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CRISIS AT ADOLESCENCE
486
Annotations CRISIS AT ADOLESCENCE
THE adolescent must cope with different orders of change. Bodily changes are rapid, their effect is striking, and they appear at a younger age than they used to. Emotional and intellectual growth run parallel, and there are the great changes from school to work, dependence to independence, security to uncertainty. Beyond his personal life, the adolescent has to face social and material changes which, from any viewpoint, move more rapidly than at any time in history. As Mr. E. M. Eppel put it to the annual conference of the National Association for Mental Health in London last week, young people may have to develop new powers of adaptation and new capacities for emotional resilience that those who are no
longer adolescents can only dimly appreciate. Indeed, adolescent conduct, both normal and disturbed, seems particularly liable to set off psychological defencemechanisms in older people-hostility, rejection, repression, and denial. Unbalanced news-reporting of teenage activities conceals the fact that, for most children, adolescence is little more turbulent than any other phase of development. Nevertheless, figures quoted at the conference give real cause for alarm. The number of youths aged 14-20 found guilty of an indictable offence doubled between 1956 and 1965 to 2800 per 100,000, with the trend still upwards; and juvenile female crime, though much less common, was going up even faster. Delinquency and emotional maladjustment were known to be intimately linked-for example, 27% of borstal boys had been found to be mentally abnormal. The National Child Development Study of 17,000 children born in one week of 1958 had shown 10% with signs of emotional maladjustment by the age of 7. Another study of 2000 children aged 10-11 had identified over 6% with definite psychiatric disorders and about a third with serious antisocial behaviour. The suicide-rate for youths of 14-20 had nearly doubled in twenty years, and a third of teenagers referred to psychiatric clinics in Edinburgh had shown suicidal conduct. Addiction was surely advancing faster than indicated by the official statistics, though these were alarming enough: 1 heroin addict under 20 in 1960, 17 in 1963, 134 in 1965. 1 boy in 5 who entered London remand homes in 1965 admitted to taking amphetamines. Psychiatric disturbance in adolescence also poses academic problems. Though schizophrenia, depression (usually of the acute reactive kind), and organic syndromes could all be recognised, pigeon-holing along Krxpelinian lines tended to be unfruitful. The psychiatrist was often left just weighing up how far a disturbance was turned inwards, leading to neuroses and suicidal trends, or outwards, producing some form of delinquency. The acting-out element in adolescence called for special techniques of treatment and administration. For severely
aggressive, persistently promiscuous, antisocial, or absconding young people, the therapeutic-community approach in an adult open psychiatric hospital was simply no good. Security, physical and psychological, and a high staff ratio were essential for therapy; as Dr. Pamela Mason, of the Home Office, pointed out, " the strength of the outside wall allows the greater freedom within ". This freedom must mean a positive use of security and control rather than a negative return to
custodialism. But open psychiatric units did suit some patients, the lesson being that " adolescent unit " could be a meaningless cliche. Many kinds of unit were called for, including the short-term assessment unit, the intensive-treatment unit, the longstay unit for psychotics, and the maximum-security unit. To equate adolescent disorders with forensic psychiatry and criminology was as grievous an error as trying, as so often happened now, to do adolescent psychiatry in adult wards. What is being done to meet the needs for treatment ? Very little, as a recent survey1 illustrates. In 1964 the Ministry of Health accepted a recommendation of 20-25 beds per million for adolescents. By last July the figure had risen from just over 3 to no more than 4-5 beds per million. Eight regional hospital boards had no provision for adolescents on their own: East Anglian, North West Metropolitan, North East Metropolitan, Newcastle, Oxford, South Western, Welsh, and Manchester. The South Western and the Welsh boards had published no plans for the future, and South East Metropolitan with 18-2 beds per million had done best.
At the present it will or be forty fifty years before the growth-rate, standard is met-assuming no population Ministry’s increase. Surely the Ministry must be prepared to push the slower boards and, above all, to make the funds available to them. The need is clear, but what point, the pessimists may ask, is being served by pressing for more ? Memoranda and white-papers of the utmost virtue and cogency have, during the past decade, called for more of this and more of that: regional centres for the diagnosis and treatment of epileptics,2special services for alcoholism and drug
addiction, regional security units, psychopathic units, children’s units. How much they are all needed, but how desperately little has been provided.
EARLY OPERATION IN ACUTE PILES
FEW surgical complaints are as painful as an acute attack of inflamed, strangulated, thrombosed piles. Anything that can shorten the patient’s misery is to be In 1964, Professor Tinckler and Dr. welcomed. Baratham3 described how they had obtained rapid and uncomplicated healing in 39 patients by operating within a few hours of their admission. Stern 4 had had similar This bold approach conflicted with the tradisuccess. tional view that operation on thrombosed vessels in a septic area was dangerous, that immediate operation increased the risk of postoperative stenosis, and that operation should be undertaken only after two or three weeks of conservative management. Commenting on this reversal of dogma, we asked whether the gamble 6 was worth the risk.5 The answer, according to Smite seems to be that it is. Microscopy reveals that the thrombosis in the pile itself does not extend into its pedicle; the risk of portal sepsis has therefore been exaggerated. And now that immediate operation is sanctioned in surgical textbooks7 surgeons will welcome the green light. 1. Mental Hlth, Lond. 1967, 26, 3. 2. See Lancet, Feb. 4, 1967, p. 259. 3. Tinckler, L. F., Baratham, G. ibid. 1964, ii, 1145. 4. Stern, W. Med. J. Aust. 1964, ii, 635. 5. Lancet, 1964, ii, 1165. 6. Smith, M. Br. J. Surg. 1967, 54, 141. 7. Bailey, H., Love, McN. Short Practice of Surgery.
London,
1965.
Annotations CRISIS AT ADOLESCENCE
THE adolescent must cope with different orders of change. Bodily changes are rapid, their effect is striking, and they appear at a younger age than they used to. Emotional and intellectual growth run parallel, and there are the great changes from school to work, dependence to independence, security to uncertainty. Beyond his personal life, the adolescent has to face social and material changes which, from any viewpoint, move more rapidly than at any time in history. As Mr. E. M. Eppel put it to the annual conference of the National Association for Mental Health in London last week, young people may have to develop new powers of adaptation and new capacities for emotional resilience that those who are no
longer adolescents can only dimly appreciate. Indeed, adolescent conduct, both normal and disturbed, seems particularly liable to set off psychological defencemechanisms in older people-hostility, rejection, repression, and denial. Unbalanced news-reporting of teenage activities conceals the fact that, for most children, adolescence is little more turbulent than any other phase of development. Nevertheless, figures quoted at the conference give real cause for alarm. The number of youths aged 14-20 found guilty of an indictable offence doubled between 1956 and 1965 to 2800 per 100,000, with the trend still upwards; and juvenile female crime, though much less common, was going up even faster. Delinquency and emotional maladjustment were known to be intimately linked-for example, 27% of borstal boys had been found to be mentally abnormal. The National Child Development Study of 17,000 children born in one week of 1958 had shown 10% with signs of emotional maladjustment by the age of 7. Another study of 2000 children aged 10-11 had identified over 6% with definite psychiatric disorders and about a third with serious antisocial behaviour. The suicide-rate for youths of 14-20 had nearly doubled in twenty years, and a third of teenagers referred to psychiatric clinics in Edinburgh had shown suicidal conduct. Addiction was surely advancing faster than indicated by the official statistics, though these were alarming enough: 1 heroin addict under 20 in 1960, 17 in 1963, 134 in 1965. 1 boy in 5 who entered London remand homes in 1965 admitted to taking amphetamines. Psychiatric disturbance in adolescence also poses academic problems. Though schizophrenia, depression (usually of the acute reactive kind), and organic syndromes could all be recognised, pigeon-holing along Krxpelinian lines tended to be unfruitful. The psychiatrist was often left just weighing up how far a disturbance was turned inwards, leading to neuroses and suicidal trends, or outwards, producing some form of delinquency. The acting-out element in adolescence called for special techniques of treatment and administration. For severely
aggressive, persistently promiscuous, antisocial, or absconding young people, the therapeutic-community approach in an adult open psychiatric hospital was simply no good. Security, physical and psychological, and a high staff ratio were essential for therapy; as Dr. Pamela Mason, of the Home Office, pointed out, " the strength of the outside wall allows the greater freedom within ". This freedom must mean a positive use of security and control rather than a negative return to
custodialism. But open psychiatric units did suit some patients, the lesson being that " adolescent unit " could be a meaningless cliche. Many kinds of unit were called for, including the short-term assessment unit, the intensive-treatment unit, the longstay unit for psychotics, and the maximum-security unit. To equate adolescent disorders with forensic psychiatry and criminology was as grievous an error as trying, as so often happened now, to do adolescent psychiatry in adult wards. What is being done to meet the needs for treatment ? Very little, as a recent survey1 illustrates. In 1964 the Ministry of Health accepted a recommendation of 20-25 beds per million for adolescents. By last July the figure had risen from just over 3 to no more than 4-5 beds per million. Eight regional hospital boards had no provision for adolescents on their own: East Anglian, North West Metropolitan, North East Metropolitan, Newcastle, Oxford, South Western, Welsh, and Manchester. The South Western and the Welsh boards had published no plans for the future, and South East Metropolitan with 18-2 beds per million had done best.
At the present it will or be forty fifty years before the growth-rate, standard is met-assuming no population Ministry’s increase. Surely the Ministry must be prepared to push the slower boards and, above all, to make the funds available to them. The need is clear, but what point, the pessimists may ask, is being served by pressing for more ? Memoranda and white-papers of the utmost virtue and cogency have, during the past decade, called for more of this and more of that: regional centres for the diagnosis and treatment of epileptics,2special services for alcoholism and drug
addiction, regional security units, psychopathic units, children’s units. How much they are all needed, but how desperately little has been provided.
EARLY OPERATION IN ACUTE PILES
FEW surgical complaints are as painful as an acute attack of inflamed, strangulated, thrombosed piles. Anything that can shorten the patient’s misery is to be In 1964, Professor Tinckler and Dr. welcomed. Baratham3 described how they had obtained rapid and uncomplicated healing in 39 patients by operating within a few hours of their admission. Stern 4 had had similar This bold approach conflicted with the tradisuccess. tional view that operation on thrombosed vessels in a septic area was dangerous, that immediate operation increased the risk of postoperative stenosis, and that operation should be undertaken only after two or three weeks of conservative management. Commenting on this reversal of dogma, we asked whether the gamble 6 was worth the risk.5 The answer, according to Smite seems to be that it is. Microscopy reveals that the thrombosis in the pile itself does not extend into its pedicle; the risk of portal sepsis has therefore been exaggerated. And now that immediate operation is sanctioned in surgical textbooks7 surgeons will welcome the green light. 1. Mental Hlth, Lond. 1967, 26, 3. 2. See Lancet, Feb. 4, 1967, p. 259. 3. Tinckler, L. F., Baratham, G. ibid. 1964, ii, 1145. 4. Stern, W. Med. J. Aust. 1964, ii, 635. 5. Lancet, 1964, ii, 1165. 6. Smith, M. Br. J. Surg. 1967, 54, 141. 7. Bailey, H., Love, McN. Short Practice of Surgery.
London,
1965.