Letter From The Editor

Dear Colleagues,

This autumn edition is set to coincide with our October conference so hopefully most of you will be in attendance at the Royal College once again. It looks to be a really dynamic event with an even wider set of contributions than ever. Hope you enjoy it!

The book on traumatic stress which includes the proceedings of our very successful April conference in Italy is now available. When ordering please specify which language version you would like. Also of course we do still have copies of the 1998 and 1996 International conference proceedings available and will be taking advance orders for the 2000.  The proceedings books together are forming quite a textbook on adolescent health and are a useful reference as well as a record of the conference proceedings.

Remember to continue checking out our websites which are improving and updating all the time – also please let us know if you have any suggestions or requests for inclusion either in the journal or in the website content.

  http://www.youthsupport.net/YSBOOKS/traumatic_stress.htm 

The journal is now also on line at www.youthsupport.net/YSBOOKS/journal.htm

Conference details are on www.youthsupport.com Those who are interested in our assessment and treatment services and particularly our family work will find this detailed at www.familycentre.com and www.youthsupport.org

Diana Birch   Director Youth Support

Our two conferences at the Royal College of Physicians in October 1996 and 1998 have both been published as proceedings books – see below. Get your personal copy now!!   Extracts will be printed in the Journal. 

SAM in Washington March 2000 - a very good SAM meeting. Further details in the International section overleaf.

Youth Support Italia - Gioventu` Duemila April 2000 - full details  published  in the  book on Traumatic stress.

The following paper was presented at the European meeting October 1999 at the Royal College of Physicians - Sponsored by Youth Support

 “Global perspectives in Adolescent Health”

Herbert Friedman

I am going to be talking about global trends, but I should warn you that most of my experience in WHO in adolescent health and development programme, is really in developing countries, that is countries economically growing challenge, are difficult, in Africa, Asia, Latin America, Middle East and so on. Of course WHO works in all of the world, including the European regional office, but the perspective I am going to put forward goes quite heavily on what goes on in some parts of the world, but maybe not so quite relevant to most of you. Nevertheless I think that the themes have some universal resonance, we still hope they do. I am going to be talking about several different things, but it’s basically looking at trends over the last 20, but especially the last 10 years in how adolescent health is being approached around the world. There’ve been some radical changes and I’ll come onto that in a minute. I am old enough to remember how it all started and you probably aren’t.

In the beginning of adolescent health 20 - or 30 years ago, roughly speaking when interest started, it really began because people in political circles saw the young people as a threat more than anything. The population was exploding and you probably know from the radio these days that it had gone from 3 to 6 billion, it doubled in about 30 years. And in many countries that meant that the proportion of young people was also growing, especially in developing countries where infant mortality was dropping. Unemployment was growing and still is in many places at the same time and that hits the young people very hard. Cultures were beginning to be crossed and now of course are madly crossed by all kinds of things. Travel of all kinds, tourism, migration, refugee population and so on, the greater mobility of people including young, and of course telecommunications, electronic media and so on have vast effect on bringing ideas, good and bad, right around the world and right up to the door-step of young people. Even in poor countries where there is very little infrastructure for telecommunications it still reaches them. And this also meant  the threat of political unrest.

 A lot of politicians around the world started to get scared. What happens if you have a large young population and unemployed?. At the same time education is improving and it also mixes the ingredient. In the beginning the health community, I think, looked at young people more as a problem. And some of the problems, I am sure they’re all familiar to you, in developing countries especially, earlier menarche, maturity at earlier age and later marriage is one of the features that become predominant now. And so the time between for young women being able to reproduce and marrying stretched, pre-marital pregnancy became a problem in places that didn’t have it before, it. And then AIDS arrived on the scene. Of course it made a huge difference as the issue of fatal disease for which there is no cure. Drug use of all kinds, including tobacco, for the most parts was increasing in the young people. Partly because of access, partly because of people pushing sales on young people. And the variety of drugs expanded and in any case the sense was that young people are using drugs, which is not always true, as you well know, but some are. Injury was another aspect, which became important to the health community. I think more important when they realised two kinds: the intentional injury, violence in some young people, both as perpetrators and victims, and suicide, self-harm. And unintentional injury that featured as accidents, certainly in relation to traffic as it’s grown all around the world. So these were discreet issues that focused on perhaps different segments of the health community as problems, young people’s problems. What’s started to change, and I think it’s in full swing now, is instead of thinking of pregnancy and AIDS separately, as singly discreet issues there was a movement towards looking at sexual reproductive health generally. And this of course means initiation of sexual relations can of course lead to pregnancy, child birth and abortion and some of the problems associated with that, as well as some of the good things associated with pregnancy and child birth. And it can also of course lead to sexually transmitted infections as well as HIV infection leading to AIDS, and this is another very crucial aspect of this. Attention to sexually transmitted infections, which are very wide-spread and in some cases growing in young people, became an important feature. But more crucially I think, was the beginning top think of sexual reproductive health as a whole integrated domain.

Adolescent behaviours. When we talked about problems, the first stage was a kind of curative approach: if there is a problem we have to do something about it after that fact. When people started looking at these problems, where this pregnancy comes from, well in fact, it comes from some behaviours that young people engage in and so on, voluntarily or otherwise. So there was an emphasis on what young people do that creates problems. Do they drive too fast, do they get drunk or they are using tobacco and alcohol indiscriminately or other drugs? Are they having sex without thinking about the consequences, etc, etc. So there was focus earlier on problems and the behaviours that led to them. As people began to look more closely at adolescent behaviours it came apparent of course, that young people are influenced by people around them and what their families and the community does becomes extremely important. And so attention is moving not to exclude adolescents themselves but to include adult behaviours, it’s a crucial aspect of understanding what’s going on.

A third trend, if you like, was looking at adolescent health, all issues we’ve talked about, but of course often some parts of these aspects, nutrition, exercise, rest and so on and looking also at adolescent development. In another words, not just taking a cross-section of the status of young people at any given moment in time, but what’s going on in the individual. Are they’re maturing appropriately, all facets of development, evolving, maturing etc. And I’ll come to that, cause I think it’s a very important issue for the future too.

Another thing that’s changed, certainly first and maybe more significantly later, there was an implicit assumption of gender inequality, it wasn’t discussed, it was just taken for granted that boys and girls were treated differently, this is the way of the world. That’s certainly moved towards a posture as very least it often more than lip service, but it’s commitment to gender equality, it doesn’t exist in many places, but it certainly a change in thinking that needs to exist.

Young people as an object, a target group of action, we have to do something for them and sometimes to them as opposed to the young people acting for themselves, what they can do. This is another significant trend in action based on what people have learnt I think.

Third issue was, as I commented earlier, young people as a problem shifts to the young people as a resource. It’s not only that young people have problems or create problems, they are an immense resource of society. This is another positive shift in that direction.

Negative is effective to positive is effective; and what I mean by that is if you frighten young people, if you threaten them, that was the way sometimes campaigns were run. Get them worried, or scare them, to punish them. It shifted I think in many ways to the positive idea: reward the young people for they do well, look at them in a positive light, take a different approach to them. It’s been known for a hundred years for psychology, for example, and probably since the beginning of time really that positive approaches are working better than negative approaches, we know that from many different sources, but we tend to forget it and the health community sometimes did. So these are four shifts in beliefs that have taken place.

Another issue if you like, was to know whole of the adolescent needs, one by one: is there a problem of smoking, are young people being sexually promiscuous, this is often the mentality, to look at adolescent as a whole, the person, not the problem. Young people have many facets to them, it’s the whole individual that’s in front of us. A second change is about the homogeneity of adolescence to the diversity. People would often when they were developing programme and projects and sometimes policy would be rather blind to the fact that young people are vastly diverse in many different ways and treat adolescents whatever group of age they took as a single homogeneous whole, that’s certainly changed. The differences in developmental stages are now being given greater attention, cultural differences, socio-economic differences, educational differences and of course individual differences. The cultural differences I think are also extremely important and have been somewhat neglected and that’s something I’ll come back to before I finish. I said of relevance of culture, if you think of all young people as the same, I am exaggerating of course, but there was a tendency towards this, then what difference does it make what their cultural background is? When you start to see diversity of young people you begin to realise that they are formed by different value systems, not only in different countries, but of course within the same society when you have different ethnic groups, feeding certain kinds of beliefs to young people and perhaps the main string community having other kinds of beliefs we have to attend to that, it becomes quite important.

I’ll now look at how action’s changed in general. I’ve already mentioned one, young people not simply as recipients, but as actors. In the beginning or earlier days people somehow thought, well, we’ll tell them what to do, we’ll tell them if you’ve got AIDS this is what will happen to you, etc. - to the recognition that information alone does not work. You need to engage young people and give them skills, skills for many different things, and greater attention to the young people’s actions in that sense.

Single interventions. We’ll have a campaign about smoking - to combined interventions where young people are seen as a whole and multiple interventions at the same time are tailored to fit the young person. This is not always the case, but there’s no question in my mind that there is a trend throughout the world in doing that. It follows on from the notion that young people is a person and not a problem, so look at the whole individual. It follows on from the idea that you are looking not only at health, but at human development.

Separate services to integrated services. This is again another trend, in many parts of the world it’s impossible to integrate services structurally, but functional integration becomes more feasible. In other words, if STDs or sexually transmitted diseases are dealt with in that clinic and pregnancy over here, you can link them in many ways through the people working in them and so on. So an approach to pull together services of different kinds, especially in reproductive health, this has been a trend towards separate services, which is obviously better for young people, it makes things more accessible and also treats them as whole human beings rather than somebody with a problem.

Another area of action I’ve mentioned before instead of just focusing on adolescents, the community including the family is looked at. Agencies working alone, agencies working together, this is a highly problematic area all over the world because as you know, as we know, when you are working in a particular organisation you have to afford to go for that, you have to raise money for that and so on and so forth. But there’s been a powerful trend towards cooperation across agencies. It again follows from working with different sectors, treating a young person as a whole and trying to integrate services. It’s a trend, no more than that. This also applies to governmental and non-governmental organisations, in much of the world public and private partnerships are now not only happening, but are actively being promoted. I think there was a lot of suspicion of the private sector on behalf of public people, and there still is, sometimes justified, profit-making organisations, how can they help? But that’s changed in many places, where we’ve seen good examples of joint public and private cooperation for young people. Sometimes it is in the interests of the firm doing it not only before their workforce, but also for public relations. But whatever the reason, good partnership can exist.

Implicit policy. Adolescent health was more or less ignored until quite really recently, if you are looking at public health. And now explicit policy in many countries around the world developing policies, which are focused on young people and their health and this is true in lots of ways. True for example, the Convention on the Rights of the Child legally binding Convention around the world, with most of the world has signed on to. It focused explicitly on needs of the child, in this case up to the age of 18. The women’s movement, the Beijing conference and so on have had sections in them devoted explicitly to young women and their needs, and so on and so forth. Written into policy and there are many organisations, WHO and UNICEF working together for example, to develop policies and so on. To make it explicit which provides real protection for young people.

If we take a look ahead, these are some ideas, some are mine and from other people, and certainly they are open for discussion, but I think some of the things, that as far as I can see work well. In order to get action in countries, build the consensus, in other words get people agreeing on what they can agree on, and the first of those is the importance and meaning of adolescence in societies. There’s been a trend in this direction recognising that if you neglect adolescence, problems arise, if you invest in them, it might pay off in the long run, because they are very important key of the society. They are also on the threshold of change, which can go in either direction, up and down. There’s a lot of controversy, certainly in the UK as well, but not only here, around the world about what to do to help adolescents. Should they have sex education or not, here is the debate today, just switch on the radio, is it causing adolescent pregnancy or preventing it? One of the things I think people can agree upon, but they don’t often talk about it, is an agreement about the need for young people to fully develop. This is one of the advantages I think of thinking about human development rather than just health, thinking about positive aspects of adolescents and not just the problems. People can agree on that from opposite corners of ideological globes so to speak, they can say, yes, we want our young people to be developed and mature, to be well, to be happy, there is a room for agreement on that as opposed to battling. The means become an issue, but the goals at least would be common.

Respect and nurture are all aspects of adolescent development, I’ll come to that in a minute. What do we mean by human development, I’ll attend to that in a second. And of course the cultural diversities and strength of young people. In every society, I am probably exaggerating for the sake of making a point, but I think I can almost say that with some voracity, in every society there is an assumption, implicit usually, that people who are different are inferior.  This is maybe a natural thing, maybe part of our protection of ourselves, but if you look around the world, not inferior in all respects necessarily, but in some respects. And we don’t think about that, we don’t talk about that and I think these implicit prejudices need to be raised to the surface. And when we think of development, they will change after a while, I think.

What are the different aspects of human development? it is a crucial area for future thinking. Everybody recognises physical development, we know about maturation of the body, etc. even if we don’t know about everything. We know something about intellectual development, a lot of attention to cognitive change, to academic achievement, etc. etc. everybody talks about that here and in most of the world as well. An economic achievements changes, I am not sure this is really an individual characteristic, but a lot of us look at how to help young people make money, be self-sufficient, etc. But some other areas I think are profoundly neglected. We all have capacity for spiritual development I never knew anyone who didn’t. Some societies give  more attention to that, but they don’t of course measure it, they don’t think of young people’s health in terms of their spiritual development usually. Emotional development, well, yes, yes and no, I mean, this is a crucial aspects of every human being, but again it’s often not measured. I won’t say it’s not attended to, but it’s often not measured. So for the development of capacity for human relationships and artistic aesthetic achievement. Young people have enormous capacities, I know Youth Support knows that, but a lot of people don’t pay attention to that. And humour. I put this in and people often ask, why have you stuck it up there, so I’ll tell you why. I’ve been in many parts of the world where people are living in the most dire conditions, conditions that were almost unimaginable to me, I mean with nothing: water, food, clothing – nothing, the most horrible conditions that you can imagine and still surviving. What keeps them alive sometimes is an ability to distance themselves, to look at their situation at perspective and humour arising from that. Never mind, you can make your own list. I think you make a great mistake unless when we’re looking at the whole individual, we’re looking at the whole individual development, we don’t attend to these different aspects. This is important especially for young people may not be good academically, who may be stunted physically, who may not be able to earn any money, but they have other qualities, that are extremely important, not only important, but in fact valued by each of us even though we don’t talk about it so much.

What needs to be done, some of this I think are clichés, but I’d like to emphasise the points anyway. Building alliances for mutual benefit. There is no question, unless people work together, resources are wasted, and given all that I think is happening about changes in the way people think about young people this is a natural follow on, between adolescents and older people, right, it follows if you’re going to look at the family and the community. The Western world, if I can use that phrase, tends to neglect I won’t say older people, but the importance of older people to some extent. And the value, the mutual benefit of positive interaction between adolescents and older people, including grand-parental generations. I think this is a very important continuity, the aborigines of Australia, in parts of Africa where there is nothing else, where grandmothers are looking after AIDS orphans, for example, and so on. And the enormous gains that are made, like good relations between generations that are quite separated, mutual respect and love is what generated like that.

Between the two sexes, yes, I think positions are changing in terms the way women see themselves, the way men see themselves, this is crucial areas for future of adolescent development, how to work together, how to mould a positive mutual relationship. Within sectors, for example, in health, how can we integrate services better even functionally, how can you make sure that adolescent who somewhat disenfranchised, who is going to have multiple problems, gets help across the board and isn’t simply sent away to go and see some other agency. Across sectors, health yes, but also social welfare, and employment, and labour, and so on at the local level need to be linked up especially. And between public and private enterprises, we’ve already mentioned that. How can you raise money in ways that are good, positive and not necessarily forced to go to the government. Just a couple of other things, one of the things that’s been have learnt and it’s part of programming now is to work in all sectors: in the home, in the school, in the church, in different services, in the work-place, in the environment and so on, in the street, using media, the mass media, electronic media, and of course also young people or people who are admired by young. These are all potential sources of positive input at the young people – there more consistent they are the more powerful is the impact of what happens, and that’s another thing we’ve learnt from research and experience.

One last point about action and things on research and then I’ll turn to you. Skills again are important but of course not just skills for work, they are absolutely essential, but that’s not all – skills for life, for living well, for enjoying good mutual relationships, for play, play in adult as well as in children is a crucial part of life, we all do and we don’t give any value to it but it’s tremendous experience of pleasure, and joy, and creativity. I’ve talked about some of this already – to remind adults of the value of young people, not their cost, but their value. Training is often neglected, how can you work well with young people? I don’t think it’s so much a matter of discipline, I don’t think it’s certainly not a matter of what kind of qualifications you have, what it does matter I think is having the right kind of attitude and of course some skills and techniques. But training is crucial, I don’t think anybody’s worth than they are ?  should be neglected on that.

Help institutions respond effectively – there are many institutions  that really don’t know what they could so better, so people working in youth sector can inform them, they lack on that very often, they really don’t know.

Help donors find the support that works. I’ve had a fair bit of dealings with donors of various kinds and most of them are really quite keen to fund but they want to fund things that are effective and they need our help in telling them what works and they need some evidence to show that. They often need to take a long-term and flexible approach, all of us who work in this field know that things change, we make mistakes, we have to go on from there, so if you write a proposal to do something in three years and in the middle of the second year you find that it’s not working and you need to shift, donors need to have some flexibility to let you do that kind of thing. And again with an intelligent dialogue with donors they will but into that. And strength of partnerships, I’ve already talked about that.

Just of couple of other things I’d like to talk about. It sometimes comes under the heading of research or learning or whatever you want to call it, but I think there are certain areas where we need to expand the knowledge base. I’ve already made reference to human development. I know form experience around the world where we can measure academic achievement, we might be able to measure growth and development physically in some respects. If you look at other aspects of human development, social development, emotional development, aesthetic abilities, humour, spiritual qualities – nobody pays any attention to this when they look at adolescent health and development, so we need first of all to find out whether it is true, do people really value that in each culture? And second, if they do, how can we best identify and measure these qualities, in whatever innovative and creative ways we can come up with.

How can we monitor it? One of the important things from policy level nationally, internationally and so on is to find out how things changing, what are the trends, are young people advancing or falling back, what’s working now for them. So we need to monitor the level of development, this is not an easy task, it’s a very difficult one in fact, but attention is beginning to turn more to that in policy makers now.

Second area, this is about the adolescent, if you like, or the young person, - understanding what works. It’s another way to feel this changed an awful lot. In the beginning one had to go around to people and say, “There is a problem, please pay attention it”. And then later one can say, “Look, young people can do things themselves.” Now the questions that are coming from governments frequently is not “should we pay attention to adolescents”, but “what should we do, what is it that works?” And of course the field of intervention research is growing but it’s still early days, I think.

What is best for adolescent health and development given the diversity, I’ve already touched on. Young people are so different, how do you reach the ones that are disenfranchised, how do you make sure that young people’s development is attended to, that all issues are touched upon, how do you reach the young people in greatest need, who typically slip away.

A couple of other areas, I think this is the last one. Positive relationships – there is a worldwide trend, actually, I don’t mean just worldwide, I think there is a multi-sectoral, across disciplines trend to look into interactions in people, instead of how can I put it, human individual psychology, or human individual health, or human individual economic achievement there is much more attention to interactions between people. As obvious as this may sound, it’s incredibly neglected area, most of the research looks at individuals rather than interactions. And I think this is something that’s crucial for adolescent development, adolescents especially, or young people, or children, because they are so profoundly affected by people around them. What makes it positive? And Of course it’s not only amongst people, but across institutions. There are models of good cooperation and there an awful lot of disasters across institutions. What works across cultures? When you have a multi-ethnic society as one does in Britain, what works, what kind of help the young people need who are living in perhaps two different value systems at the same time. And this is true for a very large number of young people.

To just digress for a second and give you one example that struck me looking at some of the American work on monitoring young people. There was a noble attempt across different ministries of secretariats to pull together data on young people from different areas, on economic, social wealth and health, etc. A very good try and they did their best. And one of the areas they were looking at, I noticed, education and they saw that young people with living in a home that was bilingual in America had greater difficulty in learning English earlier on in their school careers and so they put this down as a problem, right? There was no attention however to any advantages of living in a bilingual home, the fact that you were exposed to two cultures, not just one, the gains that come from that. Well, I do not want to be hypocritical, but perhaps you can see what I mean. We lose sight of the values of cultural diversity. It’s no question in my mind that if I learnt anything over the years it’s because of exposure to different cultures, it forces you to think and re-organise your own value systems. So the untapped issue of what can we gain from different cultures, what can the UK gain from looking at Africa, India, Asia, Latin America, a very great deal, in my opinion, it’s not obviously a one-way street, but the Western world tends to forget that. Saying the Western world you know what I mean by that.

Second issues has to do with resources and that’s how can we get community support, I don’t mean just money, but community support, backing for action that we think is important. How can we build consensus, get people not fighting each other, but joining forces. This is true also of course at a national level when different bits of government do different things and internationally. I probably know more about international level than national one in fact, and the international level is less important in my opinion. The closer we get to the local work, the more things happen, but there is a certain value in gaining support, governments do pay some attention to the international level consensus.

Just to round off by saying two things: the UK is very impressive and I know a little bit about Youth Support and it seems to me that much of the things I’ve been talking about have been going on here for many years anyway, you know better than I do about that. And the second thing is, and I do have a positive and optimistic outlook I think at the changes taking place in the world with respect to young people. The main reason for that is that young people are becoming more and more actively involved and every person I’ve come across who’s sceptical about adolescent health and development who’s had one experience of working with young people changed his mind. I’ve never seen a more magic formula for getting positive impact. Thank you.

DB: We’ll have one or two questions. Certainly there were a few points that came up in your talk that I found were very interesting. The focus on development is very important especially as I started life as paediatrician and you know, we all focus a lot on the development of a young child, don’t we, but as we’ve seen in other meetings as well that development of adolescents is so important in putting all these different aspects in perspective. I liked what you said about a link between generations because we’ll see later this morning, Liz is going to say something about our lunch club where we have an ‘adopt a gran’ approach because a lot of our families, the kids don’t only not have families, the kids don’t have grandparents and I think it’s an enormous loss. Being bilingual I also share your concerns regarding the undervaluing of cultural diversity.