Co Chairs - Diana Birch   Gustavo Girard       Treasurer Aric Schichor

                    London          Buenos Aires                         Connecticut

                    England          Argentina                           USA

Workshops /  Institutes  - Our 2000 Chapter workshop SAM 2000 -  ‘Youth in a Violent Age – The Challenge of the new millennium?’ is reported below bringing us up to date with the SAM IRC proceedings.

As reported in the last Journal - The following proposal for an Institute has been submitted to SAM for the 2001 meeting in San Diego. Please send in contributions and suggestions - Marianne Felice, Dick Mackenzie and Dick Brown will be joining us.

‘Youth in a Violent Age – The Challenge of the new millennium?’

International Regional Chapter Workshop at SAM 2000

The following is a summary of the discussions and presentations which to an extent overlapped - this workshop was marked by a good interactive format and hence individual presentations merged with discussion - a true ‘work’ shop effort! Discussion was led by Diana Birch (UK), Gustavo Girard (Argentina) and Hatim Omar (Kentucky) with contributions from 26 USA and International based SAM members.

Opening remarks - Gustavo Girard  - Looking at violence from a general point of view, from personal experience rather than from a research or quantitative perspective - What forms of violence do we come across in our every day practice?  Social violence can be pernicious and often not immediately obvious. The lack of opportunity presented to our youth, violence associated with various behaviour styles and subcultures such as prostitution and drug abuse.

The following questions present themselves What is violence, what does it mean  and how do we define it?

Group brainstorming led by Dick Brown and Diana Birch over a few minutes provided numerous examples - verbal ,TV, physical, sexual, self destructive, self harm, vehicular, gang violence, gay bashing, extreme sports, suicide, poverty, starvation, computer violence internet, war, domestic violence, witnessing violence, genocidal abortions ( i.e. selective forced abortion of female foetuses) , Munchausen and Munchausen by proxy, political violence, animal cruelty, random or directed violence, indifference and neglect, violent play and games, laser tags etc.

The apparent lack of value in human life and lack of general values. Can institutions become guardians of violence and perpetuate violence? What is the role of the police for example? In some societies they can protect from violence and in others seen as perpetuators of violence. Do our institutions and the institutional response of the law foster or prevent violence?

 Our frequent anonymous way of living can foster these ‘perverse’ values. Anonymity means lack of identification with the individual - lack of perception of connection to the individual.  Loss of personalness thus meaning that the individual is not perceived as  a human being and can be detached from. Thus perhaps we have road rage where we detach from our reality and enter a false world as if we are on a video screen.

Institutional violence - bureaucracy frustration can engender violent reactions - getting upset when waiting in line for example. Seeming pettiness of bureaucracy or school rules raising irritation and aggressive reactions.

Should we attempt to divert the energy and stress building up towards violence by engagement in other activities - e.g. sport? Does violence become more pronounced to ‘fill the space’ when youth do not have anything to do? For example in after school period when perhaps parents do not return home until 6 and school ends at 3? Do after school programmes help?  Kids who are most at risk are often those who are suspended from school and excluded from support schemes - these need school etc most - an alternative to exclusion must be explored.

Intervention needs to provide boundaries. Professional need to be confident enough to impose boundaries. Without this kids think you don’t care enough. They are very scared of their own power and aggression if adult cannot impose boundaries and will escalate until you do or until a crisis occurs..

It is probably when such programmes are linked to workers or individuals with which youth can connect and form some kind of on going connection - not just as a pastime provider - a means of keeping them busy and out of trouble - it needs more than that. Connectedness with an adult has been shown to be very important in preventing all kinds of adverse behaviour (Bob Blum) . Also this connection should be long term. A relationship with constantly changing individuals is not so beneficial and may actually be harmful in terms of feelings of abandonment. It has been said that two and a half years is the cut off period - longer relationships are positive and shorter term negative. (c.f. Gallagher lecturer James Garbarino)

Cultural issues are important in discussing the axis of violence / abuse / punishment or chastisement. Levels of say cruelty to animals etc also vary from one culture to another. How do we deal with this? Should we consider a norm or accept cultural variation as alternative norms?

Value of human life - respect for the individual. Detachment from the fact or possibility of death and serious harm are important issues - like a child believing in the cartoon characters who can get up and carry on after being killed, squashed, pushed off cliffs etc. Theme continued in video and arcade games, in media and films. Desensitising from act of killing and firing at people in training of troops with video games - our youth are being ‘trained to be capable of killing’ . Whether they kill or not is due to other factors - but ability to kill is being fostered.   Kids who are shot complain that they did not realise it would hurt. Detached from reality of being shot. Lack of empathy with victim if you depersonalise and also of course some may have personality disorder and psychopathic tendencies which would emphasise this point.  (c.f. Gallagher lecturer Garbarino who referred to PTSD - 98% of young soldiers showed signs of stress disorder if exposed to 60 days continuous combat and those who did not show such a reaction were psychopathic)

We depersonalise people in warfare - the enemy seen as ‘something different’ a group which do not have individual or ‘human’ characteristics.  This is similar to the animal reaction of ‘pack’ behaviour as opposed to individual personal behaviour. In kidnap situation or siege - the victims are at first seen as just that - impersonal victims or subjects - getting the captors to use their first names, to see them as individuals and people will improve survival and chance of a positive outcome.

Depersonalisation within games and cartoons or media has another facet too - it is encouraged that the ‘baddie’ is killed and the good person survives - there is no mourning for the death of the ‘bad’ such life is expendable and valueless. There are also perverse values expressed in shows such as ‘South Park’ where one child is killed each week - what message does that give?

A developmental view of violence was expounded by Diana Birch and further discussed. ( see also JAHW  vol 13  no 2 )    Beginning with Object relations and the Winnicottian concept of mirroring - unpleasant feelings in the infant being mirrored by the ‘mother’ figure and reflected back to the baby in a way that can be coped with. The concept of false mirroring and lack of mirroring both producing potentially pathological scenarios with children developing into youth who are unable to cope with their angry and aggressive feelings.

Lack of mirroring and lack of responses - i.e. being ignored is more harmful than being the recipient of negative feelings - i.e. negative responses are better than no response. No response means you are valueless. If you don’t value yourself you cannot value others and hence lack of empathy , lack of appreciation of harm delivered to others - so can become violent. If professionals detach too far from youth and fail to give youth a nurturing or ‘parental’ figure they can also echo the lack of mirroring - the youth can become depersonalised therefore by professionals and by institutions.  ‘It doesn’t really matter what I do - because I don’t matter.’

Problems in war zones and refugee status. Depersonalisation and dispossession. Lack of identity and connectedness again. In middle east - dual problems. The Israeli army who have recruits as young as 17, have a very high suicide rate particularly among these youth. Palestinian youth have been raised over past decades to have no real citizenship, no security in possessions, no sense of belonging. No citizenship hence their first human right removed at birth. Unable to attend school at times and education went underground. A paradox arose in terms of schooling being forbidden hence going underground and becoming acceptable and something sought after by youth - rather than perhaps the high truancy rates we have in some urban areas in Europe and USA. Education became a way of winning’ of keeping ahead.   (Ref. Defence of Children International)   Thus there has been no increase in suicides among Palestinian youth because they are fighting for survival and this involves surviving as a race. Different concept adopted by Israeli and Palestinian youth although both involved in a violent conflict.

What do we do with anger? We need to be angry with action and not with person or we perpetuate denigration of individual - lack of self worth etc.  Attacking the integrity and worth of person is worse type of violence.   Powerlessness and poor sense of self coupled to poor self esteem is at basis of most youth violence.  Frustration and lack of communication - they need to be listened to.

Everyone of us is exposed to violence. How we respond depends on development, personal conditions and ability to be resilient. The lower the ‘energy level’ ie less able to adapt, lower resilience and flexibility - the higher the passivity with more internalisation of feelings - anger hatred, lower self worth, lower coping skills  and thus the more likelihood of self hatred, self harming behaviours. As abuse / experience of violence becomes more frequent and more commonplace the individual may become more hardened and ‘acculturated’ to the experience and thus more fixed in the adopted role or behaviour pattern of behaviour and feeling.

The response to violence must not be the same as that which caused the violence.

Parenting and support is an important part of public health measures - we need a holistic approach and need to work on the strengths of youth rather than look at problems. How do youth cope in a positive way - what are their resources and how can we harness and empower them?

Risk taking is a normal part of development. Good parenting fosters ‘safer’ and ok risk taking - as the Bowlby concept of exploring from a safe base. We need not to target specific issues which are mere symptoms of the malady of youth - a holistic approach is needed.

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

Risky behaviour in adolescents

Joan Carles Suris

I trained in adolescent health in Minnesota a few years ago and I learnt a whole bunch of things there. And one of those things was that whenever you are giving a speech you are supposed to have an opening remark. Some kind of ice-breaker that gives an idea of what you are going to be talking about. I was thinking about an opening remark, when I started having problems, because what I am going to be talking about is risky behaviours and chronic illnesses. Every time I talk about chronic illness I use what I call my “grandmother overture”, which is a story about my grandmother. But unfortunately, I used that story last year, so I thought, you can’t repeat that. So I really worried about it. But I am a lucky guy and last Sunday we had a family dinner at my parents and after dinner we were talking and I said, you know, I have a problem, I don’t have an opening remark for my talk in London next Friday, and my father stood up and said, well, I may have something that can help you. So he went to his room and took out a bag of old, old slides and took out a bag that read on it “London 1975”. And he said, well, maybe you can find something here. Here is what I found - Well, I thought about risky behaviours, here you have a guy on top of something, no safety net under him – that’s a risky behaviour. Here he is smoking, another risky behaviour, and rowing on the Serpentine with no life-jacket, this is also risky behaviour. After looking at those and making sure my kids didn’t see those pictures, I thought, I should make a copy of these ones and have them in the drawer in my office, because you know, parents come very often and say, you know, have you seen how kids dress these days, it’s in the middle of the winter, and they have just T-shirt they go out with, just a T-shirt, of course, they have cold afterwards. Well, that was a wonderful flannel shirt, I can tell you, on top of a very nice T-shirt and this is London 1975 August, probably one of the hottest August you can remember in the 1990s, so things are like that, I looked younger then again. OK.

Let’s be serious now and talk about risky behaviours and chronic illness. There is the general sense that adolescents or kids in general with chronic conditions are almost “saints”. They do as they are told, always take medication, obey doctors’ orders. When you read the literature, you find this is very far from reality. What I wanted to do with my colleague Nuria Pareda was to see if there were many differences in risky behaviour between kids with chronic illness and those who have not. Because when we talk about disease with people, when we ask for money to do studies on chronic illness, they say, is this really that important, do we have many kids with chronic illness? In France, Switzerland, Sweden or Canada around 10% of adolescents have a chronic condition. It’s difficult to find prevalence rate, because it depends on how broad the definition of chronic illness is. We used the data of adolescent health service in the city of Barcelona in ’93, we surveyed over 3 thousand kids in schools in the city of Barcelona, it was a random sample of kids 14 to 19 and from this survey we took a sample of 162 adolescents, 100 of them females, with the history of cancer, epilepsy, diabetes or asthma. For the asthma kids we only took those who reported that asthma somewhat interfered with their daily activities. We took a control group of over 700 kids, more of 300 of them being females, who answered “no” to all questions related to pathological conditions. We compare and see whether there were differences between them separating male and female data because we know that boys and girls have different behaviours.

We looked first at families, the age was about 16 in both groups, about 10 to 15% of them had their parents divorced. When we looked at the relationships with their parents on the scale from 1 to 10, where 10 would be wonderful relations or a little lower, significantly lower in those with chronic conditions. Most of them, around 90% had brothers or sisters, and again they had worse relations with their siblings, the girls who had a chronic condition. When we looked at the boys, very similar, around 16 years of age, about 10% of parents divorced, no differences in the relations with their parents, pretty good, 7.5 of 10. Most of them had brothers and sisters, and again no differences in the relations with their siblings.

When we looked at school, because one of the things when you read literature about chronic illness is that you get the idea, that those kids have a lot of school problems. They attend school less often because of their therapy, or treatment or whatever, their disease, and they seem to go behind their colleagues. At least in our study this business seem to be good, most of the girls, almost 90%, like going to school, a low percentage have low grades – 15 to 18%. Only 30 to 38% of them are in vocational schools, and that’s important because in 1993 when this survey was done, when you finish primary school by the age of 13, you could choose between high school or vocational school. And that was the theory, the practice was, that if you were a good student you would go to high school, if you were a not so good student, you would go to vocational school, and again 30-38%. Relations with teachers features around 6 to 10. And only 7 to 12% had no project after school and not having a project after school, meant not knowing if after finishing high school or vocation school they wanted to keep studying, they wanted just to work or they wanted to do both things at the same time.

For boys, again high percentage like going to school, around 1 in 5 have low grades. See, here we have 30-38, here is 40 something were going to vocational school, worse relations with their teachers. And again, 13% had no project against 23% of them.

When we looked at health indicators, as expected we looked at health perception, again on the scale from to 10 where 10 would be excellent health. Girls with chronic conditions considered they have a lower health perception and this is logical. But there are no differences in seeing a physician and we know from the whole sample, that girls go to the physician more often than boys in general, but only 14 to 16% of them could talk with their physician, with their primary care physician about any problem that bother them. We asked them, if you cannot talk about anything you want with your physician, what are the reasons? The reasons were as expected, lack of confidence, there is always an adult with me, he or she will call my parents, he only talks about medicine, he never talks about nothing, or other.

When we look at boys, again low health perception, 7 against 8, more likely to have seen a physician and low percentage of kids, who can talk to their physician about any problem that may bother them.

Another of issues of chronically ill kids is abuse. Girls with chronic conditions are significantly more likely to have been physically abused, 15 against 4%, and they were slightly more likely to ever tell someone about being physically abused. They were also significantly more likely to have been sexually abused, 17 against 7%, but no difference in telling someone.

When we look at boys, more likely to have been physically abused, 13 against 5, no difference in ever telling someone. Small numbers so no differences in ever being sexually abused, although the percentage is the double the control group and no differences in ever telling someone.

By this point we thought, do these kids have more emotional problems than their healthy counterparts, because when you look what has been written about it, there are great discrepancies. There are authors who say, they have more emotional problems, there are others who say, there are no differences between them, there are others who say girls do, boys don’t, also boys do, girls don’t, etc. So we tried to see if there were really difference between them, and we learnt just 4 things. Three items on depression, sleeping problems, eating problems, lack of appetite and easy crying, and only for easy crying was there a significant difference. But there was a big difference in suicidal ideation, almost 1 in 4 girls with a chronic condition had ever had suicidal ideation against 7.4. For boys, we published a few years ago a brother study  that also found no difference so we don’t know, if  at least in Spain, boys don’t cry or if they do cry, they will never tell you.

On of the results that struck us from our study was what we call vehicle-related behaviour. One in4 or 1 in 5 kids have ever driven while intoxicated. Around 30% of those girls in both groups have ever been in a car with intoxicated driver, one half of them always use the seat belt, and around 70% always use a helmet. In Spain no matter how big the motor-cycle you are using, it’s mandatory to use a helmet, you have to use it all the time, OK, just around 60-70%. When we looked at the boys, 3 out of 10 have ever driven while intoxicated and 4 of every 10, around 27 to 38% had been in a car with an intoxicated driver, over half of them always use seat belts and again between 66 and 71% of them always use a helmet.

We looked at use of tobacco, alcohol and other illegal drugs and around 3 out of every 4 girls have ever tried tobacco no matter whether they have a chronic illness or not. Almost 80% have ever tried alcohol and this is not a very good indicator, because we only asked if they had ever tried alcohol, and you know, Spain is a wine-producing country and it’s very often that kids when they are very young, at dinner time or at lunch time they have a glass of water with a little bit of wine in it just to get some colour, it would be very strange to see a typical Spanish family having dinner together drinking milk, it would be something for people who have been living in the States probably, but not for people living really in Spain. So this is not a very good indicator. But again, 15 and 10% have ever tried cannabis, and 11% of girls with chronic condition and almost 5% of the others have tried other illegal drugs, and this difference was significant, statistically significant. For boys, 63 and 71% ever tried tobacco, around 77 and 83 ever tried alcohol, cannabis – more frequent in the control group, but the difference was not significant, and other drugs – around 10 to 15%.

Finally we looked at the sexual behaviour. There were slightly more girls in the chronic illness group who were sexually active – 16 against 12%. One third of them and one fifth of them used an unreliable contraceptive method and we understand by non-reliable using withdrawal or using no method at all. One in 4 had her first coitus before the age of 15, and 6.7 had had 4 or more sexual partners in his life-time. For boys, no difference in their sexual activity, no difference in non-reliable contraception. More frequent first coitus before the age of 15 and 1 in 5 approximately – 4 or more partners.

One of the things that we can conclude is that adolescents with chronic conditions are much less likely to receive any kind of guidance or any kind of prevention, just because of what I said in the beginning, we thinks that they are saints or they are kinds who don’t need that. And one other thing that we don’t remember is that even if they happen to have a chronic illness, they are still adolescent.

The study has some limitations. The first is that we did a survey on kids who are in school and that’s important. It means that their health is good enough to be able to attend a regular school. So we excluded those with more serious problems. Also it was based on a self-administered questionnaire and we will never know how severe their disease was.

I wanted to finish with a cartoon you probably all know about – a Calvin and  Hopes - Calvin the kid said to Hopes, “You know Hopes, my motto in this life is “live every moment intensively”. You have to live every moment the most you can, because you don’t know what the future can bring you, you know, you may cross the road and the truck may come and hit you and it’s all over. So you have to live every moment the most you can”. -  “What’s your motto Hopes?” And Hopes answers, “My motto is “look at both sides of the road before crossing”. And what we want the kids to do, because the reward, as Bob Blum used to say, is a socially competent and fully contributing adult.

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

Effects of the Kobe Earthquake on young children

Dr. Yuka Okada - Associate Professor in the Faculty of Human Development at Kobe University and a practising paediatrician.

Kobe is working area of Japan near Kyoto and Osaka. It is about 100 km distance from Tokyo.

In Japan the number of children who have psychosomatic diseases, behavioural problems and developmental problems has been increasing recently. We started at the developmental behavioural paediatric clinic to treat the children from physical aspects, but also from psychological and social aspects in 1990. Developmental behavioural paediatrics means paediatrics where patients are treated from biological, psychological, sociological, ecological and cultural aspects. We are working in collaboration with child psychiatrists.

The study addresses the psychological aspect of the Kobe earthquake. The people of Greece, Turkey and China have suffered recently from earthquake disaster.

Just before the dawn of January 17^th in 1995 the Kobe area was hit by the extremely strong earthquake. Over 6000 people including over 40 children died in the few seconds. More than 500 children lost their parents. In addition one fifth of citizens lost their houses and more than 250 thousand people were evacuated and lived in shelters. Many school buildings were used as shelters.

As paediatricians and child psychiatrists we made manuals in order to educate health, medical and educational professionals and we consulted the children who showed emotional symptoms. Through these activities we found that the parents found children’s behaviour changed, worsened. As a part of these activities we started the project to follow up the children in order to know the psychological effect of this serious disaster for young children and to seek a proper supportive approach.

We planned interventions with 240 children from 3 kindergartens in Kobe. We started the interventions one month after the earthquake. The first focused on teachers. We started our activities of mental health care by sending questionnaire about how the tragedy affected children’s behaviour. We did this survey with teachers and we discussed the children’s problems and how to deal with problems properly.

The second phase was a direct service for mothers and children .We saw a group a group of parents to hold a question-answer meeting on mental health of children after disaster. I personally met them, heard of their terrible experience and gave advice to those who needed help from us.

The results of our questionnaire at one and a half months after the earthquake were compared  with  those of the children in Miki city, which is next to Kobe city, and was not so severely damaged. In Kobe city one child died and 12% of children had completely destroyed houses.

Fifteen of 65 items from the questionnaire showed a significant difference between the groups. Common characteristic of the behavioural changes at this age are agitation and irritation, separation anxiety and other aggressive behaviours. Physical symptoms: general anxiety, post-traumatic stress disorder related symptoms. We experienced a higher level of hyper arousal and activity which was commonly noticed, but avoiding and numbing symptoms are not a common thing at this age.

The children who stayed at shelters seem more agitated and irritated to the point of becoming explosive. They seem to have more serious problems than others.

We did another survey for paediatricians in the damaged area for children below 6 years old. Regressive behaviours were the most common problems in  the group of the children under 6 years old, they could find all types of  problems. For example, sleep problems, restlessness, recurrent abdominal pain and depressive symptoms.  Paediatricians directed the mothers not to worry about it and to hold the children and to take much time to stay with them. Many children needed the feeling of safety and being held. For the young children it was the most important treatment to make sure of their emotional security base.

A 5-year old boy who lost his mother and the baby, whispered to his teacher several hours after the earthquake, “I’ll tell you a secret - My mum and the baby were dead. Now only my daddy and I are left”. He asked the teacher  never to tell of this to anybody. It’s secret.  The fact which was of course  absolutely clear for adults, but it was important that it should be kept a secret for the young boy. We should keep in mind, each child has an individual developmental character of perception, of recognition and expression.

The results of a questionnaire for their parents at 5 months and at 14 months after the earthquake showed that the avoidance level had increased and their experience of events were common  regarding avoiding and numbing behaviours, although many of them tended to take a pessimistic view of the future, most of them realised, family bonding had become tighter and that they had learned a lot about life. Four years later over 90% of them thought the same.

Though our work we came to believe that certain children had a particularly high risk of emotional problems. First, the children who had any developmental behavioural family problems before the earthquake. Second, the children who lived separately from their parents and family after the earthquake. Third, the children who had lost their parents.

In Japan the care of the children who have lost their parents is not well developed. A boy who lost his father painted a black rainbow. The black rainbow touched the hearts of the people who cared for him. They deeply hoped that this rainbow would become a colourful rainbow. Then the foster care house for the children who lost their parents named Rainbow House was built and started this year in Kobe with individual donations. Many young people from all over Japan contributed to this charity and collected money for the house.  In fact, we experience the conflict between the people who have gradually survived and who have not survived. We think the social healing approach is needed  in our society.

We did this project as a collaboration with JSPP and Chaga. JSPP is a small academic association which consists of child psychiatrists and paediatricians. Chaga is the group. It started at the Kobe earthquake as an avenue for specialists in child care to become involved in voluntary activities. The members are medical doctors, psychologists, social workers, teachers, students and journalists. We have learned key-points of child mental health-care after the Kobe earthquake.

Basically we had to develop a network of child mental health in the community. In the emergency situation the network worked quickly and effectively. The voluntary workers worked in collaboration with community network. We are sure that this is very important from a society and individual point of view and provided a family-centred mental healthcare for young people.

The people in Kobe area faced together the problem of co-operation and collaboration and professionals learned a great deal about the mental welfare and needs of children after the Kobe earthquake. We found that how working with the children encouraged not only their parents, but also the people around them. We would like to emphasise that we realised that children should be the energy for our society.

{This is a slightly abbreviated version of Yuka Okada’s talk which has also been included in the book on traumatic stress produced following our Italian conference since it relates to similar subject matter }