 between fourteen and nineteen take their own lives each year.) Even mental retardation frequently reaches a critical point in these years. In Canadian mental hospitals more than a quarter of all patients with defects that cause disorders in character, behavior or intelligence, are between ten and nineteen years old.
Adolescents have a lower mortality rate than almost any other age group. In Canada only about forty-five per 100,000 of the country’s 3.000,000 teen-agers die each year, compared to 2,700 infants and 100 adults between thirty and thirty-four. (The U. S. mortality rate is comparable in the early teens but jumps to ninety-five per
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In its research into adolescent problems, the Adolescent Unit of the Children's Hospital Medical Center in Boston is investigating a frequent cause of failure in school, especially among boys. The condition is known as Dyslexia, or Specific Language Disability. It is thought to affect between five and ten percent of all boys and about a quarter as many girls. These children, who often have high IQs and no apparent emotional difficulty, spell words strangely (“Him" for “film,” “graditute” for "gratitude.” and "exseply” for “exceptionally”) and have great difficulty reading quickly or accurately. Although their ailment is still rooted in mystery, some doctors believe it results from a hereditary lack of a dominant side to the brain. Youngsters for whom
the form and order of letters apparently don't register are often ambidextrous, and without rhythm, and have a poor sense of direction and poor co-ordination. A Canadian - born reading consultant at the Unit. Mrs. C. E. Buchan, trains tutors to help such adolescents read and spell normally. The method is fundamentally a return to the principles of phonetics and spelling. Tutors at first work with only ten phonetic letters, adding more gradually as the rules of phonetics and spelling are drilled into children to compensate for their lack of natural grasp of syllables and letter order. Youngsters with IQs below 100 are not included in the program, since it isn’t equipped to handle their difficulty. Even with intelligent youngsters, two to four years of daily half-hour tutorial sessions are often needed before they are reading normally.
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Before greeting teen-age patients, one pediatrician strips aiS the baby pictures from his office walls
100,000 for the fifteen to nineteen-yearold group. Accidents cause more than half these deaths.) Usually adolescents have outgrown communicable childhood diseases, have more resistance to infection than they had as children, and get fewer colds and respiratory ailments. Hospitals report comparatively lew bed patients ate in their teens.
Yet, when illness does hit a teen-ager it hits hard. Diabetes in adolescence is almost a different disease than in adults. (In teen-agers the pancreas produces little or no insulin of its own; daily insulin injections plus strict diet arc neccssaty to keep the blood’s sugar level steady. One of these treatments is often sufficient for older patients.) Tuberculosis is no longer a major cause of death, but takes its most volatile form in teen-agers. They are also subject to such chronic and incapacitating ailments as arthritis, epilepsy and hypertension. Often a chronic condition that was managed well enough in childhood goes rampaging in adolescence. Anxious to "be like everybody else,” a rebellious teen-ager may stop measuring his insulin, throw out his epilepsy pills, or decide he doesn’t have asthma—with serious results.
The linkage of emotional and physical health is probably stronger in adolescence than at any other time of life. A boy's acne, a girl’s painful menstruation, and many a youngster’s fatness are as likely to be based in some emotional difficulty as in any physical weakness. A fourteenyear-old’s headache may stem, not from a migraine condition or bad food but from his hatred of going to school. He may be chronically tired, not because he is anemic or is developing tuberculosis but because subconsciously he finds fatigue a tiood way to avoid a situation in which he fears failure. Intensely interested in themselves, teen-agers may fret over what they think is an abnormality until both physical and mental alertness are affected.
All this, say the boosters of adolescent medicine, is good reason why teenagers need particular understanding, and thoughtful medical attention.
The American Academy of Pediatrics, to which most U. S. and Canadian child specialists belong, has held seminars and printed a number of articles in its professional journal on the subject. Following the lead of Dr. Gallagher s Adolescent Unit in Boston, about a dozen U. S. hospitals have developed outpatient clinics or bed wings for adolescents. In Canada the Montreal Children’s Hospital has just opened an adolescent centre, financed by a federal-provincial grant; it is not a psychiatric clinic but it has a deliberate policy of sympathy toward its teen-age patients. The Vancouver General Hospital tries to group adolescents together in wards and keeps special hours for them at its outpatient clinic. It hopes to set up an adolescent section of its Child Health Centre "in the near future. Othei doctors and hospitals are interested. They point out that at this age, when youngsters are still malleable and resilient, a doctor can still work with them to strengthen their personalities permanently or build up general health. Later, a great deal of this human capacity for change is gone.
Dr. Gallagher sees adolescent medicine as a general broadening of viewpoint among pediatricians, general practitioners, internists and others who have a good many teen-age patients. He looks for a trend away from what he calls "fractional care” toward the treatment of the ado-
lescent and his ailments together, with a particular understanding of his troubles.
From a scientific standpoint. Dr. Gallagher says, a doctor gains more insight into the course of a chronic illness or disability by watching it through all stages of a patient’s development, including adolescence. Yet, in fact, until now little has been done either to encourage teenagers to seek medical help or to make them feel at home when they do.
"You can't blame an adolescent for shrinking from a pediatrician s waiting room—full of baby pictures, wailing infants and distraught mothers,” says Dr. Martin Wolfish, a thirty-five-year-old Toronto pediatrician with a particular interest in teen-agers. "Yet it he goes to an adults’ doctor he’ll probably be fussed over like an infant—after all he's probably the youngest patient the doctor has seen in ages—until he’s just as reluctant to sec him as he was to see the baby doctor.” Dr. Wolfish recently began holding special evening clinics for his adolescent patients. Before each one he whip, the baby pictures ofl the walls, scatters around copies of Life, the National Geo-
graphic and the daily papers, and bones up on a few teen-age magazines and the latest football scores. He says he not only has two or three times as many patients as before, but can give them better care. In an unhurried atmosphere of mutual confidence-—no appointment is for less than half an hour—he can usually get to the root of an adolescent’s trouble and map out effective treatment. And the adolescent is far more inclined to follow his advice than that of a less painstaking doctor.
For a teen-ager in hospital, some doctors say, the situation can also be distressing. Dr. Bruce Graham, who heads the pediatrics department of the Vancouver General Hospital, describes a teenager in a ward as "like a baseball falling between outfielders. ... He doesn't like being in with the smaller children and feels out of place among adults.”
The usual children’s hospital age limit of fifteen for inpatients has dampened many doctors’ hopes for special facilities for adolescents. In fact the pediatrician has a problem when an older teen-age patient needs hospital care. Many children s doctors con-
tinne seeing their patients until they're seventeen or eighteen. ( Dr. Wolfish likes to keep them as office patients until they are out of high school.) But the doctor can’t send an older teen-ager to a children's hospital: it won't take him. Yet the doctor probably is not on the staff of an adult hospital. The only feasible solution is to turn his patient over to another doctor w ho can get a bed in tin adult institution. Thus the bond between pediatrician and patient is broken. “Fortunately most teen-agers don't need to go to hospital or this would be an even greater problem," Dr. Wolfish says. He calls the fourteen to eighteen-year-old group the "forgotten age" in medicine.
1 he pioneer in adolescent medicine on the continent, however, is the mild-mannered fiftv-eight-year-old. Yale-trained internist, Dr. Gallagher. As staff physician at a select boys' school, Phillips Academy at Andover. Mass., he came to realize, during the late thirties and forties, howlittle was being done to give adolescents any special help with their physical and emotional problems.
"Doctors were more than busy earing for and studying younger and older patients with more serious illnesses,” he says. Ten years ago Dr. Gallagher left Phillips to found one of the first adolescent units in North America at the Children’s Hospital Medical Center, affiliated with the Harvard Medical School in Boston. The Unit nowtreats more than 1.000 new adolescent outpatients yearly and has trained doctors from all over the world in the medical problems of adolescence. It runs on Dr. Gallagher’s tenet that to give an adolescent the best care a doctor must be interested in his patient's hopes, worries and needs, as well as in his physical condition. "No other age group demands so strongly that you pay attention to them, or so quickly ignores you when you do not." he says. “Adolescents are less willing to yield something of themselves than children and less ready to compromise than adults. Yet their need for understanding is probably greater than at any other age."
The Unit is noticeably unclinical in appearance. No strong disinfectant assails the nostrils as you enter. Consulting rooms have comfortable modern furniture, with such informal touches as chintz, curf':ns. They lack the traditional doctor's desk, and the ominous professional flourishes — stethoscopes, hypodermic syringes and eye charts—are not in sight. ("No sense making things frightening with all that junk around,” Gallagher shrugs.)
Although theoretically the Unit deals with all kinds of adolescent illness, in practice most patients arrive with chronic complaints, referred by their own doctor, their school, or perhaps a social agency after routine treatment has proved ineffective. Unit doctors find many suffering from "adjustment reactions of adolescence.” Among cases often encountered are youngsters who are failing in school because of a new resentment of authority, worrying themselves into headaches, continuous fatigue, or unruly behavior over their physical development, or whose sudden strong sexual urges leave them feeling guilty and confused.
Parents are seen by Unit doctors separately. preferably the day before the teen-ager's appointment, so that pertinent medical history can be taken. In an interview with the youngster next day. a complete physical examination is conducted, with a watchful eye for such potential adolescent trouble spots as growth, weight, muscle development (in boys), vision, hearing and glands. Achievement tests are usually given as well, particularly to teenagers having trouble at school. Patients have the same doctor on all subsequent visits. F.ven when a specialist is called in the original doctor is usually on hand. If
patients need to go to hospital, a few beds in the adjoining children's medical centre are kept especially for them.
The Unit’s four-doctor permanent staff is augmented by a consulting panel of about twenty medical specialists, psychologists and graduate physicians in training. Besides a year's postgraduate course in adolescent medicine—believed to be the only one on the continent—the Unit offers a oneor two-month training course to well-established doctors, hoping some of them will start similar units across the country. So far several have done so. The
Women's and Children's Hospital in Dallas now; has an adolescent inpatient unit, the Twelve to Twenty Club. Dr. F. P. Heald, a former Boston Unit staff member, directs an inpatient w ing for teen-agers at the Children's Hospital in Washington, D.C. Similar services are operating in Denver, I.os Angeles, Columbus, Ohio. San Francisco, Philadelphia. New York and Portland. Oregon, as well as in several smaller cities.
Mollycoddling? Not at all. says Gallagher. Rather, such concentrated attention in their teens keeps many youngsters from serious trouble later. “An adoles-
cent's broken ankle will heal whether or not his doctor takes a personal interest in him,” he admits. "But how good a permanent recovery he makes depends on how he co-operates with his doctor. This hinges on his respect for him, a direct result of the doctor’s interest and attitude." To win this respect, he says, a doctor must tread a thin path between prying and overdomination (too much like a parent), and being too pally with his patient. He must show some regard for a youngster's age and feelings. It is senseless, for instance, to prescribe rest—re-
pugnant to most adolescents—unless imperative. Nor should a doctor expect a teen-ager to do anything that would unnecessarily set him apart from his contemporaries. Yet. the doctor must have opinions and give some definite instructions, or wind up a nonentity, and therefore an unconsulted medical man. in the opinion of the adolescent.
Boston doctors say the right approach often results in effective treatment of ailments which have previously confounded teen-agers, their parents and sometimes a busy practitioner with time for only limited consultation.
Many knowledgeable doctors warn against sending a teen-ager to a psychiatrist except in extreme cases. "Il makes him feel he’s different-—queer—the Ihing he w'ants least in the world to be,” says Dr. Wolfish. He thinks most teen-age emotional trouble can be smoothed out with understanding and common sense from a general physician
Ciiven a normal start, doctors say an adolescent can do much on his own to keep well. Here are a few tips:
► He should have a thorough checkup annually, preferably with someone who is particularly interested in him or his age group. Il should allow time for a complete examination and plenty of qttestions from the teen-ager on whatever
physical or emotional ills are bothering him. ("Fven if a youngster only sprains an ankle we like to examine him thoroughly since it may be the only chance we'll have in a iong time,” sa>.$ Dr. Wolfish.) Doctors often uncover conditions which wouldn't otherwise be brought to light, since teen-agers usually heartily deny they ever feel less than perfect.
► He should get some kind of regular physical exercise, even if a mild disability keeps him from such rugged activity as football. Dr. Gallagher thinks a five-mile walk to school each day would be "wonderful" for most youngsters. And he’d like to see far more playing soccer, skating or swimming, both for fun and exercise. Dr. Wolfish blames schools partly for the fact that few adolescents get enough muscle-flexing workouts. “Schools concentrate on the lop ten percent of the students for teams and ignore the others when what they should do is make sure everyone is on some kind of team,” he says. He prescribes the RCAF's 5BX and XBX exercises for flabby youngsters, and sometimes sends girls to charm school for a week or two to learn good posture.
► The teen-ager should probably eat less (unless he has put himself on a starvation diet, in which case he should probably eat more of the right things). "Food is of'en a substitute for the fun and exercise adoles-
cents are missing,” says Dr. Gallagher, and obesity is one of the most common health problems among teen-agers. Dr. Wolfish says only about one in a hundred of his adolescent patients eats properly. "Most consider a coke and a plate of potato chips a really good lunch.” Significantly. about half of them have some degree of acne.
► Finally, teen-agers should try to develop an interest or two besides school and the opposite sex. Gallagher thinks recent intense emphasis on academic prowess has damaged the health and emotional w'ell-being of many youngsters who aren't cut out for scholastic success. "Parents and teachers who try to push an adolescent beyond his capacity can do him irreparable harm,” he says. But when a teen-ager has some interest beyond school, his academic problems should get back into proportion.
Generally, adolescents should feel better than at any other time in their lives. They've outgrown the susceptibilities of childhood and have more stamina and resistance than adults. So when a teen-ager doesn't feel well, it's high time to lind out what's wrong. An understanding, welltrained doctor can probably get to the base of the trouble, physical or psychological, before it becomes deep-rooted and permanent. This is the whole philosophy behind adolescent medicine.