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Some Emotional Problems of Adolescents
Some Emotional Problems of Adolescents GRAHAM B. BLAINE, JR., M.D.*
SCHOOL PHOBIA
School phobia is seen more often in the early adolescent age group and in younger children. It is characterized by a fear of attending school and is distinctive from truancy in that it is not consciously planned. There may be physical symptoms such as abdominal pain, headache or sore throat which are not recognized by the child as excuses for not going to school. They complicate the issue, of course, particularly for the parent and sometimes also for physicians. It is important to eliminate the possibility of the presence of some physical illness which warrants staying home. Sometimes only emotional symptoms such as panic or fear are present. In our studies of the school phobias we found that about two-thirds of the cases are related to separation from home rather than to something specifically within the school situation. While the patients themselves may often blame school for their nervousness, it seems to be justified in only about onethird of the cases. Usually it is separation from mother which causes the anxiety, and the mother usually adds to this anxiety by expressing fears about the child leaving home and going to school. It seems to be a mutual involvement in which each contributes to the other's anxiety and builds it up. Two cases from our experience in The Adolescents' Unit demonstrate these factors. The first was a fourteen year old girl who had always appeared to enjoy school, had a good standing in the ninth grade and suddenly developed a fear of going to school. She complained that her teacher was too strict and that the other students teased her about being fat. Her refusal to go to school came after a prolonged convalescence from a mild case of bronchitis.
* Consultant in Psychiatry, The Adolescents' Unit, Children's Hospital Medical Center; Assistant in Psychiatry, Harvard Medical School; Chief of Psychiatry, Harvard University Health Services, Boston, Massachusetts
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Respiratory symptoms had been absent for over two weeks. She had been given firm assurance by her doctor that she was completely well and should return to school. When the school bus arrived, she ran indoors in a state of panic saying she was too scared to get aboard. Her mother wrote an excuse for her. Each morning for a week the same scene was enacted. The girl's stories of what had happened at school became more lurid, and this finally led the family to go to the school to make inquiries. On investigation. no basis for the girl's complaints against the teacher or her fellow students was found, and the school authorities advised consultation with a doctor. The family physician was perceptive and knew the home situation well. He realized that the birth of a baby brother shortly before the girl came down with bronchitis had probably made the mother more dependent on the older daughter for help with the baby and also that it had increased the daughter's need to be home so that she might fortify her position with the parents. The doctor suggested that when the father returned home from a business trip, he should take his daughter to school, panic or not, and escort her to the classroom. This firm handling worked and after a week the girl was able to ride in the regular bus once again. In another case the management was made more complicated by various outside influences, events which occurred to interfere with the firm and consistent parental attitude so important in these cases. This was a thirteen year old boy named Harry who for two years had difficulty in going to school. He was finally brought to the Clinic by his mother. He had a history of average school performance, played on the football team, and was very popular. His father was a contractor, hard-working, gruff and given to boasting. His mother was emotionally unstable, cried easily and often complained about being overworked. She occasionally took to her bed for days at a time with a sick headache. The maternal grandmother lived in the home and served as a kindly mediator. There were no other children. Two years before this boy came to the Clinic his father had suffered a heart attack, and it was during the father's hospitalization that Harry first began staying home from school. At first his excuse had been that he had been worried about his father. Soon he began to be nauseated and have stomach cramps each morning. A doctor was finally called and nothing definite could be found; all the symptoms would disappear by lunch·time. The grandmother felt that the boy was making up his illness and began chasing him out of the house. He returned to school because of this and had perfect attendance for six months. Near the end of the school year a sixteen year old cousin of his, who was recovering from a nervous breakdown, moved into the home. Then all the previous symptoms returned and no one could persuade him to leave the house to go to school. By the following fall the visiting cousin had been put into a mental hospital, and Harry started the next semester without difficulty. He had a
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perfect attendance record until February when his mother fell and broke her ankle, and then his morning nausea and stomach cramps returned. This time the school stepped in by sending a truant officer to the home and arranging a series of meetings with the guidance counselor for Harry. During these interviews discussions centered on illness in the family and Harry's need to be at home. He began to understand the feeling of obligation to help out which made him want to stay home and caused his involuntary imitation of the sicknesses suffered by other members of the family. The next year he continued his counseling and was beginning to explore the deeper meaning of his phobia and its relation to his guilt for having unconsciously wished illness on his mother and father; then the counselor became ill with pneumonia. He immediately began to have his early morning symptoms again. Pressure on him to go to school despite his symptoms resulted in intense feelings of fear and panic, and at that time he was brought to our Clinic by his mother. Treatment here was entirely supportive: encouragement rather than explanation or interpretation made up the content of the interviews. No attempt was made to probe into the meaning of the symptoms. The Unit's doctor took a firm stand about returning to school, insisting that Harry go the next morning without fail. The physician asked him to telephone him when he got to school and several times during the day. For the first two weeks Harry merely went to the principal's outer office and sat there reading magazines. Then he began going to one class and gradually to more until after a month had passed he was in full attendance. He was no longer in need of interviews. Four years later he graduated from high school having experienced only one brief return of symptoms which required a month of further treatment at the time of his father's death the year before. These cases illustrate the kinds of background from which these phobias come, as well as the type of treatment which is most effective. A study of this illness done at the Judge Baker Guidance Center showed that starting treatment early is extremely important. Almost all cases treated there during the first three months were cured without remission. For those in which treatment was started after six months, the percentage of cure was much lower. The most important element in the treatment is to get the child back to school as soon as possible and insist that he stay. Occasionally there are difficulties which are connected with school, such as a teacher who may present a particularly threatening image to the student, one who perhaps has the same attitudes found at home. He may produce an unreasonable amount of anxiety and fear in the student. Sometimes a teacher who looks like a parent who is overly punitive may arouse enough anxiety in a child to cause him to fear to go to school. Occasionally a child who is much bigger or much smaller than his contemporaries feels self-conscious and so uncomfortable in a classroom that he develops school
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phobia. Sometimes, also, it is caused by the nature of the school work itself -either it is not sufficiently challenging or perhaps too challenging. A student may feel overly pressed and inferior or in the other instance not sufficiently interested. Being bored, and as a result getting into trouble for acting up in class, may lead to a fear of going to school. Sometimes a single incident in school such as in a smaller child not being able to make the bathroom on one occasion may start a feeling of fear and threat about being in the classroom, which may be reactivated when the child is older and in a classroom with a threatening teacher. These conditions may be altered by changing the student into another school or a different classroom or by giving reassurance, but in these cases, as well as in the separation anxiety cases, the most important maneuver is to get the child back and help him to stay there by whatever means. DEPRESSION
Depression is the most alarming emotional symptom that we see in adolescents and adults. It is a worrisome symptom for doctors, and one over which they lose more sleep than any other single symptom. When we are dealing with the adolescent, we can feel reassured to some degree because suicides among adolescents are quite rare. Table 1 shows the number of suicides per 100,000 population in the United States in various age groups. The overall average for men is 10.6 per 100,000, for women 2.9, and the proportion remains much the same all the way up the scale until the age of seventy-five. Men succeed in suicide more frequently than women though suicide attempts among women are from six to ten times as frequent as among men. Whether this speaks for better efficiency on the part of men or for stronger intent is not known. The 10-14 age groups are far below the average of all ages, and the 15-19 category is also well below the average. At the college age we find the rate a little higher. In the young adolescent or young child suicide is usually connected with an act of compulsive retaliation and not, as a rule, with depression. Table 1.
Suicides b)1 Age Groups in the United States per 100,000 Population AGE
MEN
WOMEN
1-74 10-14 15-19 20-24 25-34 75 and over
10.6 .7 3.6 8.6 12.4 60.1
2.9 .2 1.1 2.2 3.9 8.1
(Adapted from Dublin, Louis I.: Suicide, New York, Ronald Press, 1963)
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Here in the Boston area a short time ago a ten year old child who was refused permission to go out on Halloween went upstairs and hung himself in the closet. This sudden sporadic striking out is hard to predict. Table 2 shows the much higher suicide rate in people who are widowed and divorced as opposed to the overall average. The highest figures of all are for divorced men over 75. These figures indicate that loneliness is probably the most important motivation for suicide. Within the adolescent age group the suicide method used is shown in Table 3; girls show a much higher use of poison and boys of firearms. The poison is usually barbiturates. In the college population the reported suicide rate is considerably higher than it is in the general population. Comparing figures of colleges around the country we find that the Harvard rate of two and one-half suicides a year (about twenty per 100,000), as opposed to the national figure of about one-half that for that age, is typical for United States colleges generally. Why the college student should be more susceptible is not known, but probably his stresses are greater, and his need to excel and to fulfill family requirements makes his depression deeper and more dangerous. Despite the fact that suicide is rare, depression is still a symptom that we must be very careful to evaluate cautiously and completely. Table 2.
A Comparison of Suicide Rates in Widowed or Divorced Persons with the Overall Average for Men and Women
AGE
MEN
1-74
WOMEN
10.6
20-24 25-34 75+
Table 3.
2.9
WIDOWED
DIVORCED
WIDOWED
DIVORCED
78.0 75.7 76.2
30.7 100.4 139.1
7.7 13.9 8.7
11.6 17.4 16.0
Methods of Suicide in rounger Age Group (Ages 70 to 24) MALES
Firearms ................. 52.8 Hanging ................. 14.5 Poison ................... 15.] Gas. .. . . . . . . . . . . . . . . . . .. 9.7 Drowning................ 2.9 Jumping.. . . . . . . . . . . . . . .. 2.0
FEMALES
22.6 3.4 53.0 12.0 4.0 2.4
(Tables 2 and 3 adapted from Dublin, Louis 1.: Suicide, New York, Roland Press, 1963)
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In dealing with any patient who is depressed, certain signs are more ominous than others. One is an expression of extreme self-depreciation such as irrational statements about being an evil person, having something basically bad inside which is irrevocable, or of feeling a burden to parents or society. Self-derogatory statements such as these usually mean that the depression is a deep one and that special measures such as referral or hospitalization should be taken to make sure that suicide does not occur. Another ominous sign is secretiveness. For patients with whom the doctor does not feel in full communication, it would be well to seek consultation or perhaps to arrange for psychological tests to gain a better understanding of what is really going on. When patients say there is no way out, that every way they think of moving to get out of their dilemma is blocked, then, too, one should be especially alert. Many doctors ask whether they should bring up suicide spontaneously when talking with a patient who is depressed. Some fear that they might put the idea into the patient's head by mentioning it. On the contrary, bringing up the possibility is almost always a helpful maneuver. One can often test the depth of depression by bringing up suicide, perhaps not using the word itself but by asking the patient if there are times when he feels that life is not worth living, or is suggesting that there may be moments when he feels that he would be better off dead. Questions like this give the patient a chance to tell you that he may be seriously contemplating taking his life. Bringing up these topics does not encourage a patient to act on them. Often we are reluctant to speak about the possibility of suicide because we do not want to know the answer. If the patient is this badly off and in this much need of attention, we may avoid raising the issue to save ourselves worry and concern. Sometimes patients talk of suicide as a philosophical concept and appear to toy with it almost jokingly. This is truer of the adolescent than of older patients. He often thinks about it in abstract terms, and we do not have to worry too much about this kind of philosophizing. Particularly it appears in the broader context of ruminating about the meaning of life. Most adolescents who commit suicide are schizophrenic and are not depressed. Out of thirty-four suicides that occurred at Harvard over a fifteen-year period, only two of the victims had consulted the college's Mental Health Service before committing suicide and none of them had been clinically depressed at the time of their clinic visit. They may have been somewhat discouraged, but most were found in retrospect to have been psychotic or at least seriously disturbed at the time of the act. We do have to worry about suicide in the student who is schizophrenic. They really fall into the category of secretiveness described above, for these students are unpredictable. The psychotic nature of their thinking makes it impossible for us to know what is going on in their minds. Often hospitalization is a
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necessary protection against their acting on an impulse or in response to a hallucinating voice, destroying themselves suddenly and without warning. IDENTITY PROBLEMS
Identity formation is the main task of adolescence. The word "identity" has been bandied about a good deal by all kinds of people, but I think Erikson in Childhood and Society has defined it most clearly. He describes it as "a feeling of being at home in one's body and a sense of knowing where one is going." He also says that it is something that may occur suddenly and that the individual may be quite surprised to make its acquaintance. It is the achievement of a sense of self, and it requires an incorporation into the self of certain identifications with valued people in the environment. It usually occurs during college age (between eighteen and twentytwo) and is an identifiable and essential step in the direction of achieving maturity and adulthood. There are certain factors which interfere with the formation of identity and the achievement of a sense of self. One of these is the death of an important identification figure during the early teens, or a disillusionment in such a person. The classic description of this is in Arthur Miller's play, Death of a Salesman, where the son, Biff, who has become disillusioned with his father, says to his mother, "I just can't take hold, Ma, I just can't take hold of some way of life." This is the feeling of being lost and drifting about with a sense of purposelessness which Erikson has called "role diffusion." Instead of having a feeling of a definite role in life, an individual feels diffused and spread out over many areas and cannot become committed to any occupation or ideal. Another influence that interferes most commonly with the formation of identity is what we have come to call "intrusiveness" on the part of parents. This is more frequent in mothers. It is their constant questioning and depreciating of the child and their refusal to let him have any privacy. These parents demand that they be a continual part of every phase of their child's life. This has the same effect as shaking up a solution that is trying to crystallize with the result that it can never set and gel or gain solidity. Often for the healthy development of identity a "psychosocial moratorium". is necessary. This is a phase which is most distressing to parents. It may take the form of a period of apathy when the adolescent seems particularly gutless and is only able to sit around doing nothing. This characterizes what has now become known as the "drop-out," the student who leaves school for a temporary period during this period of adjustment. This seems to be a necessary step for a few students who can only in this way throw off parental standards which feel superimposed. It is a period
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JR.
when the old values have been cast off but new ones have not yet made themselves apparent. This moment of moral nakedness can bring with it a fear that one is just a "nebbish"-a nobody who has no real substance. Some students who are in this identity crisis are not apathetic but instead are anxious and disturbed because of concern about this nothingness within. The process of dropping out often makes the difference because the student is able to get the feeling afterwards that he has made a real change from the established pattern that had been set down for him since early in life. When he comes back he feels that he is now going to college for his own reasons. This improves his ability to perform. The other great advantage of dropping out of college is the feeling of accomplishment which may result from doing a job, even if it is a very simple one, and doing it rightwell enough in fact to receive hard cash in return. This gives him a feeling of confidence which he can carry back into college work. Dropping out is generally a healthy experience, though, of course, it is not a necessary one for many students. We wish that we knew why some have to go through this apathy phase while others are able to shift rather rapidly from a feeling of dependency to one of independence, finding an identity successfully without this timeconsuming moratorium. The most extreme example of apathy is the beatnik who goes through a long and extreme period of rebelliousness during which he acts as though he were against everything and for nothing. However, even being a beatnik seems to be a self-limited disease and almost all come back and become surprisingly conformist in their behavior. The last beatnik I followed is now in the Harvard Business School. One should never give up hope for them. THE SEX PROBLEM
When it comes to the problem of sex we have less that is definite. We, as adults, and even as doctors, are confused about the rules here. It is an area in which we have no completely satisfactory answer for the adolescent. His strongest sex urges occur at this time. Boys from fourteen to eighteen are in the age in which the sexual desire is strongest; for girls it is from 15 to 20. Yet we in our present-day society have provided no outle~ for this age group which is both legal and moral. We can give the adolescent no answer completely satisfactory to the problem of what he should do with his sexual impulses at this stage of his development. The principle of continence and chastity for all until marriage is the ideal which has been presented to him since the days of the Garden of Eden, but it is one which has never been lived up to and one which we
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know is incompatible with his basic nature. It is no wonder that we are ill at ease when the adolescent comes to us with questions about his behavior and standards in this area. However, transferring our confusion to him does not help. He needs guidelines and principles to go by even if we can't justify everyone of them by logic. In general, I think that the factual information about sex is better transmitted to young people of adolescent age by reading material and conversation with family doctors than by parents. Most parents find that talking about sex with their children is extremely embarrassing. They usually feel self-conscious when they do so. This does not help the young person feel comfortable himself about sex, and it often transmits guilt and shame about sex. However, the parents can certainly contribute a great deal by example. This, I think, is very important. What the child sees and feels about the physical relationship between the parents themselves is translated into his own attitudes toward sex. What one would hope is that the adolescent would develop a respect for sex with the realization that it is a powerful force but at the same time is respectable and not something to be afraid or ashamed of. How to be specific about transmitting this is very difficult. It is like trying to teach parents attitudes about toilet training. Doctors tend to say, "Well, you know, just don't make him feel guilty about it." But how do you actually effect the feeling that this function is not dirty. It is hard to be specific in our instructions. I think, in general, parents can build healthy attitudes in their children if they are aware of the fact that they are trying to transmit an attitude and if they do not get bogged down by talking about the facts of sex in detail. There has been considerable controversy lately about the change in sexual morality amongst college age adolescents. It is hard to be sure of what is going on, statistics being as misleading as they often are. People who should know, such as the physicians who take care of students and the administrators in schools and universities, feel almost unanimously that there is a definite trend now toward more premarital intercourse in college and high school students. This is a change in regard to the girls rather than the boys. It is simply that the boys are finding their partners on a neigh boring campus instead of in the neighboring town. This seems to be a very real change and has occurred for various reasons. One is that venereal disease is no longer the kind of threat that it used to be despite the fact that we are having a resurgence of venereal disease: young people know that these diseases are easily cured. A saying that used to be prevalent when I was in college was "One night with Venus, ten years with Mercury." This is no longer true, and the expression would not mean anything at all to the average college
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student; this threat or deterrent to sexual activity is simply no longer effective. Also, contraceptive information is more easily available, and students feel that they can be secure about not having babies when they do not want them. Even so, there are a great many unwanted pregnancies usually because students just do not use contraceptives even though they know all about them. Then, too, the church has become less strict and less vocal about absolute morality. Ministers do not stress as strongly as they did the moral prohibition implicit in the Bible. Students who engage in premarital sex do not so often feel that they are sinning against divine authority. Local pastors have become more interested in asking why you do things rather than telling you not to do them. And finally the demand for equality on the part of women has been the factor that has changed presentday sexual morality more than anything else. The double standard by which men were allowed a certain degree of sexual permissiveness without condemnation while women were not, does not hold today because women feel they should be allowed to live by the same standards as men. All of these factors, as well as the relaxing of censorship in regard to stage, movies and literature, have given young people a feeling that adultery and promiscuity are so prevalent and so safe that they must be all right. Whether or not this trend is really an unhealthy one is still an unanswered question. It may be that this kind of liberality and permissiveness will lead to better adjusted sexual partners in marriage, and it may relieve a lot of the guilt surrounding sex. On the other hand, it may not, and it may lead to disruption of the home. If we have more premarital sex relationships, we will probably have more extramarital relationships. When we examine the Scandinavian experience, we find that indeed there have been certain advantages to the permissive attitudes instituted there, but there also have been disadvantages: although the divorce rate has not gone up, the number of extramarital sexual relationships has, and their orphanages are bursting at the seams. Despite the facts that young people do have full contraceptive information before marriage, abortion is easier to arrange and there is no stigma attached to getting married when pregnant, still there are many more children than previously who have no parents willing to care for them and that must be brought up in orphanages. The Scandinavian experience is not conclusive and it is still too early to tell whether the trend in this country is one that should be fostered or one that should be opposed. The recent events in Cambridge have really involved another issueone which I think is very important. That is, what attitude should college administrators take toward this trend? Should they get on the bandwagon and support it, or should they toe the line and uphold the same kind of moral standards that families do in their own home? I think the issue here was well put by a Presbyterian minister who spoke in Denver at the American College Health Absociation's recent national meeting. He pointed out
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that in the old days the basis for morality was fear-fear of veneral disease, fear of an unwanted pregnancy or fear of hell fire, and that this kind of fear has no meaning to the present younger generation. These fears have lost their bite and we, as adults, have to find another basis for morality which will have meaning for our young people. The principles which we have come to believe in through our own experience are what we feel, and rightly so, to be the right ones, but how to communicate them to young people today without using fear is something that I feel we should spend some time thinking about. COMMENT
DR. GALLAGHER: I'd like to comment on a couple of the things that Dr. Blaine said. Certainly as far as school phobia is concerned, I think the primary concern when faced with a youngster who does not want to go to school is to try to find out what the symptom is saying to you-what does this behavior say? In general, these youngsters are saying one of two things: "I cannot stand being in school" or "I cannot leave home without worry." If it is the first, it is certainly then up to us to try to figure out what there is about school that makes it such an unhappy and unsatisfactory place. The reason may be a reality situation, the bathroom kind of one, or teasing by a bully, or something about the teacher. There is one which I have occasionally come across which Dr. Blaine did not mention and that is the homosexual threat from some teacher. At this time these youngsters have difficulty adjusting their feelings and they can feel quite threatened by the oversolicitous, overaffectionate type of teacher. They can think of nothing better to do than to duck out of such a situation. Anyway, I am sure that our job is to try to find out what goes on in school and then move rapidly to get the youngster back to that school situation, having first straightened out whatever is wrong there. It may be as simple as getting the youngster out of the class taught by a threatening person. Suicide bothers all of us. Some of us sweep it under the rug because we think that, if we ask directly about it and the youngster then tells us that he is contemplating suicide, we will be responsible if he goes ahead and does it. Dr. Blaine said it was rare. Well, it may be rare but it is final. It is certainly more common than it used to be. We should be particularly suspicious of those adolescents who say they are going to commit suicide if they happen to be rather impulsive individuals; I am sure that there are very few of us dealing with young people who haven't had the experience of having one of our impulsive young friends commit suicide. The reporting of suicides in this country is probably pretty spotty, particularly among the upper economic social brackets. I would think that
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the reason the incidence appears to be higher at Harvard is not because Harvard does not have the happy atmosphere that one finds, say, in New Haven, but rather because the reporting by the college's Health Service is much more complete than that of the general public. I suspect that these suicides reported at Harvard would not be reported if the youngsters had been at home in, say, Detroit. This may be the reason why the reported incidence is so high in countries such as Denmark. Dr. Blaine was talking mainly about identity problems at the college level, particularly when he referred to drop-outs. I mention this only because, with all the talk today about drop-outs, it is important to remember that at different levels and with different socio-economic backgrounds varying reasons account for them. Comment on the sex business could, I am sure, go on all afternoon. One of the most important things to remember is that, though we don't like these people's behavior, many of them don't like it either. These are the ones who come to us with anxiety states, saying to us "Please, get me out of this." There is the college girl who can't go back into a situation where it is either behave like the others, or else. In my opinion, in regard to sexual ethics what these young people need is an opportunity to talk openly with respected, reasonably informed, but humble adults. They have got to work the problem out with effort; they have got to work it out for themselves. I don't think we can work it out for them. We can help them by such efforts as Larry Frank has made, and I do hope you will read his book, "The Conduct of Sex." Finally, in connection with suicide I should mention the frequent comment that many of these attempts at suicide are nothing more than attention-seeking. This kind of comment is at best thoughtless. These people are seeking attention, they are literally crying for help. For us to brush this off by refusing to give them any more attention is a better index of our own feelings than it is of our understanding of theirs. I don't care how silly their attempts are, they should be interpreted by all of us as a cry for help, and we jolly well better give it. The question of how much we subsequently give is answered similarly to that on whether the internist should take care of a school phobia or not. I think he should by all means take a whirl at it and then, if he seems to be reasonably successful in a relatively short period of time, continue. It is going to take quite a while to dig up a psychiatrist to take over anyway and by that time, with a little bit of luck, the youngster will be back in school. Someone has asked me if I would attempt to define emotional health. I would say first that I can define it negatively which is no way at all, but it will make a start. It is not just freedom from anxiety, guilt or depression. To me, their absence is ominous. Nor should it be equated with the absence of traumatic experiences. Struggle is good: I'm sure you learn to handle
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unhappiness and trauma by having a reasonable amount of them-not an overwhelming dose. Well, that is what emotional health is not. If I were to attempt to evaluate a youngster's emotional health, I would think of his responses in three areas-his attitude toward authority, his progress toward developing his own identity, and his degree of maturity. I will have to expand that a little. Now take authority! If you have a youngster who has nothing good to say about anybody-everyone is literally no good-this is bad. On the other hand, if it is only the harsh, punitive, sareastic sort of individual whom he cannot stand, this, to me, is all right. In short, are there people whom this individual would want to be like? When there are, I think he has at least one good score on the emotional health test. Now for the identity item: if he is confused, or has no selfesteem, then this is certainly bad; but if he knows who he is and he knows where he is going, knows what he wants, is tolerant, decisive, I think that this is all to the good. As for maturity, I think one must evaluate it on the basis of interest in others than himself. Now we can't expect much from the young adolescent along this line, but if he is showing signs of becoming interested in other people and, secondly, is able to give up short-term pleasures for long-range goals, these, too, are good criteria. A combination of those three will perhaps enable you to evaluate the individual's emotional health. Someone asked me to discuss briefly the doctor's role in all of this. What role can he play that will make for better adolescents? Well, to begin with, I think that nothing we can do for adolescents will be half as effective as a few things we can do for younger children. If we can all only do these half-way decently then the problems of adolescents are going to be decimated. This all starts with a group which I don't think is represented here, the obstetrician. He has an opportunity to contribute a great deal to adolescent well-being. If he, in addition to taking the urine and blood pressure, will evaluate the attitude of this expectant mother and the father of the child who is about to be and will try to modify these, if they need to be modified, then I am sure that this child will be off to a good start. You all know that the closest and most therapeutically useful relationship that the expectant mother has is with the obstetrician. To waste this seems to me a little short of criminal. Then, during the early years it is the pediatrician and the general practitioner who have the opportunity to do something about what Dr. Kanner used to refer to as the three A's-acceptance, affection and approval. Do the mother and father-the father unfortunately is too often left out of this-really want this child, do they really show affection toward him, and during the time when he is growing up do they really show approval of him? Can they give this youngster a reasonable amount of praise? Do they build into this youngster some controls? Are
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they afraid to say "no" at age three, four and five? You all know the results of the ridiculously permissive school of thought which we have suffered through for a while. There are a large number of people today who have had no experience in accepting control and when they need to during adolescence they make a mess of it. Finally, and here is a place where internists as well as pediatricians and certainly the general practitioner come in, there is a need to do something for younsters in the really forgotten periods of life, six to twelve. Some people have referred to this as the latency period, a term which seemed to give carte blanche to all doctors and everybody else to ignore these kids. In ignoring them, opportunities are lost for many things which would have made a great difference in their ability to withstand the subsequent stresses of adolescence. "It is the time when you not only see that he has had his shots, take his blood pressure, look at rashes and see if his tonsils ought to come out, but also inquire if he is having any successes, getting any satisfaction, is broadening his horizons at all?" Dr. Erikson referred to this as one of the most important periods of life and talks about the necessity for the development of the capacity for work enjoyment at this time of life. I would just like to quote at this point exactly what he did say about these in-between years of six to twelve: "School days are the time when the child wants to learn how to do things, how to make things with others; he learns to accept instruction and recognition by producing things. He opens the way for the capacity of work enjoyment. The danger in this period is the development of a sense of inadequacy and inferiority in a child who does not receive recognition for his efforts." So certainly the child who is not learning to play the piano, or can't play baseball, or isn't doing well in school, or isn't getting along with people, is lacking the means to develop the self-esteem and self-confidence which would enable him to handle the problems that are coming up. Of course, the final thing that we can do for adolescents is to give some of our time and some of ourselves to these young people, who may very badly need something from us temporarily while they are trying to break away from their parents. QUESTIONS AND ANSWERS QUESTION: What should be done if an adolescent is found to have homosexual urges or behavior?
DR. BLAINE: Homosexual behavior is, for some reason we don't know, felt most strongly during the adolescent years. Many adolescents have homosexual feelings and engage in homosexual practices and are never again
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troubled by the problem. If one has to have homosexual urges or behavior, adolescence is the time to have them. Just knowing this is a great help to many adolescents. We see many students every year who are frightened of homosexuality. They have had an urge or perhaps have acted on an urge and then felt that this has committed them to a homosexual way of life. They seem to think homosexuality is something deep inside them waiting to leap out at any moment and if they give in, even to thinking about it, they are going to fall into the pit. Just knowing that the period they are going through is transient, helps. Many young people have no further difficulty with this kind of thought or impulse, once they are reassured. Unfortunately, this is not true of all. Some do have a problem in this area that can be helped by good psychotherapy, and in these cases I think that consultation with a psychiatrist or psychologist is a good idea because a person who is not trained in this area finds it difficult to make an evaluation and to decide whether and what treatment is indicated. QUESTION: Is there a possibility that the child's total upbringing in his formative years, rather than the factors you enumerated, is related to the presence or absence of promiscuity? DR. BLAINE: Now promiscuity is a little bit different from what I was talking about. Promiscuity is an illness in itself, and it represents a sexual acting out which is neurotic and is not a healthy expression of sexuality. Promiscuity is related, usually, to things that have happened during the formative years; it represents a seeking of gratification, usually in the area of love and emotion through sexual acting out. It is an attempt to gain something in a futile way and that is why it builds on itself. What is being sought is emotional, not physical, love so that there is a constant feeling of frustration and dissatisfaction with each successive sexual act. This is very similar to the problem of obesity in that many children eat because they are hungry for love and they are never satisfied because they are not filling themselves up with the things they really need. In promiscuity, too, there is a searching in a futile, frustrating direction for something that is not there. What I was talking about was really a new pattern of behavior which is not a neurotic one. It is not so much in the formative years that the use of self-control is so important but rather during adolescence when one is trying to conform to the pattern of one's peers-trying to live as they do. These influences are very strong. Now when one is able to do what he feels is right, then his conscience becomes involved-and certainly the formative years are very important in the development of conscience. If the young people who are doing things today that they don't want to do had developed
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strong consciences by having had limits set more definitely in their formative years, their behavior during adolescence would be under better control. QUESTION: Is underachievement more related to school influences or parent-child problems? How do you approach this problem? Will you comment on apathy in adolescence?
DR. BLAINE: I think that underachievement in school usually does represent some kind of parent-child difficulty. The areas in which the basic problem lies are quite complicated and are related to the expectations of the parents. Sometimes the problem has to do with feelings of inferiority and inadequacy that are unconsciously put into the child by the parents; at other times it results from pressure from the parent that brings forth a rebellious reaction from the child as the latter strikes back by not doing well in school-this is an unconscious force. This problem of underachievement makes up the large bulk of the presenting complaints of the parents whom we see in the Adolescents' Unit, and is often difficult to deal with. We usually can resolve it best by conferring with the parents, the child and the school. Usually, if help is possible, it is through some kind of change in the relationship between the parent and the child. Apathy in older adolescents is often part of the process of gaining identity and in younger adolescents it is often due to a feeling of inferiority, fear of competition, a reaction against the threat of being involved in an aggressive situation, and over-reaction in the direction of withdrawal or a fear of losing or of being hurt. Some amount of apathy is normal in adolescence. During the growth spurt it is partly physical, I am sure. Energy is lower then and there seems to be a natural willingness to do nothing and just "hack around," as the saying goes, which is not unhealthy. QUESTION: Could you talk about drug addiction in teen-agers and the prognosis of the heroin add~·ct?
DR. BLAINE : We don't see much heroin addiction in this community, and I know little about its treatment. We do see a number of marijuana and mescaline takers. Use of these substances seems to represent a way of escaping from some stressful situation and a way to experiment with danger. The so-called "brinkmen" are interested in experimenting with drugs and trying to see what they can do in the way of producing hallucinations and attaining a different state of consciousness. To some degree it is danger that intrigues them and for some it is an attempt to make one's self into someone else. We don't worry too much about the marijuana and mescaline takers because these drugs are not addictive. The main problem is that the
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"pushers" of these drugs are the ones who also "push" heroin. We want our patients to avoid becoming involved with any of the addictive narcotics. QUESTION: Do you sometimes use drugs such as the monoamine oxidase inhibitors to increase an adolescent's willingness or ability to communicate his problems to you?
DR. BLAINE: We do occasionally, but rarely to help communication. There is a great difference in the ability of young and older adolescents to communicate. The younger adolescent is often afraid to talk about himself. The older adolescent is usually much more curious about himself and is anxious and willing to talk. In my experience, drugs do not help much in increasing the ability to communicate. QUESTION: If dropping-out so often helps solid1fy the new personality, why do so many drop-outs never return to school?
DR. BLAINE: I think that failure to return to school is truer of the high school drop-out than the college drop-out, as Dr. Gallagher suggested. A large proportion of the drop-outs who do not return are those for whom the kind of education that is offered is not appropriate. We are all aware of the downgrading of trade schools in this country and the need of more of this kind of training for persons who are doers and not thinkers. There is a great stress in this country on university education, but many high school students feel quite out of tune with this type of education. If we could offer them manual training in the trades, many of them would stay in school or return to school. This is even truer of the midwestern colleges where the drop-out rate is as much as 50 per cent. These drop-outs are, for the most, students who come to the state university because it is so easy to get in, but then find that they are not really interested in the kind of education that is being offered. They prefer to go to work. Of course, we are losing a certain number of students who have internal problems that make them unable to study, but I don't think their number is as large as the figures suggest. I think that a very large percentage of the drop-outs who do not return are students upon whom an education of the liberal arts type would probably be wasted. QUESTION: Do you feel that the internist can handle school phobia? Should these patients be referred?
DR. BLAINE: I think the internist can handle most cases of school phobia if he can get the cooperation of the parents and the school in setting
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up the kind of consistent program that I spoke about. Some of the more difficult cases may require some degree of interpretative treatment. As Dr. Gallagher said, it is important to get some part of the unconscious motivation to the surface and then talked about. But more often environmental manipulation, reassurance of the parents and so on can do the trick. QUESTION: Is it harmful for a seventeen or eighteen year old boy to have his genitals exposed by a female physician?
DR. BLAINE: No, I don't think so. The safety of the office and the feeling of respect that a patient has toward a physician should overcome any fears. If the doctor does not feel upset, the patient will not either.
sex.
QUESTION:
Comment on some emotional rather than physical aspects of
DR. BLAINE: Sex is certainly something that reinforces and increases emotional closeness between people if it is used appropriately, but, on the undergraduate level this is rarely applicable. More often, extending emotional closeness into a full sexual relationship has brought more complications rather than less. It hasn't helped or deepened the relationship even though the young people often think it will. QUESTION:
on the old fears?
As a psychiatrist, can you find a basis for morality not based
DR. BLAINE: I think that is the problem we are all working on. I am not sure where the answer will come from, and I am not sure it will come from the psychiatrist. Somehow, I think, when we are stacking up the rights and wrongs of behavior and making moral decisions, that we must take more than our own selves into consideration. This perhaps can be made a basis for morality. There is much thinking that needs to be done here by ministers, philosophers, teachers-and physicians, too. 75 Mt. Auburn Street Cambridge, Massachusetts
SCHOOL PHOBIA
School phobia is seen more often in the early adolescent age group and in younger children. It is characterized by a fear of attending school and is distinctive from truancy in that it is not consciously planned. There may be physical symptoms such as abdominal pain, headache or sore throat which are not recognized by the child as excuses for not going to school. They complicate the issue, of course, particularly for the parent and sometimes also for physicians. It is important to eliminate the possibility of the presence of some physical illness which warrants staying home. Sometimes only emotional symptoms such as panic or fear are present. In our studies of the school phobias we found that about two-thirds of the cases are related to separation from home rather than to something specifically within the school situation. While the patients themselves may often blame school for their nervousness, it seems to be justified in only about onethird of the cases. Usually it is separation from mother which causes the anxiety, and the mother usually adds to this anxiety by expressing fears about the child leaving home and going to school. It seems to be a mutual involvement in which each contributes to the other's anxiety and builds it up. Two cases from our experience in The Adolescents' Unit demonstrate these factors. The first was a fourteen year old girl who had always appeared to enjoy school, had a good standing in the ninth grade and suddenly developed a fear of going to school. She complained that her teacher was too strict and that the other students teased her about being fat. Her refusal to go to school came after a prolonged convalescence from a mild case of bronchitis.
* Consultant in Psychiatry, The Adolescents' Unit, Children's Hospital Medical Center; Assistant in Psychiatry, Harvard Medical School; Chief of Psychiatry, Harvard University Health Services, Boston, Massachusetts
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Respiratory symptoms had been absent for over two weeks. She had been given firm assurance by her doctor that she was completely well and should return to school. When the school bus arrived, she ran indoors in a state of panic saying she was too scared to get aboard. Her mother wrote an excuse for her. Each morning for a week the same scene was enacted. The girl's stories of what had happened at school became more lurid, and this finally led the family to go to the school to make inquiries. On investigation. no basis for the girl's complaints against the teacher or her fellow students was found, and the school authorities advised consultation with a doctor. The family physician was perceptive and knew the home situation well. He realized that the birth of a baby brother shortly before the girl came down with bronchitis had probably made the mother more dependent on the older daughter for help with the baby and also that it had increased the daughter's need to be home so that she might fortify her position with the parents. The doctor suggested that when the father returned home from a business trip, he should take his daughter to school, panic or not, and escort her to the classroom. This firm handling worked and after a week the girl was able to ride in the regular bus once again. In another case the management was made more complicated by various outside influences, events which occurred to interfere with the firm and consistent parental attitude so important in these cases. This was a thirteen year old boy named Harry who for two years had difficulty in going to school. He was finally brought to the Clinic by his mother. He had a history of average school performance, played on the football team, and was very popular. His father was a contractor, hard-working, gruff and given to boasting. His mother was emotionally unstable, cried easily and often complained about being overworked. She occasionally took to her bed for days at a time with a sick headache. The maternal grandmother lived in the home and served as a kindly mediator. There were no other children. Two years before this boy came to the Clinic his father had suffered a heart attack, and it was during the father's hospitalization that Harry first began staying home from school. At first his excuse had been that he had been worried about his father. Soon he began to be nauseated and have stomach cramps each morning. A doctor was finally called and nothing definite could be found; all the symptoms would disappear by lunch·time. The grandmother felt that the boy was making up his illness and began chasing him out of the house. He returned to school because of this and had perfect attendance for six months. Near the end of the school year a sixteen year old cousin of his, who was recovering from a nervous breakdown, moved into the home. Then all the previous symptoms returned and no one could persuade him to leave the house to go to school. By the following fall the visiting cousin had been put into a mental hospital, and Harry started the next semester without difficulty. He had a
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perfect attendance record until February when his mother fell and broke her ankle, and then his morning nausea and stomach cramps returned. This time the school stepped in by sending a truant officer to the home and arranging a series of meetings with the guidance counselor for Harry. During these interviews discussions centered on illness in the family and Harry's need to be at home. He began to understand the feeling of obligation to help out which made him want to stay home and caused his involuntary imitation of the sicknesses suffered by other members of the family. The next year he continued his counseling and was beginning to explore the deeper meaning of his phobia and its relation to his guilt for having unconsciously wished illness on his mother and father; then the counselor became ill with pneumonia. He immediately began to have his early morning symptoms again. Pressure on him to go to school despite his symptoms resulted in intense feelings of fear and panic, and at that time he was brought to our Clinic by his mother. Treatment here was entirely supportive: encouragement rather than explanation or interpretation made up the content of the interviews. No attempt was made to probe into the meaning of the symptoms. The Unit's doctor took a firm stand about returning to school, insisting that Harry go the next morning without fail. The physician asked him to telephone him when he got to school and several times during the day. For the first two weeks Harry merely went to the principal's outer office and sat there reading magazines. Then he began going to one class and gradually to more until after a month had passed he was in full attendance. He was no longer in need of interviews. Four years later he graduated from high school having experienced only one brief return of symptoms which required a month of further treatment at the time of his father's death the year before. These cases illustrate the kinds of background from which these phobias come, as well as the type of treatment which is most effective. A study of this illness done at the Judge Baker Guidance Center showed that starting treatment early is extremely important. Almost all cases treated there during the first three months were cured without remission. For those in which treatment was started after six months, the percentage of cure was much lower. The most important element in the treatment is to get the child back to school as soon as possible and insist that he stay. Occasionally there are difficulties which are connected with school, such as a teacher who may present a particularly threatening image to the student, one who perhaps has the same attitudes found at home. He may produce an unreasonable amount of anxiety and fear in the student. Sometimes a teacher who looks like a parent who is overly punitive may arouse enough anxiety in a child to cause him to fear to go to school. Occasionally a child who is much bigger or much smaller than his contemporaries feels self-conscious and so uncomfortable in a classroom that he develops school
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phobia. Sometimes, also, it is caused by the nature of the school work itself -either it is not sufficiently challenging or perhaps too challenging. A student may feel overly pressed and inferior or in the other instance not sufficiently interested. Being bored, and as a result getting into trouble for acting up in class, may lead to a fear of going to school. Sometimes a single incident in school such as in a smaller child not being able to make the bathroom on one occasion may start a feeling of fear and threat about being in the classroom, which may be reactivated when the child is older and in a classroom with a threatening teacher. These conditions may be altered by changing the student into another school or a different classroom or by giving reassurance, but in these cases, as well as in the separation anxiety cases, the most important maneuver is to get the child back and help him to stay there by whatever means. DEPRESSION
Depression is the most alarming emotional symptom that we see in adolescents and adults. It is a worrisome symptom for doctors, and one over which they lose more sleep than any other single symptom. When we are dealing with the adolescent, we can feel reassured to some degree because suicides among adolescents are quite rare. Table 1 shows the number of suicides per 100,000 population in the United States in various age groups. The overall average for men is 10.6 per 100,000, for women 2.9, and the proportion remains much the same all the way up the scale until the age of seventy-five. Men succeed in suicide more frequently than women though suicide attempts among women are from six to ten times as frequent as among men. Whether this speaks for better efficiency on the part of men or for stronger intent is not known. The 10-14 age groups are far below the average of all ages, and the 15-19 category is also well below the average. At the college age we find the rate a little higher. In the young adolescent or young child suicide is usually connected with an act of compulsive retaliation and not, as a rule, with depression. Table 1.
Suicides b)1 Age Groups in the United States per 100,000 Population AGE
MEN
WOMEN
1-74 10-14 15-19 20-24 25-34 75 and over
10.6 .7 3.6 8.6 12.4 60.1
2.9 .2 1.1 2.2 3.9 8.1
(Adapted from Dublin, Louis I.: Suicide, New York, Ronald Press, 1963)
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Here in the Boston area a short time ago a ten year old child who was refused permission to go out on Halloween went upstairs and hung himself in the closet. This sudden sporadic striking out is hard to predict. Table 2 shows the much higher suicide rate in people who are widowed and divorced as opposed to the overall average. The highest figures of all are for divorced men over 75. These figures indicate that loneliness is probably the most important motivation for suicide. Within the adolescent age group the suicide method used is shown in Table 3; girls show a much higher use of poison and boys of firearms. The poison is usually barbiturates. In the college population the reported suicide rate is considerably higher than it is in the general population. Comparing figures of colleges around the country we find that the Harvard rate of two and one-half suicides a year (about twenty per 100,000), as opposed to the national figure of about one-half that for that age, is typical for United States colleges generally. Why the college student should be more susceptible is not known, but probably his stresses are greater, and his need to excel and to fulfill family requirements makes his depression deeper and more dangerous. Despite the fact that suicide is rare, depression is still a symptom that we must be very careful to evaluate cautiously and completely. Table 2.
A Comparison of Suicide Rates in Widowed or Divorced Persons with the Overall Average for Men and Women
AGE
MEN
1-74
WOMEN
10.6
20-24 25-34 75+
Table 3.
2.9
WIDOWED
DIVORCED
WIDOWED
DIVORCED
78.0 75.7 76.2
30.7 100.4 139.1
7.7 13.9 8.7
11.6 17.4 16.0
Methods of Suicide in rounger Age Group (Ages 70 to 24) MALES
Firearms ................. 52.8 Hanging ................. 14.5 Poison ................... 15.] Gas. .. . . . . . . . . . . . . . . . . .. 9.7 Drowning................ 2.9 Jumping.. . . . . . . . . . . . . . .. 2.0
FEMALES
22.6 3.4 53.0 12.0 4.0 2.4
(Tables 2 and 3 adapted from Dublin, Louis 1.: Suicide, New York, Roland Press, 1963)
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In dealing with any patient who is depressed, certain signs are more ominous than others. One is an expression of extreme self-depreciation such as irrational statements about being an evil person, having something basically bad inside which is irrevocable, or of feeling a burden to parents or society. Self-derogatory statements such as these usually mean that the depression is a deep one and that special measures such as referral or hospitalization should be taken to make sure that suicide does not occur. Another ominous sign is secretiveness. For patients with whom the doctor does not feel in full communication, it would be well to seek consultation or perhaps to arrange for psychological tests to gain a better understanding of what is really going on. When patients say there is no way out, that every way they think of moving to get out of their dilemma is blocked, then, too, one should be especially alert. Many doctors ask whether they should bring up suicide spontaneously when talking with a patient who is depressed. Some fear that they might put the idea into the patient's head by mentioning it. On the contrary, bringing up the possibility is almost always a helpful maneuver. One can often test the depth of depression by bringing up suicide, perhaps not using the word itself but by asking the patient if there are times when he feels that life is not worth living, or is suggesting that there may be moments when he feels that he would be better off dead. Questions like this give the patient a chance to tell you that he may be seriously contemplating taking his life. Bringing up these topics does not encourage a patient to act on them. Often we are reluctant to speak about the possibility of suicide because we do not want to know the answer. If the patient is this badly off and in this much need of attention, we may avoid raising the issue to save ourselves worry and concern. Sometimes patients talk of suicide as a philosophical concept and appear to toy with it almost jokingly. This is truer of the adolescent than of older patients. He often thinks about it in abstract terms, and we do not have to worry too much about this kind of philosophizing. Particularly it appears in the broader context of ruminating about the meaning of life. Most adolescents who commit suicide are schizophrenic and are not depressed. Out of thirty-four suicides that occurred at Harvard over a fifteen-year period, only two of the victims had consulted the college's Mental Health Service before committing suicide and none of them had been clinically depressed at the time of their clinic visit. They may have been somewhat discouraged, but most were found in retrospect to have been psychotic or at least seriously disturbed at the time of the act. We do have to worry about suicide in the student who is schizophrenic. They really fall into the category of secretiveness described above, for these students are unpredictable. The psychotic nature of their thinking makes it impossible for us to know what is going on in their minds. Often hospitalization is a
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necessary protection against their acting on an impulse or in response to a hallucinating voice, destroying themselves suddenly and without warning. IDENTITY PROBLEMS
Identity formation is the main task of adolescence. The word "identity" has been bandied about a good deal by all kinds of people, but I think Erikson in Childhood and Society has defined it most clearly. He describes it as "a feeling of being at home in one's body and a sense of knowing where one is going." He also says that it is something that may occur suddenly and that the individual may be quite surprised to make its acquaintance. It is the achievement of a sense of self, and it requires an incorporation into the self of certain identifications with valued people in the environment. It usually occurs during college age (between eighteen and twentytwo) and is an identifiable and essential step in the direction of achieving maturity and adulthood. There are certain factors which interfere with the formation of identity and the achievement of a sense of self. One of these is the death of an important identification figure during the early teens, or a disillusionment in such a person. The classic description of this is in Arthur Miller's play, Death of a Salesman, where the son, Biff, who has become disillusioned with his father, says to his mother, "I just can't take hold, Ma, I just can't take hold of some way of life." This is the feeling of being lost and drifting about with a sense of purposelessness which Erikson has called "role diffusion." Instead of having a feeling of a definite role in life, an individual feels diffused and spread out over many areas and cannot become committed to any occupation or ideal. Another influence that interferes most commonly with the formation of identity is what we have come to call "intrusiveness" on the part of parents. This is more frequent in mothers. It is their constant questioning and depreciating of the child and their refusal to let him have any privacy. These parents demand that they be a continual part of every phase of their child's life. This has the same effect as shaking up a solution that is trying to crystallize with the result that it can never set and gel or gain solidity. Often for the healthy development of identity a "psychosocial moratorium". is necessary. This is a phase which is most distressing to parents. It may take the form of a period of apathy when the adolescent seems particularly gutless and is only able to sit around doing nothing. This characterizes what has now become known as the "drop-out," the student who leaves school for a temporary period during this period of adjustment. This seems to be a necessary step for a few students who can only in this way throw off parental standards which feel superimposed. It is a period
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when the old values have been cast off but new ones have not yet made themselves apparent. This moment of moral nakedness can bring with it a fear that one is just a "nebbish"-a nobody who has no real substance. Some students who are in this identity crisis are not apathetic but instead are anxious and disturbed because of concern about this nothingness within. The process of dropping out often makes the difference because the student is able to get the feeling afterwards that he has made a real change from the established pattern that had been set down for him since early in life. When he comes back he feels that he is now going to college for his own reasons. This improves his ability to perform. The other great advantage of dropping out of college is the feeling of accomplishment which may result from doing a job, even if it is a very simple one, and doing it rightwell enough in fact to receive hard cash in return. This gives him a feeling of confidence which he can carry back into college work. Dropping out is generally a healthy experience, though, of course, it is not a necessary one for many students. We wish that we knew why some have to go through this apathy phase while others are able to shift rather rapidly from a feeling of dependency to one of independence, finding an identity successfully without this timeconsuming moratorium. The most extreme example of apathy is the beatnik who goes through a long and extreme period of rebelliousness during which he acts as though he were against everything and for nothing. However, even being a beatnik seems to be a self-limited disease and almost all come back and become surprisingly conformist in their behavior. The last beatnik I followed is now in the Harvard Business School. One should never give up hope for them. THE SEX PROBLEM
When it comes to the problem of sex we have less that is definite. We, as adults, and even as doctors, are confused about the rules here. It is an area in which we have no completely satisfactory answer for the adolescent. His strongest sex urges occur at this time. Boys from fourteen to eighteen are in the age in which the sexual desire is strongest; for girls it is from 15 to 20. Yet we in our present-day society have provided no outle~ for this age group which is both legal and moral. We can give the adolescent no answer completely satisfactory to the problem of what he should do with his sexual impulses at this stage of his development. The principle of continence and chastity for all until marriage is the ideal which has been presented to him since the days of the Garden of Eden, but it is one which has never been lived up to and one which we
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know is incompatible with his basic nature. It is no wonder that we are ill at ease when the adolescent comes to us with questions about his behavior and standards in this area. However, transferring our confusion to him does not help. He needs guidelines and principles to go by even if we can't justify everyone of them by logic. In general, I think that the factual information about sex is better transmitted to young people of adolescent age by reading material and conversation with family doctors than by parents. Most parents find that talking about sex with their children is extremely embarrassing. They usually feel self-conscious when they do so. This does not help the young person feel comfortable himself about sex, and it often transmits guilt and shame about sex. However, the parents can certainly contribute a great deal by example. This, I think, is very important. What the child sees and feels about the physical relationship between the parents themselves is translated into his own attitudes toward sex. What one would hope is that the adolescent would develop a respect for sex with the realization that it is a powerful force but at the same time is respectable and not something to be afraid or ashamed of. How to be specific about transmitting this is very difficult. It is like trying to teach parents attitudes about toilet training. Doctors tend to say, "Well, you know, just don't make him feel guilty about it." But how do you actually effect the feeling that this function is not dirty. It is hard to be specific in our instructions. I think, in general, parents can build healthy attitudes in their children if they are aware of the fact that they are trying to transmit an attitude and if they do not get bogged down by talking about the facts of sex in detail. There has been considerable controversy lately about the change in sexual morality amongst college age adolescents. It is hard to be sure of what is going on, statistics being as misleading as they often are. People who should know, such as the physicians who take care of students and the administrators in schools and universities, feel almost unanimously that there is a definite trend now toward more premarital intercourse in college and high school students. This is a change in regard to the girls rather than the boys. It is simply that the boys are finding their partners on a neigh boring campus instead of in the neighboring town. This seems to be a very real change and has occurred for various reasons. One is that venereal disease is no longer the kind of threat that it used to be despite the fact that we are having a resurgence of venereal disease: young people know that these diseases are easily cured. A saying that used to be prevalent when I was in college was "One night with Venus, ten years with Mercury." This is no longer true, and the expression would not mean anything at all to the average college
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student; this threat or deterrent to sexual activity is simply no longer effective. Also, contraceptive information is more easily available, and students feel that they can be secure about not having babies when they do not want them. Even so, there are a great many unwanted pregnancies usually because students just do not use contraceptives even though they know all about them. Then, too, the church has become less strict and less vocal about absolute morality. Ministers do not stress as strongly as they did the moral prohibition implicit in the Bible. Students who engage in premarital sex do not so often feel that they are sinning against divine authority. Local pastors have become more interested in asking why you do things rather than telling you not to do them. And finally the demand for equality on the part of women has been the factor that has changed presentday sexual morality more than anything else. The double standard by which men were allowed a certain degree of sexual permissiveness without condemnation while women were not, does not hold today because women feel they should be allowed to live by the same standards as men. All of these factors, as well as the relaxing of censorship in regard to stage, movies and literature, have given young people a feeling that adultery and promiscuity are so prevalent and so safe that they must be all right. Whether or not this trend is really an unhealthy one is still an unanswered question. It may be that this kind of liberality and permissiveness will lead to better adjusted sexual partners in marriage, and it may relieve a lot of the guilt surrounding sex. On the other hand, it may not, and it may lead to disruption of the home. If we have more premarital sex relationships, we will probably have more extramarital relationships. When we examine the Scandinavian experience, we find that indeed there have been certain advantages to the permissive attitudes instituted there, but there also have been disadvantages: although the divorce rate has not gone up, the number of extramarital sexual relationships has, and their orphanages are bursting at the seams. Despite the facts that young people do have full contraceptive information before marriage, abortion is easier to arrange and there is no stigma attached to getting married when pregnant, still there are many more children than previously who have no parents willing to care for them and that must be brought up in orphanages. The Scandinavian experience is not conclusive and it is still too early to tell whether the trend in this country is one that should be fostered or one that should be opposed. The recent events in Cambridge have really involved another issueone which I think is very important. That is, what attitude should college administrators take toward this trend? Should they get on the bandwagon and support it, or should they toe the line and uphold the same kind of moral standards that families do in their own home? I think the issue here was well put by a Presbyterian minister who spoke in Denver at the American College Health Absociation's recent national meeting. He pointed out
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that in the old days the basis for morality was fear-fear of veneral disease, fear of an unwanted pregnancy or fear of hell fire, and that this kind of fear has no meaning to the present younger generation. These fears have lost their bite and we, as adults, have to find another basis for morality which will have meaning for our young people. The principles which we have come to believe in through our own experience are what we feel, and rightly so, to be the right ones, but how to communicate them to young people today without using fear is something that I feel we should spend some time thinking about. COMMENT
DR. GALLAGHER: I'd like to comment on a couple of the things that Dr. Blaine said. Certainly as far as school phobia is concerned, I think the primary concern when faced with a youngster who does not want to go to school is to try to find out what the symptom is saying to you-what does this behavior say? In general, these youngsters are saying one of two things: "I cannot stand being in school" or "I cannot leave home without worry." If it is the first, it is certainly then up to us to try to figure out what there is about school that makes it such an unhappy and unsatisfactory place. The reason may be a reality situation, the bathroom kind of one, or teasing by a bully, or something about the teacher. There is one which I have occasionally come across which Dr. Blaine did not mention and that is the homosexual threat from some teacher. At this time these youngsters have difficulty adjusting their feelings and they can feel quite threatened by the oversolicitous, overaffectionate type of teacher. They can think of nothing better to do than to duck out of such a situation. Anyway, I am sure that our job is to try to find out what goes on in school and then move rapidly to get the youngster back to that school situation, having first straightened out whatever is wrong there. It may be as simple as getting the youngster out of the class taught by a threatening person. Suicide bothers all of us. Some of us sweep it under the rug because we think that, if we ask directly about it and the youngster then tells us that he is contemplating suicide, we will be responsible if he goes ahead and does it. Dr. Blaine said it was rare. Well, it may be rare but it is final. It is certainly more common than it used to be. We should be particularly suspicious of those adolescents who say they are going to commit suicide if they happen to be rather impulsive individuals; I am sure that there are very few of us dealing with young people who haven't had the experience of having one of our impulsive young friends commit suicide. The reporting of suicides in this country is probably pretty spotty, particularly among the upper economic social brackets. I would think that
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the reason the incidence appears to be higher at Harvard is not because Harvard does not have the happy atmosphere that one finds, say, in New Haven, but rather because the reporting by the college's Health Service is much more complete than that of the general public. I suspect that these suicides reported at Harvard would not be reported if the youngsters had been at home in, say, Detroit. This may be the reason why the reported incidence is so high in countries such as Denmark. Dr. Blaine was talking mainly about identity problems at the college level, particularly when he referred to drop-outs. I mention this only because, with all the talk today about drop-outs, it is important to remember that at different levels and with different socio-economic backgrounds varying reasons account for them. Comment on the sex business could, I am sure, go on all afternoon. One of the most important things to remember is that, though we don't like these people's behavior, many of them don't like it either. These are the ones who come to us with anxiety states, saying to us "Please, get me out of this." There is the college girl who can't go back into a situation where it is either behave like the others, or else. In my opinion, in regard to sexual ethics what these young people need is an opportunity to talk openly with respected, reasonably informed, but humble adults. They have got to work the problem out with effort; they have got to work it out for themselves. I don't think we can work it out for them. We can help them by such efforts as Larry Frank has made, and I do hope you will read his book, "The Conduct of Sex." Finally, in connection with suicide I should mention the frequent comment that many of these attempts at suicide are nothing more than attention-seeking. This kind of comment is at best thoughtless. These people are seeking attention, they are literally crying for help. For us to brush this off by refusing to give them any more attention is a better index of our own feelings than it is of our understanding of theirs. I don't care how silly their attempts are, they should be interpreted by all of us as a cry for help, and we jolly well better give it. The question of how much we subsequently give is answered similarly to that on whether the internist should take care of a school phobia or not. I think he should by all means take a whirl at it and then, if he seems to be reasonably successful in a relatively short period of time, continue. It is going to take quite a while to dig up a psychiatrist to take over anyway and by that time, with a little bit of luck, the youngster will be back in school. Someone has asked me if I would attempt to define emotional health. I would say first that I can define it negatively which is no way at all, but it will make a start. It is not just freedom from anxiety, guilt or depression. To me, their absence is ominous. Nor should it be equated with the absence of traumatic experiences. Struggle is good: I'm sure you learn to handle
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unhappiness and trauma by having a reasonable amount of them-not an overwhelming dose. Well, that is what emotional health is not. If I were to attempt to evaluate a youngster's emotional health, I would think of his responses in three areas-his attitude toward authority, his progress toward developing his own identity, and his degree of maturity. I will have to expand that a little. Now take authority! If you have a youngster who has nothing good to say about anybody-everyone is literally no good-this is bad. On the other hand, if it is only the harsh, punitive, sareastic sort of individual whom he cannot stand, this, to me, is all right. In short, are there people whom this individual would want to be like? When there are, I think he has at least one good score on the emotional health test. Now for the identity item: if he is confused, or has no selfesteem, then this is certainly bad; but if he knows who he is and he knows where he is going, knows what he wants, is tolerant, decisive, I think that this is all to the good. As for maturity, I think one must evaluate it on the basis of interest in others than himself. Now we can't expect much from the young adolescent along this line, but if he is showing signs of becoming interested in other people and, secondly, is able to give up short-term pleasures for long-range goals, these, too, are good criteria. A combination of those three will perhaps enable you to evaluate the individual's emotional health. Someone asked me to discuss briefly the doctor's role in all of this. What role can he play that will make for better adolescents? Well, to begin with, I think that nothing we can do for adolescents will be half as effective as a few things we can do for younger children. If we can all only do these half-way decently then the problems of adolescents are going to be decimated. This all starts with a group which I don't think is represented here, the obstetrician. He has an opportunity to contribute a great deal to adolescent well-being. If he, in addition to taking the urine and blood pressure, will evaluate the attitude of this expectant mother and the father of the child who is about to be and will try to modify these, if they need to be modified, then I am sure that this child will be off to a good start. You all know that the closest and most therapeutically useful relationship that the expectant mother has is with the obstetrician. To waste this seems to me a little short of criminal. Then, during the early years it is the pediatrician and the general practitioner who have the opportunity to do something about what Dr. Kanner used to refer to as the three A's-acceptance, affection and approval. Do the mother and father-the father unfortunately is too often left out of this-really want this child, do they really show affection toward him, and during the time when he is growing up do they really show approval of him? Can they give this youngster a reasonable amount of praise? Do they build into this youngster some controls? Are
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they afraid to say "no" at age three, four and five? You all know the results of the ridiculously permissive school of thought which we have suffered through for a while. There are a large number of people today who have had no experience in accepting control and when they need to during adolescence they make a mess of it. Finally, and here is a place where internists as well as pediatricians and certainly the general practitioner come in, there is a need to do something for younsters in the really forgotten periods of life, six to twelve. Some people have referred to this as the latency period, a term which seemed to give carte blanche to all doctors and everybody else to ignore these kids. In ignoring them, opportunities are lost for many things which would have made a great difference in their ability to withstand the subsequent stresses of adolescence. "It is the time when you not only see that he has had his shots, take his blood pressure, look at rashes and see if his tonsils ought to come out, but also inquire if he is having any successes, getting any satisfaction, is broadening his horizons at all?" Dr. Erikson referred to this as one of the most important periods of life and talks about the necessity for the development of the capacity for work enjoyment at this time of life. I would just like to quote at this point exactly what he did say about these in-between years of six to twelve: "School days are the time when the child wants to learn how to do things, how to make things with others; he learns to accept instruction and recognition by producing things. He opens the way for the capacity of work enjoyment. The danger in this period is the development of a sense of inadequacy and inferiority in a child who does not receive recognition for his efforts." So certainly the child who is not learning to play the piano, or can't play baseball, or isn't doing well in school, or isn't getting along with people, is lacking the means to develop the self-esteem and self-confidence which would enable him to handle the problems that are coming up. Of course, the final thing that we can do for adolescents is to give some of our time and some of ourselves to these young people, who may very badly need something from us temporarily while they are trying to break away from their parents. QUESTIONS AND ANSWERS QUESTION: What should be done if an adolescent is found to have homosexual urges or behavior?
DR. BLAINE: Homosexual behavior is, for some reason we don't know, felt most strongly during the adolescent years. Many adolescents have homosexual feelings and engage in homosexual practices and are never again
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troubled by the problem. If one has to have homosexual urges or behavior, adolescence is the time to have them. Just knowing this is a great help to many adolescents. We see many students every year who are frightened of homosexuality. They have had an urge or perhaps have acted on an urge and then felt that this has committed them to a homosexual way of life. They seem to think homosexuality is something deep inside them waiting to leap out at any moment and if they give in, even to thinking about it, they are going to fall into the pit. Just knowing that the period they are going through is transient, helps. Many young people have no further difficulty with this kind of thought or impulse, once they are reassured. Unfortunately, this is not true of all. Some do have a problem in this area that can be helped by good psychotherapy, and in these cases I think that consultation with a psychiatrist or psychologist is a good idea because a person who is not trained in this area finds it difficult to make an evaluation and to decide whether and what treatment is indicated. QUESTION: Is there a possibility that the child's total upbringing in his formative years, rather than the factors you enumerated, is related to the presence or absence of promiscuity? DR. BLAINE: Now promiscuity is a little bit different from what I was talking about. Promiscuity is an illness in itself, and it represents a sexual acting out which is neurotic and is not a healthy expression of sexuality. Promiscuity is related, usually, to things that have happened during the formative years; it represents a seeking of gratification, usually in the area of love and emotion through sexual acting out. It is an attempt to gain something in a futile way and that is why it builds on itself. What is being sought is emotional, not physical, love so that there is a constant feeling of frustration and dissatisfaction with each successive sexual act. This is very similar to the problem of obesity in that many children eat because they are hungry for love and they are never satisfied because they are not filling themselves up with the things they really need. In promiscuity, too, there is a searching in a futile, frustrating direction for something that is not there. What I was talking about was really a new pattern of behavior which is not a neurotic one. It is not so much in the formative years that the use of self-control is so important but rather during adolescence when one is trying to conform to the pattern of one's peers-trying to live as they do. These influences are very strong. Now when one is able to do what he feels is right, then his conscience becomes involved-and certainly the formative years are very important in the development of conscience. If the young people who are doing things today that they don't want to do had developed
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strong consciences by having had limits set more definitely in their formative years, their behavior during adolescence would be under better control. QUESTION: Is underachievement more related to school influences or parent-child problems? How do you approach this problem? Will you comment on apathy in adolescence?
DR. BLAINE: I think that underachievement in school usually does represent some kind of parent-child difficulty. The areas in which the basic problem lies are quite complicated and are related to the expectations of the parents. Sometimes the problem has to do with feelings of inferiority and inadequacy that are unconsciously put into the child by the parents; at other times it results from pressure from the parent that brings forth a rebellious reaction from the child as the latter strikes back by not doing well in school-this is an unconscious force. This problem of underachievement makes up the large bulk of the presenting complaints of the parents whom we see in the Adolescents' Unit, and is often difficult to deal with. We usually can resolve it best by conferring with the parents, the child and the school. Usually, if help is possible, it is through some kind of change in the relationship between the parent and the child. Apathy in older adolescents is often part of the process of gaining identity and in younger adolescents it is often due to a feeling of inferiority, fear of competition, a reaction against the threat of being involved in an aggressive situation, and over-reaction in the direction of withdrawal or a fear of losing or of being hurt. Some amount of apathy is normal in adolescence. During the growth spurt it is partly physical, I am sure. Energy is lower then and there seems to be a natural willingness to do nothing and just "hack around," as the saying goes, which is not unhealthy. QUESTION: Could you talk about drug addiction in teen-agers and the prognosis of the heroin add~·ct?
DR. BLAINE : We don't see much heroin addiction in this community, and I know little about its treatment. We do see a number of marijuana and mescaline takers. Use of these substances seems to represent a way of escaping from some stressful situation and a way to experiment with danger. The so-called "brinkmen" are interested in experimenting with drugs and trying to see what they can do in the way of producing hallucinations and attaining a different state of consciousness. To some degree it is danger that intrigues them and for some it is an attempt to make one's self into someone else. We don't worry too much about the marijuana and mescaline takers because these drugs are not addictive. The main problem is that the
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"pushers" of these drugs are the ones who also "push" heroin. We want our patients to avoid becoming involved with any of the addictive narcotics. QUESTION: Do you sometimes use drugs such as the monoamine oxidase inhibitors to increase an adolescent's willingness or ability to communicate his problems to you?
DR. BLAINE: We do occasionally, but rarely to help communication. There is a great difference in the ability of young and older adolescents to communicate. The younger adolescent is often afraid to talk about himself. The older adolescent is usually much more curious about himself and is anxious and willing to talk. In my experience, drugs do not help much in increasing the ability to communicate. QUESTION: If dropping-out so often helps solid1fy the new personality, why do so many drop-outs never return to school?
DR. BLAINE: I think that failure to return to school is truer of the high school drop-out than the college drop-out, as Dr. Gallagher suggested. A large proportion of the drop-outs who do not return are those for whom the kind of education that is offered is not appropriate. We are all aware of the downgrading of trade schools in this country and the need of more of this kind of training for persons who are doers and not thinkers. There is a great stress in this country on university education, but many high school students feel quite out of tune with this type of education. If we could offer them manual training in the trades, many of them would stay in school or return to school. This is even truer of the midwestern colleges where the drop-out rate is as much as 50 per cent. These drop-outs are, for the most, students who come to the state university because it is so easy to get in, but then find that they are not really interested in the kind of education that is being offered. They prefer to go to work. Of course, we are losing a certain number of students who have internal problems that make them unable to study, but I don't think their number is as large as the figures suggest. I think that a very large percentage of the drop-outs who do not return are students upon whom an education of the liberal arts type would probably be wasted. QUESTION: Do you feel that the internist can handle school phobia? Should these patients be referred?
DR. BLAINE: I think the internist can handle most cases of school phobia if he can get the cooperation of the parents and the school in setting
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up the kind of consistent program that I spoke about. Some of the more difficult cases may require some degree of interpretative treatment. As Dr. Gallagher said, it is important to get some part of the unconscious motivation to the surface and then talked about. But more often environmental manipulation, reassurance of the parents and so on can do the trick. QUESTION: Is it harmful for a seventeen or eighteen year old boy to have his genitals exposed by a female physician?
DR. BLAINE: No, I don't think so. The safety of the office and the feeling of respect that a patient has toward a physician should overcome any fears. If the doctor does not feel upset, the patient will not either.
sex.
QUESTION:
Comment on some emotional rather than physical aspects of
DR. BLAINE: Sex is certainly something that reinforces and increases emotional closeness between people if it is used appropriately, but, on the undergraduate level this is rarely applicable. More often, extending emotional closeness into a full sexual relationship has brought more complications rather than less. It hasn't helped or deepened the relationship even though the young people often think it will. QUESTION:
on the old fears?
As a psychiatrist, can you find a basis for morality not based
DR. BLAINE: I think that is the problem we are all working on. I am not sure where the answer will come from, and I am not sure it will come from the psychiatrist. Somehow, I think, when we are stacking up the rights and wrongs of behavior and making moral decisions, that we must take more than our own selves into consideration. This perhaps can be made a basis for morality. There is much thinking that needs to be done here by ministers, philosophers, teachers-and physicians, too. 75 Mt. Auburn Street Cambridge, Massachusetts