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The Adolescent's Office Visit
The Adolescent's Office Visit J. ROSWELL GALLAGHER, M.D., F.A.C.P.*
OUR MUDDLED ASSUMPTIONS ABOUT ADOLESCENTS
I would like first to discuss some of the assumptions regarding adolescents which we should bring to bear on any adolescent who comes to us as a patient. Out of our past experiences in life and with patients, each of us develops a set of assumptions, a frame of reference, ways of thinking of, managing and understanding those people with whom we come in contact. These assumptions we have found appropriate in evaluating and treating various sorts of people and patients. When we choose the right set of assumptions, then the signals from this person come into us loud and clear and we tend to act in ways and give the sort of advice that meets that particular individual's needs. All this is very well illustrated by the line from the play, The Country Wife. A distraught woman walking around the stage, looking in vain for her again mislaid spectacles, finally turns and says, "Where would I be if I were a pair of glasses?" Obviously, if, as it were, we can think like a pair of glasses, our chances of coming up with the solution in any given situation will be very much better. Unfortunately, for many of us, the set of assumptions which we bring to bear when the patient is an adolescent is nowhere near as clear as when our patient is a little tot, an adult or an elderly citizen. The reasons for this are many, and it may not be unprofitable to review a few of them. One is that there are as yet very few clinics or medical schools in which the teaching of physicians in the care of this age group is as yet part of the curriculum: pediatrics and geriatrics, yes; but the medical care of adolescents, no. Furthermore, there are very few postgraduate courses and very few sessions such as this one; very few fellowships; comparatively few courses for medical students and house officers; and very little research. Happily, all that is rapidly changing. "Chief, The Adolescents' Unit, Children's Hospital Medical Center; Lecturer on Pediatrics, Harvard Medical School, Boston, Massachusetts.
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Another reason for the ineffective approach which some tend to have toward the adolescent is that the word adolescent itself tends to carry connotations which muddy our thinking. When we hear the word adolescent, we immediately think of problems, of delinquency, of rebellion, of disrespect, of lack of cooperation, of fast cars, late hours and, if it's a boy, we think of girls. I don't know why we pick on the male so much! If we are unusually forgiving, the best that many say is that "boys will be boys." We even ignore the rest of that very nice quotation which many now don't even know because it has so frequently been left unfinished. It really ends " ... and even that wouldn't matter if we could prevent girls from being girls. "1 The point is that we do have these sorts of feelings and we make these assumptions when we are faced with an adolescent. We tend to think of them today, just as Shakespeare did: "I wish there were no age between ten and three and twenty, or that youth would sleep out the rest. For there is nothing in between but getting wenches with child, wronging the ancientry, stealing and fighting."2 There are only a few adults who tend, instead of this, to tune in on the wavelength which was Mr. Shaw's when he said that youth is such a wonderful time that it is a shame to waste it on young people. Still another reason for our muddied thinking is that our reaction to these young people is apt to be adversely affected by our own pasts, by those conflicts of ours which we did not satisfactorily resolve during our own adolescence. So here again we have the same danger which faces all doctors at all times, regardless of the age of his patient: that his own feelings may strongly influence the manner in which he talks to and manages his patient and the treatment and advice he gives. For these and other reasons, our assumptions about adolescents are not as clear and desirable as those we bring to patients who are in other age groups. They are not as clear about what these young patients are like, physiologically and psychologically, or about what their real needs and sources of worry are. In short, we are not really sure about the many ways in which they differ from younger people and from older people, or of what they really need from us. Before we get on to discuss the sort of assumptions which I believe we can and should make about these young people when they come to us as patients, I would like to digress for a moment, and to temper what many of you may feel is my unwarranted crusade for this age group. First, I would like to emphasize that I hope and pray that our efforts here, and that those efforts of people elsewhere who have shown a special interest in this age group, will not spawn another specialty. I cannot imagine anything that would be more disastrous, both to these young people and to Medicine than to isolate the care of these young people from that of little tots, adults and
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the elderly. Should that happen we will miss many extraordinary opportunities for progress. This age group is rife with aspects of human development, health and disease which must not be isolated from these young people's pasts or from their futures. This is the major reason why our Unit here has internists, pediatricians and general practitioners on its staff and in training. We have deliberately chosen those whose backgrounds have been in pediatrics, internal medicine or rotating hospital training when recruiting our staff and when we go about selecting from among those young doctors who wish to come to us for training and experience with this age group. VALID ASSUMPTIONS, A SET OF MIND
All that follows is based on the beliefs that we treat people, not diseases, and that what we know about them is of no less importance than what we know about the partiCUlar disease or organ which brings the patient to us. It also assumes that adolescents are different from little children and adults. If this assumption is not made, and were it not a valid one, the major reason for giving members of this age group special attention would not exist. How do adolescents differ? What are the matters about them that we need to keep in mind? What are the assumptions that we need to make when we are faced with them? The first is that during this period of life people grow and change more than they do at any other time except during the first year. They change rapidly and extensively in height, in weight, in muscle mass, and in sexual maturity. The estrogens begin to rise sharply in girls at ten or eleven years of age, and by the time they are twelve or fourteen reach some twenty times their childhood levels. In boys estrogens rise, too, but it is usually a year or two later than in girls, and the rise is only about four-fold. Similarly the excretion of 17-ketosteroids increases: it remains around 2 mg. per day during childhood, and then at about ten years of age begins to rise to up to 8 to 15 mg. in boys, and from 4 to 9 mg. in girls, by age eighteen. The gonadotropins also rise: from a level of about one rat unit per twenty-four hours until about age twelve when they begin to go up to about ten times that level in girls, and about six times that level in boys, by age sixteen. Concurrently, under the influence of the pituitary, growth hormone is produced in large quantities: it increases height, but does not advance skeletal maturity. Then, after the menarche, when girls begin to form corpus luteum, progesterone is produced and ovulation becomes part of their menstrual cycle. These are some of the processes and changes that go on: ones which
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are uniquely the adolescent's, and each most relevant to his evaluation and care. Many of them have nutritional and a variety of other implications, sueh as nutritional implications for the adolescent who has a chronic disorder such as tuberculosis or nephritis or obesity. In any disease in which diet is a factor, growth needs must be taken into account, just as must the special requirements of the disease. Rapid growth, with dangling arms and with the feet suddenly so far from the head, does many things and must be thought of in many other connections. It can breed self-consciousness or have much to do with poor posture and with athletic injuries. It also concerns the treatment of fractures which are near an epiphysis, and needs to be taken into consideration when plastic surgery is being considered on the nose. The fact that rapid growth usually occurs at this time of life certainly bears on the anxiety of those young people who for one reason or another are unusually slow to grow or who do not grow at the same rate, at the same time or to the same extent as do others. It has to do, too, with the increase in heart size that may change the quality of a previously damaged valve's murmur-which does not mean that the heart is any less efficient, and with the increase in size of the thyroid gland-which may bring anxiety and yet is usually no more than a physiologic response to the unusual demands put upon it. Along with the rapid rise in androgens and estrogens, the pH and odor of the sweat change, acne and gynecomastia appear, and so do the secondary sexual characteristics. Anyone of these may bring some degree of anxiety to an insecure adolescent, and will bring to all of these young people new attitudes, new interests and new possible sourees of worry. An increased resistance to upper respiratory infections also usually develops. Unfortunately, this is not true in regard to tuberculosis, but this increase of resistance to minor infections does allow the doctor to relax those restrictions that formerly may have been suitable for the frail child. This is important because, when restrictions and unnecessarily protective measures are continued, this young person may not be able to engage successfully in those activities which could yield him the confidence he badly needs if he is to develop his personality satisfactorily. Adolescents don't like being different, and they don't like being kept dependent. They should not be restricted without good reason from those activities which can really help them to develop. Furthermore, it is important to remember that, since normal young people vary tremendously from one another in the timing, the rate and extent in which all of these changes occur, chronological age is an extremely poor yardstick for this age group. When adolescents are to be evaluated, described, or planned for, some other yardstick than chronological age should be used. Another assumption we can make is that these young people have a
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fantastic capacity for change. They are more resilient than people at any other time of life, and they vacillate more frequently and more widely in response to illness, in endocrine levels, in moods and interests than any other age group. What we see today may be gone or unrecognizable tomorrow. So long-range prescriptions or long-range predictions are inappropriate if not downright hazardous. Their tuberuclosis can go like wildfire and their depressions may dissipate within a week. Serial judgments are preferable to judgments based on observations at a single point in time when dealing with this age group. Anna Freud says all this very nicely, though obviously she is thinking more about adolescents' psychological disturbances than their physical ones. "I take it that it is normal for an adolescent to behave for a considerable length of time in an inconsistent and an unpredictable manner; to fight his impulses and accept them; to fight them off successfully and to be overrun with them; to love his parents and to hate them; to revolt against them and to be dependent upon them; to be deeply ashamed to acknowledge his mother before others, and unexpectedly to desire heartto-heart talks with her; to thrive on the imitation of and identification with others, while searching unceasingly for his own identity; to be more artistie, idealistic, generous and unselfish than he will ever be again, but also the opposite: more self-centercd, egotistic and calculating. Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life. At this time they may signify no rnore than that an adult structure of personality takes a long time to emerge."3 Similarly, it takes considerable length of time for an adult physiologic structure to emerge. Faced with adolescents, there are many assumptions to be made about their psychological traits and the psychological growth processes which go on at this time of life. The most important of these is their capacity quickly to form and quickly to abandon a therapeutically useful relationship with those adults whom they trust and respect and who are genuinely interested in them. So it is wise to treat them confidentially, and in talking to them to ask them to tell you about those matters that are important to them-and to most people at this time of life. They have great interest in themselves and tend to reject adults who do not show an interest in them. So see them alone, and listen more than you talk. We can assume that they worry about their bodies and tend to deny illness while at the same time they become extremely concerned with the most minor blemish. So, when possible, avoid mutilating surgery, such as cardiac surgery or the correction of an undescended testicle at this time of life. Do not brush off their questions even when they concern matters which may seem very minor to us. We can assume, too, that they are adjusting to a very much height-
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ened sexual drive, so we can expect new symptoms and new questions that they would like to have answered. They are attempting to acquire independence, so we should do things in such a way that their confidence will be increased, knowing that it is often the insecure young person who finds acquiring independence so difficult. We can also assume that their feelings toward each parent are changing and that, therefore, they may temporarily need other models than their parents to imitate and also some support from a respected adult to whom they are not closely emotionally attached. Their doctor could very well be such a person. They are trying to develop an adult sort of conscience since they find that the "no-no" mama-type of conscience which got them through age ten is no longer sufficient. Knowing this, we should be more than willing to answer such questions as they may hesitatingly ask us. They are also attempting to gain their own "who-ness" and "what-ness," as Dr. Plant used to call it, so we should be willing to be one person who will listen to their hopes, their plans, their wild ideas and their concerns about their own future without interruption or quick criticism. We can assume that the sorts of things that worry these people are school, their relationships at home, acceptance by and recognition from their own age group, their families, their bodies, their growth, sex and their futures. So we should include questions about these in our history taking, and we should consider them likely sources of the psychosomatic disorders they may bring to us. We can assume, too, that these young people will be much more verbal than little children and that their conflicts will be much less deeply buried than are those of adults. So even brief and infrequent opportunities for them to talk will be much more rewarding than similar opportunities would be for little tots or older people. They exaggerate, so it is important to remember that what bothers them is much more significant than how they express it. Because they are great imitators, we should be quick to try to furnish them with good models and slow to give them advice. We can assume that they need the sort of confidence which success and recognition and accomplishment can yield so we should be quick to think of ways to strengthen them that they may later successfully handle the inevitable physical and psychological stresses they are going to encounter; and, on the other hand, be extremely slow to suggest restrictions or rest: these are much more appropriate for adults and for children. Those are some of the more important physiologic and psychologic assumptions to make about these young people. If these thoughts are running through our minds, then the signals from these young people should come in reasonably loud and clear. This is most likely to happen when we think of them and what they are like, do not confuse their traits
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and needs with a child's or an adult's, and do not think chiefly of the heart murmur or sprained knee or whatever it was that brought them to us. THE OFFICE VISIT
The Doctor's Attitude How can the mentioned assumptions be taken into account when we see these young people in our office or clinic? Of first importance is the doctor's attitude toward his patient and toward adolescents in general. If he really does not like them, if they annoy him, if he is uncomfortable with them, then his tendency will be to ignore them and to give most of his attention to the knee or to the heart. Now there may be anyone of a number of reasons for this, but the significant matter is whether or not this doctor is able to modify his feelings toward these young people so that he can be effective with them. This is not to say that in order to be successful with adolescents the doctor needs to think that these young people are perfect, needs to agree with all of their opinions or to accede to their every wish and whim. Nor does it mean that he must fail to take a stand or must prefer them to little tots or to adults. It is definitely not to say that he should be one of them: they want a doctor, not a companion. The points are that the doctor should be comfortable with them, that his feelings not strongly influence the treatment and advice that he gives them, and that he be able to convey to them a feeling of his genuine interest in them and respect for them, even though he may be unable to accept their disease, ideas or behavior. The Patient Must Be Seen Alone The second matter of importance is to see these young people alone and to make clear to them and to their parents that the doctor is their doctor, not the parent's doctor; and that the problem is primarily this young person's, not his parents'. When this is done, it can yield all the values which are traditionally inherent in a confidential visit with the doctor. Under those circumstances adolescents tell their doctors more, tell it more quickly and tell it with more feeling, and therefore with more benefit. Remarks such as "Don't tell her I told you, she'd harp on it day and night" or "He'd kill you if he knew I told you this" are not likely to come out if the parent is present or if the adolescent feels that you are going to report his conversation to them. Nor will adolescents use those emotionallyladen words which are important parts of their vocabulary unless they feel that this visit is confidential. Furthermore, to see them in this way will reinforce the relationship with them·~ften the most valuable therapeutic tool we have. It also promotes the adolescent's sense of responsibility for
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his own health and avoids your making a contribution to the perpetuation of this young person's immaturity.
Role of the Parents The parent, if not known to you, should be seen first, preferably on a day prior to the boy's or girl's visit. It will hardly make the adolescent feel that he is your primary concern if he is kept waiting while the parents tell you their story. At that parent's first visit, the reasons for your subsequently wishing to sce the boy or girl alone and for wishing to make the boy or girl feel that the problem is his should be explained clearly, and they should be asked to discuss these matters with their son or daughter prior to the youngster's visit. Those few parents who are very possessive or insecure, or those who want you to act as their agent for some mode of treatment or some plan that they have devised will need more than a brief comment from you. At times it helps to point out that previous efforts with parents dominating the picture have not been successful, and that the very immaturity of which they complain may respond best to this reasonable increase in responsibility and evidence of the parents' and doctor's confidence. At this same visit (or over the telephone if a parent's visit is not needed), it should be made clear that the patient must be told why he is coming in and that no subterfuge will do. Parents occasionally seek a "check-up" because of their desire to exclude a boy from athletics, or because of some sexual behavior which they find unacceptable. The answer to this sort of request is "no." In the first place, the patient deserves your honesty; and in the second, it is going to be very difficult under such circumstances to introduce the problem that the parents want you to bring up. Finally, the parents should be told that you will subsequently talk to them only with the young person's knowledge and only about matters that he knows you are going to discuss with them. You may wish later to have your patient bring his parents in; and you are certainly going to keep the parents informed about what is going on, discuss with them any matter with which they can really help, and, in the event that the boy or girl has a really serious disorder, you will need to deal with the parents more fully. The point is to get parents to realize that a confidential visit is not only more effective but also a very valuable experience. As these young people grow up, our management of them should change, just as do the ways of schoolmasters, club leaders, ministers and churches, but none of this is meant to suggest that the parent should not receive or may not need your help. In fact, if an adolescent refuses your help, your only means of being any assistance to him may be to help his parents in their efforts to manage him. Furthermore, if your efforts to help the patient are to be reasonably effective, the parents may need assistance. Finally, many parents need your help with their own problems and for their own sakes. However,
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it is the boy or girl who is your patient and your primary interest. This does not mean that you will ignore the father's alcoholism or a mother's anxiety; you may not be the appropriate person to give long-term help with these, but if you are not, you will sce to it that someone does. After all, parents are people, too. In recent years, several clinics have been established exclusively for this age group. To offer these young people special facilities of their own helps to make it clear that the institution has a real interest in them, realizes that they arc different, and appreciates their dislike of being mixed up with "little brats" or "old fogies." However, at least as far as private practice is concerned, the manner in which the adolescent is treated is more important than the setting. Just giving the adolescent a special place will not guarantee his cooperation or his respect; it is how the doctor talks to him, treats him, that really counts.
How to Get an Adolescent to Talk Getting the patient to talk is a matter that seems to bother some doctors, especially getting them to talk freely and with feeling about those things that really matter. Some adolescents don't talk freely, but most are willing, able, even anxious to talk, and present no problem-except to those adults who have a very limited amount of time! Often if the parent says that Billy or Susie won't say a word, you can prellict that your problem will be to get them to stop! As a matter of fact, to stop these young people from talking is just as important as to get them to talk. If they say too much to you at the first visit, later, because of guilt or embarrassment or increased anxiety, they may be unwilling to return. Those adolescents who are suspicious of all adults and who doubt an adult's interest in them, or those who are depressed, arc very likely to require much more time and patience than others. The simple rules are to see the parents first, to try not to keep an adolescent waiting, to avoid interruptions, to establish privacy. All of these help to convince the adolescent that he is your primary concern. Then listen attentively with no shock or surprise, without interrupting and without breaking in with advice. Basically, the matter of getting the adolescent to talk depends on being a good listener. James Stephens defined a good listener as one who likes the person who is talking. Praise them when they deserve it and don't destroy your praise with that "but" which so many parents insert! "That was great, Billy, that A in math, but next time why don't you see if you can also bring up your mark in history." "That was great" (period) is much better. The tendency to be quick with advice to these young people is difficult for many adults to overcome. Adolescents have had advice for years. What they now need is an opportunity to talk confidentially, to be listened to, and to put those feelings into words that have previously been expressed
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either in symptoms resembling disease or in unacceptable behavior. They have already heard that education is essential, that they cannot get a good job without it. What they now need is a chance to tell you why education gives them a pain in the neck, a queasy stomach, a headache, or makes them smash windows, or leads to whatever the symptom is that brought them in to see you. On the other hand, when these youngsters ask for advice, we should give it. To refuse to give an opinion to an adolescent who asks for it will only increase his confusion. It is wise, however, not to leap at this carrot when it is offered. Answer with authority but do not be authoritarian. The Physical Examination
Chronologic age is a poor yardstick. Skeletal age, state of secondary sexual characteristics, and cycles post-menarche tell much more. The examination should include tests of vision and hearing, for these are relevant to schoolwork which is the major part of adolescents' lives. During the physical examination the excessive body concern characteristic of these young people should be remembered. Girls should be examined with a chaperone present and should be draped thoughtfully but not in a manner suggesting overeoneern. In general, because they will be better relaxed, a rectal examination will be more rewarding for girls under seventeen (and will certainly be less apt to upset them) than would a vaginal examination. A pilonidal sinus and gynecomastia should be looked for and features of growth and development noted. The state of nutrition is best determined by observation and "pinching" (skin folds). Weight can be a poor yardstick: many adolescents who are overweight are not overfat. The blood pressure must be taken: some adolescents who come to our clinic have never had this done. Fitness for either cardiovascular stress or muscle-joint stress should be evaluated in such a way that it will be comparable to the kind of stress the adolescent will experience when he leaves your office.
A Note on Treatment In prescribing for adolescents and when predicting about them, remember their capacity for change. Strengthen them rather than rest them and be ready to yield a little with those who have a chronic illness, but don't yield so much that their illness will get out of control. Should it do so, you will then have to deal with their increased anxiety-they dislike restrictions, but they fear illness. Discuss your plans openly with them: don't be authoritarian, but don't hesitate to be firm when it really matters. This review of some of the differences between adolescents on the one hand and children and adults on the other will serve as an introduction to
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the discussions which follow. An understanding of the physiologic and psychologic traits of adolescents will lead to those basic assumptions, that set of mind, which one must have if he is most effectively to help them. I have tried to suggest how these can be taken into account by all of us when we try to treat their ailments. QUOTATION SOURCES 1. Hope, Anthony: "Boys will be boys . . . . " The Dolly Dialogues, 16. 2. Shakespeare, William: "I would there were no age .... " A 'Winter's Tale, Act Il I, Scene 3. 3. Freud, Anna: Psychoanalytic Study of the Child, 1958, Vol. 13, p. 255.
FOR FURTHER READING Balser, B. H. (Ed.): Psychotherapy of thc Adolescent. New York, International Universi ties Press, 1957. Bayer, L. M. and Bayley, N.: Growth Diagnosis. Selected Methods for Interpreting and Predicting Physical Development from One Year to Maturity. Chicago, University of Chicago Press, 1959. Blaine, G. B., Jr.: Patience and Fortitude: The Parents' Guide to Adolescence. Boston, Little, Brown, 1962. DeLorme, T. L. and Watkins, A. L.: Progressive Resistance Exercise: Technic and Medical Application. New York, Appleton-Century-Crofts, 1951. Doniger, S. (Ed.): Becoming the Complete Adult. N ew York, Association Press, 1962. Faegre, M. L.: The Adolescent in Your Family. Publication No. 347. Washington, D. C., Department of Health, Education and Welfare, 1955. Frank, M. and Frank, L. K.: Your Adolescent at Home and in School. New York, Viking Press, 1956. Frank, L. K.: The Conduct of Sex. New York, William Morrow, 1961 (also Black Cat Paperback). Gallagher, J. R.: Medical Care of the Adolescent. New York, Appleton-Century-Crofts, 1960. Gallagher, J. R. and Harris, H. I.: Emotional Problems of Adolescents. 2nd Ed. New York, Oxford University Press, 1964. Greulich, W. W. and Pyle, S. 1.: Radiographic Atlas of Skeletal Development of the Hand and Wrist. 2nd Ed. Stanford, Calif., Stanford University Press, 1959. Guild, W. R.: How to Keep Fit and Enjoy It. New York, Harper & Bros., 1962. Kirkendall, L. A.: Understanding Sex. Chicago, Science Research Associates Life Adjustment Booklet, 1957. Nixon, R. E.: The Art of Growing. New York, Random House, 1962. Parsons, L. and Sommers, S. C.: Gynecology. Philadelphia, W. B. Saunders Co., 1962. Sturgis, S. H. et al.: The Gynecologic Patient. New York, Grune & Stratton, 1962. Tanner, J. M.: Growth at Adolescence. 2nd Ed. Oxford, England, Blackwell Scientific Publications, 1962. Wilkins, L.: Diagnosis and Treatment of Endocrine Disorders in Childhood and Ad· olescence. 2nd Ed. Springfield, Ill., C. C Thomas, 1957. 300 Longwood Avenue Boston, Massachusetts
OUR MUDDLED ASSUMPTIONS ABOUT ADOLESCENTS
I would like first to discuss some of the assumptions regarding adolescents which we should bring to bear on any adolescent who comes to us as a patient. Out of our past experiences in life and with patients, each of us develops a set of assumptions, a frame of reference, ways of thinking of, managing and understanding those people with whom we come in contact. These assumptions we have found appropriate in evaluating and treating various sorts of people and patients. When we choose the right set of assumptions, then the signals from this person come into us loud and clear and we tend to act in ways and give the sort of advice that meets that particular individual's needs. All this is very well illustrated by the line from the play, The Country Wife. A distraught woman walking around the stage, looking in vain for her again mislaid spectacles, finally turns and says, "Where would I be if I were a pair of glasses?" Obviously, if, as it were, we can think like a pair of glasses, our chances of coming up with the solution in any given situation will be very much better. Unfortunately, for many of us, the set of assumptions which we bring to bear when the patient is an adolescent is nowhere near as clear as when our patient is a little tot, an adult or an elderly citizen. The reasons for this are many, and it may not be unprofitable to review a few of them. One is that there are as yet very few clinics or medical schools in which the teaching of physicians in the care of this age group is as yet part of the curriculum: pediatrics and geriatrics, yes; but the medical care of adolescents, no. Furthermore, there are very few postgraduate courses and very few sessions such as this one; very few fellowships; comparatively few courses for medical students and house officers; and very little research. Happily, all that is rapidly changing. "Chief, The Adolescents' Unit, Children's Hospital Medical Center; Lecturer on Pediatrics, Harvard Medical School, Boston, Massachusetts.
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Another reason for the ineffective approach which some tend to have toward the adolescent is that the word adolescent itself tends to carry connotations which muddy our thinking. When we hear the word adolescent, we immediately think of problems, of delinquency, of rebellion, of disrespect, of lack of cooperation, of fast cars, late hours and, if it's a boy, we think of girls. I don't know why we pick on the male so much! If we are unusually forgiving, the best that many say is that "boys will be boys." We even ignore the rest of that very nice quotation which many now don't even know because it has so frequently been left unfinished. It really ends " ... and even that wouldn't matter if we could prevent girls from being girls. "1 The point is that we do have these sorts of feelings and we make these assumptions when we are faced with an adolescent. We tend to think of them today, just as Shakespeare did: "I wish there were no age between ten and three and twenty, or that youth would sleep out the rest. For there is nothing in between but getting wenches with child, wronging the ancientry, stealing and fighting."2 There are only a few adults who tend, instead of this, to tune in on the wavelength which was Mr. Shaw's when he said that youth is such a wonderful time that it is a shame to waste it on young people. Still another reason for our muddied thinking is that our reaction to these young people is apt to be adversely affected by our own pasts, by those conflicts of ours which we did not satisfactorily resolve during our own adolescence. So here again we have the same danger which faces all doctors at all times, regardless of the age of his patient: that his own feelings may strongly influence the manner in which he talks to and manages his patient and the treatment and advice he gives. For these and other reasons, our assumptions about adolescents are not as clear and desirable as those we bring to patients who are in other age groups. They are not as clear about what these young patients are like, physiologically and psychologically, or about what their real needs and sources of worry are. In short, we are not really sure about the many ways in which they differ from younger people and from older people, or of what they really need from us. Before we get on to discuss the sort of assumptions which I believe we can and should make about these young people when they come to us as patients, I would like to digress for a moment, and to temper what many of you may feel is my unwarranted crusade for this age group. First, I would like to emphasize that I hope and pray that our efforts here, and that those efforts of people elsewhere who have shown a special interest in this age group, will not spawn another specialty. I cannot imagine anything that would be more disastrous, both to these young people and to Medicine than to isolate the care of these young people from that of little tots, adults and
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the elderly. Should that happen we will miss many extraordinary opportunities for progress. This age group is rife with aspects of human development, health and disease which must not be isolated from these young people's pasts or from their futures. This is the major reason why our Unit here has internists, pediatricians and general practitioners on its staff and in training. We have deliberately chosen those whose backgrounds have been in pediatrics, internal medicine or rotating hospital training when recruiting our staff and when we go about selecting from among those young doctors who wish to come to us for training and experience with this age group. VALID ASSUMPTIONS, A SET OF MIND
All that follows is based on the beliefs that we treat people, not diseases, and that what we know about them is of no less importance than what we know about the partiCUlar disease or organ which brings the patient to us. It also assumes that adolescents are different from little children and adults. If this assumption is not made, and were it not a valid one, the major reason for giving members of this age group special attention would not exist. How do adolescents differ? What are the matters about them that we need to keep in mind? What are the assumptions that we need to make when we are faced with them? The first is that during this period of life people grow and change more than they do at any other time except during the first year. They change rapidly and extensively in height, in weight, in muscle mass, and in sexual maturity. The estrogens begin to rise sharply in girls at ten or eleven years of age, and by the time they are twelve or fourteen reach some twenty times their childhood levels. In boys estrogens rise, too, but it is usually a year or two later than in girls, and the rise is only about four-fold. Similarly the excretion of 17-ketosteroids increases: it remains around 2 mg. per day during childhood, and then at about ten years of age begins to rise to up to 8 to 15 mg. in boys, and from 4 to 9 mg. in girls, by age eighteen. The gonadotropins also rise: from a level of about one rat unit per twenty-four hours until about age twelve when they begin to go up to about ten times that level in girls, and about six times that level in boys, by age sixteen. Concurrently, under the influence of the pituitary, growth hormone is produced in large quantities: it increases height, but does not advance skeletal maturity. Then, after the menarche, when girls begin to form corpus luteum, progesterone is produced and ovulation becomes part of their menstrual cycle. These are some of the processes and changes that go on: ones which
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are uniquely the adolescent's, and each most relevant to his evaluation and care. Many of them have nutritional and a variety of other implications, sueh as nutritional implications for the adolescent who has a chronic disorder such as tuberculosis or nephritis or obesity. In any disease in which diet is a factor, growth needs must be taken into account, just as must the special requirements of the disease. Rapid growth, with dangling arms and with the feet suddenly so far from the head, does many things and must be thought of in many other connections. It can breed self-consciousness or have much to do with poor posture and with athletic injuries. It also concerns the treatment of fractures which are near an epiphysis, and needs to be taken into consideration when plastic surgery is being considered on the nose. The fact that rapid growth usually occurs at this time of life certainly bears on the anxiety of those young people who for one reason or another are unusually slow to grow or who do not grow at the same rate, at the same time or to the same extent as do others. It has to do, too, with the increase in heart size that may change the quality of a previously damaged valve's murmur-which does not mean that the heart is any less efficient, and with the increase in size of the thyroid gland-which may bring anxiety and yet is usually no more than a physiologic response to the unusual demands put upon it. Along with the rapid rise in androgens and estrogens, the pH and odor of the sweat change, acne and gynecomastia appear, and so do the secondary sexual characteristics. Anyone of these may bring some degree of anxiety to an insecure adolescent, and will bring to all of these young people new attitudes, new interests and new possible sourees of worry. An increased resistance to upper respiratory infections also usually develops. Unfortunately, this is not true in regard to tuberculosis, but this increase of resistance to minor infections does allow the doctor to relax those restrictions that formerly may have been suitable for the frail child. This is important because, when restrictions and unnecessarily protective measures are continued, this young person may not be able to engage successfully in those activities which could yield him the confidence he badly needs if he is to develop his personality satisfactorily. Adolescents don't like being different, and they don't like being kept dependent. They should not be restricted without good reason from those activities which can really help them to develop. Furthermore, it is important to remember that, since normal young people vary tremendously from one another in the timing, the rate and extent in which all of these changes occur, chronological age is an extremely poor yardstick for this age group. When adolescents are to be evaluated, described, or planned for, some other yardstick than chronological age should be used. Another assumption we can make is that these young people have a
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fantastic capacity for change. They are more resilient than people at any other time of life, and they vacillate more frequently and more widely in response to illness, in endocrine levels, in moods and interests than any other age group. What we see today may be gone or unrecognizable tomorrow. So long-range prescriptions or long-range predictions are inappropriate if not downright hazardous. Their tuberuclosis can go like wildfire and their depressions may dissipate within a week. Serial judgments are preferable to judgments based on observations at a single point in time when dealing with this age group. Anna Freud says all this very nicely, though obviously she is thinking more about adolescents' psychological disturbances than their physical ones. "I take it that it is normal for an adolescent to behave for a considerable length of time in an inconsistent and an unpredictable manner; to fight his impulses and accept them; to fight them off successfully and to be overrun with them; to love his parents and to hate them; to revolt against them and to be dependent upon them; to be deeply ashamed to acknowledge his mother before others, and unexpectedly to desire heartto-heart talks with her; to thrive on the imitation of and identification with others, while searching unceasingly for his own identity; to be more artistie, idealistic, generous and unselfish than he will ever be again, but also the opposite: more self-centercd, egotistic and calculating. Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life. At this time they may signify no rnore than that an adult structure of personality takes a long time to emerge."3 Similarly, it takes considerable length of time for an adult physiologic structure to emerge. Faced with adolescents, there are many assumptions to be made about their psychological traits and the psychological growth processes which go on at this time of life. The most important of these is their capacity quickly to form and quickly to abandon a therapeutically useful relationship with those adults whom they trust and respect and who are genuinely interested in them. So it is wise to treat them confidentially, and in talking to them to ask them to tell you about those matters that are important to them-and to most people at this time of life. They have great interest in themselves and tend to reject adults who do not show an interest in them. So see them alone, and listen more than you talk. We can assume that they worry about their bodies and tend to deny illness while at the same time they become extremely concerned with the most minor blemish. So, when possible, avoid mutilating surgery, such as cardiac surgery or the correction of an undescended testicle at this time of life. Do not brush off their questions even when they concern matters which may seem very minor to us. We can assume, too, that they are adjusting to a very much height-
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ened sexual drive, so we can expect new symptoms and new questions that they would like to have answered. They are attempting to acquire independence, so we should do things in such a way that their confidence will be increased, knowing that it is often the insecure young person who finds acquiring independence so difficult. We can also assume that their feelings toward each parent are changing and that, therefore, they may temporarily need other models than their parents to imitate and also some support from a respected adult to whom they are not closely emotionally attached. Their doctor could very well be such a person. They are trying to develop an adult sort of conscience since they find that the "no-no" mama-type of conscience which got them through age ten is no longer sufficient. Knowing this, we should be more than willing to answer such questions as they may hesitatingly ask us. They are also attempting to gain their own "who-ness" and "what-ness," as Dr. Plant used to call it, so we should be willing to be one person who will listen to their hopes, their plans, their wild ideas and their concerns about their own future without interruption or quick criticism. We can assume that the sorts of things that worry these people are school, their relationships at home, acceptance by and recognition from their own age group, their families, their bodies, their growth, sex and their futures. So we should include questions about these in our history taking, and we should consider them likely sources of the psychosomatic disorders they may bring to us. We can assume, too, that these young people will be much more verbal than little children and that their conflicts will be much less deeply buried than are those of adults. So even brief and infrequent opportunities for them to talk will be much more rewarding than similar opportunities would be for little tots or older people. They exaggerate, so it is important to remember that what bothers them is much more significant than how they express it. Because they are great imitators, we should be quick to try to furnish them with good models and slow to give them advice. We can assume that they need the sort of confidence which success and recognition and accomplishment can yield so we should be quick to think of ways to strengthen them that they may later successfully handle the inevitable physical and psychological stresses they are going to encounter; and, on the other hand, be extremely slow to suggest restrictions or rest: these are much more appropriate for adults and for children. Those are some of the more important physiologic and psychologic assumptions to make about these young people. If these thoughts are running through our minds, then the signals from these young people should come in reasonably loud and clear. This is most likely to happen when we think of them and what they are like, do not confuse their traits
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and needs with a child's or an adult's, and do not think chiefly of the heart murmur or sprained knee or whatever it was that brought them to us. THE OFFICE VISIT
The Doctor's Attitude How can the mentioned assumptions be taken into account when we see these young people in our office or clinic? Of first importance is the doctor's attitude toward his patient and toward adolescents in general. If he really does not like them, if they annoy him, if he is uncomfortable with them, then his tendency will be to ignore them and to give most of his attention to the knee or to the heart. Now there may be anyone of a number of reasons for this, but the significant matter is whether or not this doctor is able to modify his feelings toward these young people so that he can be effective with them. This is not to say that in order to be successful with adolescents the doctor needs to think that these young people are perfect, needs to agree with all of their opinions or to accede to their every wish and whim. Nor does it mean that he must fail to take a stand or must prefer them to little tots or to adults. It is definitely not to say that he should be one of them: they want a doctor, not a companion. The points are that the doctor should be comfortable with them, that his feelings not strongly influence the treatment and advice that he gives them, and that he be able to convey to them a feeling of his genuine interest in them and respect for them, even though he may be unable to accept their disease, ideas or behavior. The Patient Must Be Seen Alone The second matter of importance is to see these young people alone and to make clear to them and to their parents that the doctor is their doctor, not the parent's doctor; and that the problem is primarily this young person's, not his parents'. When this is done, it can yield all the values which are traditionally inherent in a confidential visit with the doctor. Under those circumstances adolescents tell their doctors more, tell it more quickly and tell it with more feeling, and therefore with more benefit. Remarks such as "Don't tell her I told you, she'd harp on it day and night" or "He'd kill you if he knew I told you this" are not likely to come out if the parent is present or if the adolescent feels that you are going to report his conversation to them. Nor will adolescents use those emotionallyladen words which are important parts of their vocabulary unless they feel that this visit is confidential. Furthermore, to see them in this way will reinforce the relationship with them·~ften the most valuable therapeutic tool we have. It also promotes the adolescent's sense of responsibility for
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his own health and avoids your making a contribution to the perpetuation of this young person's immaturity.
Role of the Parents The parent, if not known to you, should be seen first, preferably on a day prior to the boy's or girl's visit. It will hardly make the adolescent feel that he is your primary concern if he is kept waiting while the parents tell you their story. At that parent's first visit, the reasons for your subsequently wishing to sce the boy or girl alone and for wishing to make the boy or girl feel that the problem is his should be explained clearly, and they should be asked to discuss these matters with their son or daughter prior to the youngster's visit. Those few parents who are very possessive or insecure, or those who want you to act as their agent for some mode of treatment or some plan that they have devised will need more than a brief comment from you. At times it helps to point out that previous efforts with parents dominating the picture have not been successful, and that the very immaturity of which they complain may respond best to this reasonable increase in responsibility and evidence of the parents' and doctor's confidence. At this same visit (or over the telephone if a parent's visit is not needed), it should be made clear that the patient must be told why he is coming in and that no subterfuge will do. Parents occasionally seek a "check-up" because of their desire to exclude a boy from athletics, or because of some sexual behavior which they find unacceptable. The answer to this sort of request is "no." In the first place, the patient deserves your honesty; and in the second, it is going to be very difficult under such circumstances to introduce the problem that the parents want you to bring up. Finally, the parents should be told that you will subsequently talk to them only with the young person's knowledge and only about matters that he knows you are going to discuss with them. You may wish later to have your patient bring his parents in; and you are certainly going to keep the parents informed about what is going on, discuss with them any matter with which they can really help, and, in the event that the boy or girl has a really serious disorder, you will need to deal with the parents more fully. The point is to get parents to realize that a confidential visit is not only more effective but also a very valuable experience. As these young people grow up, our management of them should change, just as do the ways of schoolmasters, club leaders, ministers and churches, but none of this is meant to suggest that the parent should not receive or may not need your help. In fact, if an adolescent refuses your help, your only means of being any assistance to him may be to help his parents in their efforts to manage him. Furthermore, if your efforts to help the patient are to be reasonably effective, the parents may need assistance. Finally, many parents need your help with their own problems and for their own sakes. However,
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it is the boy or girl who is your patient and your primary interest. This does not mean that you will ignore the father's alcoholism or a mother's anxiety; you may not be the appropriate person to give long-term help with these, but if you are not, you will sce to it that someone does. After all, parents are people, too. In recent years, several clinics have been established exclusively for this age group. To offer these young people special facilities of their own helps to make it clear that the institution has a real interest in them, realizes that they arc different, and appreciates their dislike of being mixed up with "little brats" or "old fogies." However, at least as far as private practice is concerned, the manner in which the adolescent is treated is more important than the setting. Just giving the adolescent a special place will not guarantee his cooperation or his respect; it is how the doctor talks to him, treats him, that really counts.
How to Get an Adolescent to Talk Getting the patient to talk is a matter that seems to bother some doctors, especially getting them to talk freely and with feeling about those things that really matter. Some adolescents don't talk freely, but most are willing, able, even anxious to talk, and present no problem-except to those adults who have a very limited amount of time! Often if the parent says that Billy or Susie won't say a word, you can prellict that your problem will be to get them to stop! As a matter of fact, to stop these young people from talking is just as important as to get them to talk. If they say too much to you at the first visit, later, because of guilt or embarrassment or increased anxiety, they may be unwilling to return. Those adolescents who are suspicious of all adults and who doubt an adult's interest in them, or those who are depressed, arc very likely to require much more time and patience than others. The simple rules are to see the parents first, to try not to keep an adolescent waiting, to avoid interruptions, to establish privacy. All of these help to convince the adolescent that he is your primary concern. Then listen attentively with no shock or surprise, without interrupting and without breaking in with advice. Basically, the matter of getting the adolescent to talk depends on being a good listener. James Stephens defined a good listener as one who likes the person who is talking. Praise them when they deserve it and don't destroy your praise with that "but" which so many parents insert! "That was great, Billy, that A in math, but next time why don't you see if you can also bring up your mark in history." "That was great" (period) is much better. The tendency to be quick with advice to these young people is difficult for many adults to overcome. Adolescents have had advice for years. What they now need is an opportunity to talk confidentially, to be listened to, and to put those feelings into words that have previously been expressed
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either in symptoms resembling disease or in unacceptable behavior. They have already heard that education is essential, that they cannot get a good job without it. What they now need is a chance to tell you why education gives them a pain in the neck, a queasy stomach, a headache, or makes them smash windows, or leads to whatever the symptom is that brought them in to see you. On the other hand, when these youngsters ask for advice, we should give it. To refuse to give an opinion to an adolescent who asks for it will only increase his confusion. It is wise, however, not to leap at this carrot when it is offered. Answer with authority but do not be authoritarian. The Physical Examination
Chronologic age is a poor yardstick. Skeletal age, state of secondary sexual characteristics, and cycles post-menarche tell much more. The examination should include tests of vision and hearing, for these are relevant to schoolwork which is the major part of adolescents' lives. During the physical examination the excessive body concern characteristic of these young people should be remembered. Girls should be examined with a chaperone present and should be draped thoughtfully but not in a manner suggesting overeoneern. In general, because they will be better relaxed, a rectal examination will be more rewarding for girls under seventeen (and will certainly be less apt to upset them) than would a vaginal examination. A pilonidal sinus and gynecomastia should be looked for and features of growth and development noted. The state of nutrition is best determined by observation and "pinching" (skin folds). Weight can be a poor yardstick: many adolescents who are overweight are not overfat. The blood pressure must be taken: some adolescents who come to our clinic have never had this done. Fitness for either cardiovascular stress or muscle-joint stress should be evaluated in such a way that it will be comparable to the kind of stress the adolescent will experience when he leaves your office.
A Note on Treatment In prescribing for adolescents and when predicting about them, remember their capacity for change. Strengthen them rather than rest them and be ready to yield a little with those who have a chronic illness, but don't yield so much that their illness will get out of control. Should it do so, you will then have to deal with their increased anxiety-they dislike restrictions, but they fear illness. Discuss your plans openly with them: don't be authoritarian, but don't hesitate to be firm when it really matters. This review of some of the differences between adolescents on the one hand and children and adults on the other will serve as an introduction to
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the discussions which follow. An understanding of the physiologic and psychologic traits of adolescents will lead to those basic assumptions, that set of mind, which one must have if he is most effectively to help them. I have tried to suggest how these can be taken into account by all of us when we try to treat their ailments. QUOTATION SOURCES 1. Hope, Anthony: "Boys will be boys . . . . " The Dolly Dialogues, 16. 2. Shakespeare, William: "I would there were no age .... " A 'Winter's Tale, Act Il I, Scene 3. 3. Freud, Anna: Psychoanalytic Study of the Child, 1958, Vol. 13, p. 255.
FOR FURTHER READING Balser, B. H. (Ed.): Psychotherapy of thc Adolescent. New York, International Universi ties Press, 1957. Bayer, L. M. and Bayley, N.: Growth Diagnosis. Selected Methods for Interpreting and Predicting Physical Development from One Year to Maturity. Chicago, University of Chicago Press, 1959. Blaine, G. B., Jr.: Patience and Fortitude: The Parents' Guide to Adolescence. Boston, Little, Brown, 1962. DeLorme, T. L. and Watkins, A. L.: Progressive Resistance Exercise: Technic and Medical Application. New York, Appleton-Century-Crofts, 1951. Doniger, S. (Ed.): Becoming the Complete Adult. N ew York, Association Press, 1962. Faegre, M. L.: The Adolescent in Your Family. Publication No. 347. Washington, D. C., Department of Health, Education and Welfare, 1955. Frank, M. and Frank, L. K.: Your Adolescent at Home and in School. New York, Viking Press, 1956. Frank, L. K.: The Conduct of Sex. New York, William Morrow, 1961 (also Black Cat Paperback). Gallagher, J. R.: Medical Care of the Adolescent. New York, Appleton-Century-Crofts, 1960. Gallagher, J. R. and Harris, H. I.: Emotional Problems of Adolescents. 2nd Ed. New York, Oxford University Press, 1964. Greulich, W. W. and Pyle, S. 1.: Radiographic Atlas of Skeletal Development of the Hand and Wrist. 2nd Ed. Stanford, Calif., Stanford University Press, 1959. Guild, W. R.: How to Keep Fit and Enjoy It. New York, Harper & Bros., 1962. Kirkendall, L. A.: Understanding Sex. Chicago, Science Research Associates Life Adjustment Booklet, 1957. Nixon, R. E.: The Art of Growing. New York, Random House, 1962. Parsons, L. and Sommers, S. C.: Gynecology. Philadelphia, W. B. Saunders Co., 1962. Sturgis, S. H. et al.: The Gynecologic Patient. New York, Grune & Stratton, 1962. Tanner, J. M.: Growth at Adolescence. 2nd Ed. Oxford, England, Blackwell Scientific Publications, 1962. Wilkins, L.: Diagnosis and Treatment of Endocrine Disorders in Childhood and Ad· olescence. 2nd Ed. Springfield, Ill., C. C Thomas, 1957. 300 Longwood Avenue Boston, Massachusetts