ADOLESCENCE
Summary
of
Round
Table
Discussion
By J. Roswell Gallagher, M.D., and Felix P. Heald, Jr., M.D.
Adolescent Unit, Children’s Hospital, Boston, and Department of Pediatrics, harvard Medical School
INTRODUCrORY REMARKS (Dr. Gallagher) : seemi will also permit tile carrying out of
I BELIEVE that it will be profitable to begin statistically valid research.
our discussion of adolescence with a Today I would like to spend our time in
few remarks about the Adolescent Unit at discussing the ways in which we go about the Children’s Hospital in Boston : what it treating these young people. We will talk
is and why it is. This Unit is a general about some of their illnesses, but our pni-medical clinic designed for the care and many purpose in this session is to talk treatment of young people between the ages about the characteristics of this age group of 12 and 21. As there is often confusion in and how these affect your thinking about
the minds of not only the physician but the them and your management of them. laity as to whether this Adolescent Unit is It isn’t enough to know their diseases. a psychiatric clinic, I would like to stress The doctor must also know these people.
that our Unit is a general clinic for all He must be interested in his patient’s
con-young people, whether their complaints be cerns and needs and in his patient’s worries. a backache, dysmenornhea, acne, diabetes, This is the way to treat all patients, of
seizures, or amiy other ailment which is course, but it is essential to the treatment either common on uncommon in adoles- of adolescents becaimse the adolescent is so cemice. Our discussion will not be psy- mmnyieldingly overconcerned with himself
chiatricably but rather psychologically on- that he demands your attention. The doctor
ented to this age group. can’t deal effectively with them unless he
It has not been our intention to create pays just as much attention to them as he a new specialty, but rather to give special does to their symptom on illness.
care to this somewhat neglected age group. To impress them with our interest in In our Adolescent Unit we have pediatni- them, we have given them an attractive
cians, internists, and general practitioners clinic of their own. We give each patient working side by side in a common effort to a definite appointment time and we bend provide over-all medical care for these every effort to keep the appointment
boys and girls. Young people deserve a promptly. Every patient is introduced to
clinic of their own just as do little children his or her doctor so that from the very and adults. They need a place where they beginning there is a personal relationship can tell their own story to their own doctor, between the doctor and the patient. Par-and where their doctor can talk to them ents are seen separately, preferably on a
aboimt what they should do to care for them- day prior to the patient’s initial visit. We
selves. see the adolescent alone. The desk is the
In addition to our primary function, least conspicuous piece of furniture in the which is to care for the adolescent and his office: the doctor never sits behind it, but or her ailment, the Unit also serves for the sits facing the patient with nothing be-training of the physician in the cane of tween them. Nothing in the room or in the these young people. A clinic such as ours, doctor’s manner smacks of authoritarianism.
where large numi)ens of adolescents are On the return visit the results of the
examni-Presented at the Annual Meeting, October 3, 1955.
Smmimmmnary prepared by Robert P. Masland, Jr., Ml).
1020 GALLAGHER - ADOLESCENCE
nation and laboratory tests are discussed with the patient. Then, with the consent of the patient, the case is reviewed with the parents in his presence.
It is important during any interview with an adolescent to ask him about the matters which are uppermost in young people’s minds. There should be questions and con-versation about school, hobbies and
careers. He or she must be treated more as an adult than as a child. They must
under-stand quickly that doctors are people who are interested in them as individuals and who want to help them with their problems
in living as much as with their illness.
Next, I would like to discuss some of the attitudes which are particularly peculiar to this age group. The adolescent is fearful
of being abnormal. His concern is often focused on his size, growth and maturation. One of his common questions is, “Am I
average?” A presenting symptom may be the result of anxiety about growth and
maturation. Second, is the adolescent’s
great capacity for change. It is not unusual to see a patient terribly upset or ill today
and a week later back to normal. A
won-ned short boy becomes tall over the sum-men (or a dumpy, unattractive, pimply
young girl is transformed into an attractive young lady). Third, these young people live strenuously. They strive constantly for success and recognition. One must be slow to restrict activities in these youngsters. It is just not in the adolescent’s tradition to
nest. One can be sure that they will be very
active and must be sure that they are strong enough to stand it. After an
inca-pacitating illness they should quickly but
gradually be returned to full activity with-out unduly prolonging their convalescence. Next, school is very important to them. It is
an ever-present source of success,
frustra-tion, aches and pains, and we need to be ever aware that school problems can be responsible for many of their somatic
com-plaints. Lastly, we need to remember many of the reasons for their happiness or anxieties. These youngsters want friends
and they want group approval. They rebel
against authority both in school and at
home. They are looking fom adults to copy and they are often comifused as to which parent to copy. They are comifused by
death, religion, sex, and conflicts at home
may prove to be a source of unrest. They find it difficult to talk to their parents, and need another adult, with whom they have
no close emotional ties, to talk to. For this reason, their doctor is in a most fortunate
position. He has no close emotional ties,
and if he will present himself as a strong,
warm, interested person, nonauthonitarian,
neither approving nor disapproving adult, he will gain their confidence and can be of great help.
Q
IJESTION : How can we get theadoles-cents to come to us when they look upon the pediatrician as a “baby doctor?”
DR. GALLAGHER: I think you can get around it by having special hours for the adolescents. They should have their own waiting room. Some pediatricians devote
an afternoon on special evenings to these youngsters. I might suggest that when you
do see them, you change the props in your
office! Change the pictures, magazines, and examining table. If they see a baby’s scale in your examining room, they are not going to be too happy. But it is just as important
to change your manner, your questions, your attitude, your methods, as it is to change your setting.
Q
UESTION: Do you have any difficulty examining the girls?DR. GALLAGHER: No. We have a nurse
who prepares the patient and drapes her correctly. The young girl quickly senses that she is being treated in an adult
man-ner and the actmmal physical examination goes off without any difficulty. We never do pelvic examinations on these girls, but if it is necessary to check pelvic organs we do so by rectal examination. Occasionally a vaginal smear is necessary, and this is
usually secured by the nurse. On the very rare instance when it is necessary for a physician to do a vaginal examination, it
should be done under anesthesia. We avoid
emotional impact which they may have on
these young people who are in the throes
of growing up. I might also add at this
time that one should also be hesitant to
recommend operative procedures on the l)oys genitalia.
Q
UESTION : I am interested in why youhave chosen 12 years for the bower limits in your clinic? Is it not true that some
youngsters, particularly the girls, may ma-tune and begin menstruating before the age of 12?
DR. GALLAGHER: If a youngster is an
early maturer and has begun her menses
at, we will say, the age of 10 on 11, then we will certainly consider her as a patient for
our Unit.
Q
UESTION: What about the adolescentwho mimiimizes his symptoms? How do you
get around that?
DR. GALLAGHER: Who is concerned about the symptom-the parent on the
child? The patient may have a slight cough
which is certainly not aggravating him, and yet the mother complains that it is
“driving lien crazy to hear him cough.”
In this case the patient is minimizing his
mothers complaint. Or the mother may
have made the appointment for a time when the boy on girl would rather be doing something else, such as going to football
practice on attending some interesting
school activity. For this reason, I think it is
important to see the adolescent at a time
which is not in conflict with something all-important to him. Remember, too, to see
him or her alone-never with the mother or father present. I recall a young boy in my
office last year. During the course of his physical examination I discovered that he was unable to flex his back over a normal
range and that there was a great deal of tenderness in the lower lumbar region.
When I asked him about this stiffness and tenderness he stated that he had had it for
some time. He had, in fact, seen an
ontho-pedic surgeon about it 3 weeks prior to his visit with me, but in front of his parents
had told the doctor that he had no pain. “If I had told him I still had pain, my
mother would have nagged me about it ‘til doomsday.” Under such circumstances
many adolescents will not admit their
aches and complaints.
Q
UESTION : How close do you work with the school?DR. GALLAGHER : Mutual understanding between the physician and the school sys-t?m is imperative. Many schools are on
the defensive and doctors are too often authoritarian. It is for each to understand
the other so that the youngster will not suffer. If teacher and doctor can get
ac-quainted there need be very little, if any, misunderstanding.
Q
UESTION: If you were treating theado-lescent without the parent’s presence, is there a medical-legal problem involved if
you should treat the child without the
parents’ consent?
DR. GALLAGHER: We don’t treat these
patients without the parents’ knowledge.
They know in a general way what we are trying to do. It is not necessary that they know what Billy said on why Many can’t
get along with everyone at home. The
par-ent is really interested in the oven-all re-sults. As fan as the use of drugs is
con-cerned, naturally the parents are aware of what the medication is, and for what pun-pose it is being given. I do not believe that there is any real medical-legal problem involved in the way that we handle our
patients.
Q
UESTION: What about the mother who calls on comes into the office and asks the doctor to tell junior about the facts of life?DR. GALLAGhER: First and most
impor-tant, the mother must be told that the patient must be aware of why he is coming into the office. He must not be told that he is going down to see about that “little commgh” on that “upset stomach” of 2 on 3 weeks ago. When the boy comes into the office, I usually say to him that I am
cer-tam that he probably knows much more about “the facts of life” than his mother
realizes; perhaps more than I do. I give
him a pamphlet, Understanding Sex by
1022 GALLAGHER - ADOLESCENCE
and to come back to see me in a week on two if he has any questions. This approach
works out better than a “talk.” The return visit, a week later, may or may not produce questions. At any rate by that time you can be certain that the boy is well informed.
Dn. GALLAGHER: I think we might dis-cuss a few patients whom we have seen in our Unit in order that we may illustrate
some of the points which we have been making.
I would like first to tell you about a 17-year-old girl who was referred to me by a
heart specialist with the request that I was to “follow her heart.” I was somewhat
amused by this request, and allowed my-self to show as much interest in her as I did in her symptom, chest pain. Hen father
had died in the past year from coronary thrombosis and in the interim since his death Carol had had intermittent chest pain
which had been studied by the referring cardiologist.
It was apparent that Carol was having a
great deal of trouble getting along with her overprotective, smothering mother : she said that hen pain felt as though “someone
was sitting on my chest.” She was deter-mined to be independent and had made up hen mind to get as far away from home as possible. Her mother wanted her to go to an eastern school, and Carol had selected
one on the west coast. After a bit of maneu-vening, I was able to affect a compromise and the girl is now happily situated in
Missouri! Hen chest pain disappeared, and it is no longer necessary for me to “follow her heart.” The reasons for a vise-like on constricting chest pain are not the same in
the adolescent as in the adult!
I’d like now to. ask Dr. Heald to tell us about one of his patients.
DR. HEALD: Sally at 14 years had a
multi-tude of complaints. She was nervous, had
menstrual cramps, had a draining ear, and
she had been told she had an underactive
thyroid. Her most distressing symptom was the memistrual discomfort: the cramps were severe enough to keep her from school as
well as many of the activities which she
disliked to miss. It was apparent that she was overly attached to lien father, and had a poor relationship with hen mother.
Sally’s physical examination, except for chronic otitis extenna, was within normal limits. There was no evidence of
hypothy-roidism. At her subsequent visits she was encouraged to discuss her difficulties at home, and gradually her menstrual cramps
subsided. During the period when she was having hen greatest dysmenorrhea, she
fre-quently dreamed that she was a brides-maid; later, when hen menstrual cramps
were practically gone, she said that she was having the same type dream, but now
she was the bride!
DR. GALLAGHER: Perhaps reaction to
menstruation is a better term for us to use than dysmenorrhea since it is certainly true that many of the cramps in this age group
at least can often be traced to some conflict at home on school or related to growing up and becoming an adult female.
DR. GALLAGmm: The question has been asked as to what part specialists play in
our Unit. We refer very few patients to specialists-almost none except for nefrac-tion, general or orthopedic surgery or
psy-chiatry. But first and foremost we ask our-selves, “what is it that this symptom is try-ing to say?” And in this instance, “what is it that gripes this girl.” Then we must think of those things which bother a young girl. It may be desirable to call upon a specialist for opinion in regard to the
diag-nosis and therapy. When it is necessary for patients to have this added service, the specialist comes as a supervisor and teacher
as well as a consultant. He sees the patient, usually with his on her physician present, and then discusses the situation with the physician. The specialist does not take oven the cane of the patient; he advises and teaches the physician. This is true of the gynecologist, the endocrinologist, the
card-iologist, and psychiatrist.
Q
UESTION: What do yomm do to givepa-tiemits a pain-free menstrual period?
possi-l)le to have a period vithout To do this we give them estrogen, 1 mug. daily for
21 days, beginnimig on the first day of their
menstrual period. This therapy will mnake their next menses a painless one. We do not
continue this therapy since it would lead to
dependence on hormones and then we
would have another problem on our hands.
DR. GALLAGHER: I would like to men-tion strenuous living again. Adolescents
have a tremendous need for physical
activ-ity. If an athletic youngster suffers an in-jury or illness, he should not be sidelined for an interminable period, but should be returned as quickly as is proper to full
activity. This makes it important for us to evaluate their physical condition in terms of what they are going to attempt. I am
particularly concerned with the evaluation of their cardiovascular system. The doctor who when attempting to evaluate their fitness for exercise tests them at something
comparable to the stress they will be under
in their games will have a better measure of their condition than if he simply has
them hop up and down for say 100 times. To simulate vigorous exercise by putting more strain on the heart than simple hop-ping we use the step test. We use a stool
18 inches high, and have our patient step
up and down 30 times a minute for 4
minutes, and take the heart nate 1, 2 and 3 minutes after exercise. Physical condition is rated on the basis of the rapidity of the deceleration of the heart rate after exercise.
Boys can understand and will usually
accept restrictions or recommendations based on a test procedure such as this.
Q
UESTION : How do you handle the pa-tient who isn’t going to get well?DR. GALLAGHER : Here it is the physi-cian’s own reaction which is so important.
He must not be afraid of death himself.
He must be honest and yet kind, and make
possible many opportunities for the patient to talk with other people. These patients need support: you’ve got to be there or
have another person there as a substitute.
DR. HiALD: I would like to tell you
about a 14-year-old boy who was referred
to OU Unit because of severe headaches of approxiniately 6 months’ (luration. He had
seen several doctors and had had exhaus-tive mietmrobogical studies prior to emitrance
to our hospital, and except for a slight elevation of the spinal fluid protein, no
abnormalities were noted.
When Carl was admitted to the hospital
it was obvious that he was terribly fright-ened. He knew that the headache was a
mystery to the doctors, and he was afraid that no one would be able to help him. His first question was, “Doctor, am I going to get well?” He was immediately told that of
course he was going to get well, and in answer to his next question, “how long will
I be in the hospital?” he was told without
hesitation “4 days.” There are times when
one has to take a calculated risk-and hope that a show of confidence will not lead to trouble. The knowledge that a lack of con-fidence is just the wrong thing for such a
patient justifies the chance one takes. He began to be relaxed and almost immedi-ately went through the remainder of the
hospital stay with very little tension. A review of the medical and neurological studies failed to demonstrate any organic lesion. But his history revealed such things
as that this youngster had developed the
headaches shortly after attending his grandfather’s funeral the previous summer. Because of the war, the boy’s father had been away during Garb’s early life and he
had become tremendously attached to his grandfather. Everyone had remarked how he had shown little outward grief at his
grandfather’s funeral. When Carl returned to school in September, he had headaches and seemed terribly fatigued. He was un-abbe to compete in athletics
(
“I couldn’tseem to get in shape”) and his school work went from bad to worse. His mother, a very
bright person, put a tremendous amount of pressure on the boy to do well in school. His father, who had not been a good
stu-dent, remained on the sidelines.
A few simple spelling and reading tests
spell-1024 GALLAGHER - ADOLESCENCE
ing and reading were characteristic of a
specific language disability and were
enough to explain his frustration and fail-ure when faced with a high school course with its foreign language and long reading requirements. The situation was reviewed
with Carl, and it was pointed out to him his headaches and fatigue were not due to
any intrinsic disease of the brain, but was
what one might expect from a combination
of his grandfather’s death, his language disability, and his mother’s insistence that he do well in school. “Doe, how do you
know?” During the summer, with the help of a tutor, he improved his spelling and reading, and he has had no further
head-aches on fatigue.
DR. GALLAGHER: This again is a good example of the sort of things which pro-duce symptoms in an adolescent. Some-times they have brain tumors, and no one would dare not to examine them thoroughly. But then one ought to get around to
think-ing of school and death and reaction of parental pressure as the possible causes.
School can make you very tired if you’re doing poorly. A nagging parent can make
an adolescent feel as though the top of his head would blow off.
As for the language disability, it is cer-tainly true that many youngsters who slide
through the first 6 grades in school go into a tailspin in grammar and high school. Our Unit is interested in this problem, and further research is planned in an effort to
reach a better etiologic interpretation of this disorder. The pediatrician and
practi-tioner will do well to remember that school is a problem to adolescents. A simple spell-ing test can be done in your own office:
and it does not take an expert to suspect that bizarre spelling-a good index of
lan-guage ability-and consequent failure in school are causing the symptoms.
Q
UESTION : I wonder if you might say a word or two about the care of acne.Dn. Gs.ucmmiii: First and foremost we
don’t make light of it. We tell the patient that we will do everything we can to help them through this difficult business. We
have no panacea on new treatment to offer. We do have a few simple rules and
pen-haps you might like like to hear them. We tell our patient to wash his face as often as necessary to prevent it from becoming
greasy. We do not say how many times a day because some patients may need to wash their face only once a day in order to keep it grease free, whereas other
pa-tients may have to wash it 5 times a day. We tell the patient to keep his hair clean and not to use oily shampoos. We suggest
that they omit nuts, chocolate, and fatty foods. We spend a great deal of time
tell-ing them about the disease, in order to decrease their guilt and anxiety: their guilt
about masturbation, for example, may
often cause them to think this is the reason for the skin trouble, and keep them anxious. We prescribe a drying lotion and
advise sunlight, exercise, and plenty of sleep at night. We try to eliminate any chronic infection. We defer x-ray treatment but do not withhold it when it is clearly
indicated.
Q
UESTION: What about the patient who is delayed in reaching his on her physicalgrowth in comparison to the other young-sters of a similar age?
DR. GALLAGHER: We look for endocrine disorders, infection and malnutrition first.
Then if we have ruled out these disorders, we can sometimes reassure the patient by explaining the differences between
per-fectiy normal people in the rate, time and extent of growth. We can strengthen this if their own hand-wrist roentgenograms ne-veal a bone age a year on two below their chronological age. For example, a 17-year-old patient whose bone age is 15 years, can be reassured that he has 2 years more of
growth ahead of him than do other
17-year-olds.
Q
UESTION: What about inpatient caneof the adolescents?
DR. G.ucim’.r: It is advisable for the
velI. We are planning to have a vimig in our new hospital where the adolescents will be together as a group. For those who require a long hospital stay, wand rather than single-room cane is desirable because
of the effects of group morale.
Dmi. GALLAGHER: In summary, what we
have been trying to do here today is to review some of the characteristics of this age group and to point out how a
nealiza-tion and understanding of adolescents
tImemr1sel’es is essential to au (‘fiective lfl(I
correct diagnosis amid management of their ailments. What these young people are like, their needs, the matters which worry
them-all these must be taken into con-sidenation. The few case histories we have
outlined here have illustrated that, and made it clean that one must deal with them, and think about them, in a different fashion than is proper with either little
