Originally published in The Ottawa Citizen September 20, 2004
Original Title: The Testes of Time

Young men rarely see their family doctor (if they have one). There is a tendency to think that nothing can really go wrong in your late teens or 20s.

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2. Detecting how well a cancer treatment is working in real time
3. Monitoring cancer treament response in real time

Originally Published in The Medical Post, May 11, 2004 Volume 40 Issue 19

As more adolescents adopt a meat-free diet, solid planning can ensure they meet energy and nutrient needs

Increasing numbers of adolescents, especially girls, are adopting vegetarian diets. Their reasons for choosing a vegetarian diet vary from animal welfare, health benefits and food safety to environmental and sociopolitical concerns. Surveys suggest that approximately 8% of adolescents in the United Kingdom and 6% of older elementary and high-school students in the midwestern United States consume a vegetarian diet.

Although vegetarian diets differ, the underlying principle remains the same. The human body needs adequate calories from fat and carbohydrates, specific nutrients and proteins. This can be accomplished with solid dietary planning but many youngsters do not follow an appropriate regimen. The “all things green” philosophy, although well-intentioned, does not provide a rational basis for proper nutrition.

Vegetarian lifestyle practices usually include exercise, reduced consumption of alcohol and avoidance of cigarettes, among other health-conscious decisions. Indeed, the vegetarian lifestyle is associated with a lower incidence of type 2 diabetes, obesity and heart disease.

Rapid growth cycles in childhood and adolescence consume nutrients at a rapid rate. Well-planned vegetarian diets can provide children with all the necessary nutrients that play a role in their growth and development.

The foods and supplements required depend on the degree of vegetarianism. There are five vegetarian categories:

• Semi-vegetarian: Meat is included in the diet occasionally. Some may consume chicken and/or fish but not red meat.

• Lacto-ovo vegetarian: Avoidance of meat, but eggs and milk are included.

• Lacto vegetarian: Dairy products are included, but eggs and meat are excluded.

• Vegan: All animal products, including eggs and dairy products are excluded from the diet.

It is not necessarily the type of vegetarian diet per se but the quality, variety and amount of food consumed that is relevant.

• Macrobiotic: Whole grains, especially brown rice, are emphasized and vegetables, fruit, legumes and seaweeds are included in the diet. Animal foods are limited to white meat, or white-meat fish may be included in the diet once or twice a week.

Vegetarian adolescents should eat a diet low in saturated fat and cholesterol and high in fibre, complex carbohydrates (such as beans and vegetables) and antioxidants.

High-fibre vegetarian diets tend to include less calorie-dense foods. This may create a sense of stomach fullness before enough energy is consumed. This is problematic for adolescents because of the great energy requirements during pubertal development.

Adolescents should eat frequent meals and snacks that include energy-dense foods such as whole-grain breads, enriched cereals, nuts, peanut, almond and cashew butters, tahini, cooked legumes, soybeans, sesame and sunflower seeds, avocados and dried fruits.

Food selection must be built around the consumption of essential amino acids. Animal-source proteins contain all the essential amino acids, but plant-based foods, except for soy, do not. Adding soybean products, complementary plants (such as brown rice to legumes or nut butters to bread), dairy or eggs will compensate for this lack. It is not necessary to consume all essential amino acids during the same meal, but they should be included over the course of a day.

Rapidly growing adolescents, especially menstruating females, require iron. Fifteen to 35% of the iron within meat (heme iron) is absorbed by the intestine, compared to 2% to 20% from plant sources (non-heme iron).

Certain chemical compounds within foods will bind with non-heme iron and prevent its absorption: tannins and polyphenols in tea and coffee form iron-tannate complexes that greatly reduce non-heme iron absorption. Phytates found in legumes, nuts, seeds, grains and soy will form insoluble non-heme complexes and reduce iron absorption.

Parents can encourage their adolescent child to choose from iron-fortified cereal, whole-grain or enriched bread, pasta or grains, legumes, dried fruit, green leafy vegetables, soy products, blackstrap molasses, bulgur and wheat germ. Milk and eggs are not good sources of iron.

Vitamin C will improve non-heme iron absorption. It must be consumed with the meal because of its mechanism of action. It will prevent the formation of less soluble ferric compounds, promote non-heme iron absorption and can counteract the inhibitory effect of phytates. A 75 mg dose of ascorbic acid increases the absorption of non-heme iron by three- to four-fold.

The addition of fruits and vegetables like citrus fruit, strawberries, broccoli and tomatoes can increase the absorption by three- to four-fold. Teens should be encouraged to consume vitamin C with every meal.

Zinc deficiency can lead to growth impairment, infections, diarrhea and pneumonia. Plant sources include whole grains, cereals, legumes, wheat germ and nuts. It is also found in dairy products, shellfish and meat.

Seventy-five per cent of the calcium requirements for children and adolescents come from the consumption of cow’s milk and dairy products. In the absence of dairy, calcium-fortified foods such as soy milk, orange juice, breakfast bars, waffles, pastas and cereals can help teens meet daily requirements. Calcium-rich foods do help, but large quantities would be needed. These include kale, turnips, mustard greens, broccoli, bok choy, dried figs, blackstrap molasses and lime-processed tortillas.

Calcium supplements can be used, but food sources are better because they include extra nutrients. Vegetarian children who do not drink cow’s milk should receive at least one calcium-rich or fortified food with each meal and snack. The daily calcium requirement for adolescents is about 1,000 to 1,500 mg per day.

Our bones attain peak bone mineral density by our mid-20s. Thereafter, bone mineral density will slowly decline. It is imperative that adolescents maximize their peak bone mineral density as a means of minimizing the debilitating effects of osteoporosis in later life. The principal dietary source of vitamin D for most people is fortified milk. Those who do not consume fortified cow’s milk, soy milk or breakfast cereal are at risk for deficiency that can lead to osteomalacia in adults.

Sun exposure and a dietary intake of 200 to 400 IU will maintain a healthy bone architecture. During the winter months, many can benefit from vitamin D supplements and enriched foods.

Meat, shellfish, eggs and dairy products provide virtually the only dietary source of vitamin B12. Without supplementation, many vegetarians, with the possible exception of semi-vegetarians, will suffer from vitamin B12 deficiency. This can cause anemia and nervous system dysfunction. Indeed, it is becoming all too common to uncover macrocytic anemias on younger people due primarily to dietary deficiencies.

Fortified meat substitutes, soy beverages, nutritional yeasts and cereals are good vegetarian sources of B12. Adolescents require about 6 mcg to 9 mcg daily.

The risk of nutritional deficiencies increases with the more restrictions within the diet. With proper planning, vegetarian diets are healthful. Dieticians are a valuable resource and should be involved with the adolescent patient’s dietary planning.

Related articles:

1. Trust, teens and the family doc
2. What teens want to know
3. Discourage smoking by appealing to teens’ independent spirit

Originally published in The Medical Post, VOLUME 39, NO. 29, August 12, 2003

By uncovering the motives of adolescent behaviour, you, your patients and the teens themselves all stand to gain

Your 15-year-old patient wants to go on the Pill. Why? What does she stand to gain from a sexual relationship? Does she fear her boyfriend will dump her if she does not take this step? If so, what does this imply about respect and the state of their relationship? What will they do if she does become pregnant?

My previous column discussed the stages of adolescent development and many of the problems children face as they progress toward adulthood. The “adolescent toolkit” is designed to help foster the development of age-appropriate behaviours and decisions, and promote independence based on respect, honour, dignity and integrity.

These staid qualities are not just words. Indeed, today they seem to be branded as quaint human characteristics from an era long ago. The tangible loss of these qualities contributes to the difficulties our children face.

Witness the willingness to sacrifice self-respect and honour for a chance at fame and fortune on the take-your-pick reality TV show.

The loss of the meaning of these words leaves many to act selfishly; we can do what pleases us as long as it does not harm others. This is first-order thinking—the concrete, immediate response to a problem or situation with little consideration of the consequences.

For example, teen sexual activity while living at home does affect the rest of the family. The family deals with the fallout if pregnancy or serious illness occurs. Drug and alcohol abuse acts like a virus, infecting everyone around it. The angst and stress due to illness, infection, surgery or depression is not borne alone by the individual.

The toolkit contains these important pieces: three defining questions, two “life rules,” the concept of true self versus false self and second-order thinking.

The three questions help many teens understand their concept of friendship, relationships and their self image:

• “What do you like and dislike about yourself?” This focuses on personality and physical characteristics and attributes.

• “What is good and bad about you?” What are their moral and ethical values? How does it affect their behaviour?

• “What are your definitions of a friendship and a relationship?” Many teens confuse the two or provide incomplete definitions. A starting point would include independence as a prerequisite in any relationship—two independent people contributing love, trust, compassion and support so their union exceeds the sum of each individual’s qualities with neither losing their sense of self.

One can discern possible contradictions and congruencies in the answers and use them to help the teen discover broader, more reliable and consistent definitions to use in their lives. It can challenge the first-order thinking inherent in their early and middle stages of development.

The life rules focus on two straightforward statements: “It is not what people say but rather how they act that reveals their true intent,” and “People always do things for a reason.”

Many teens choose to ignore these rules for reasons of discomfort, lack of support and feelings of hopelessness. They do not hold others accountable for their behaviour, in effect condoning it through their own inaction or denial. The undercurrent in this response is fear of rejection if they do not project an image of compassion and understanding.

For example, many of us have heard a spouse’s explanation of living with his/her alcoholic wife/husband as “He/she is great when they are sober,” and “She/he promised they would stop but they always return to their drinking.”

The alcoholic’s actions continually supercede their words of promise.

Yet the spouse continues to give one chance after another until the act loses its value. This damages one’s sense of self and independence.

The concept of the true self versus false self defines who we are. The true self usually discerns right from wrong. It is our conscience, sounding an alarm if confronted by something that threatens our commitment to be true to ourselves. People who follow their inner voice tend to respect themselves and their motives.

They become more self-confident and self-reliant. They are not afraid to say no.

The false self ignores the alarm. He/she knows the action is wrong but do it anyway. Frustrated with this contradiction, they direct their anger inward, damaging their self-respect.

Over time, this pattern of behaviour and decision making leads to a loss of independence. These people have difficulty saying no.

They try to solve everyone else’s life problems except their own, and rarely experience similar acts of consideration from others.

Before parents use these tools, it is essential they try to avoid first-order thinking. Visceral reactions (“Are you out of your mind?” or “What were you thinking?”) rarely solve problems. Second-order thinking invites the person to step back and ask a series of questions to uncover the true reasons behind a behaviour, action or thought.

It gives the adolescent a chance to reflect on their motives for their actions and holds them accountable in an adult framework.

Adolescents strive for independence. Appealing to this desire is a pragmatic means of providing a solid foundation of rules, limits and encouragement.

Mature and appropriate actions in response to the rules deserve respect: Parents can loosen the reins in an age-appropriate manner.

Flouting the rules should have predetermined consequences. The adolescent bears the responsibility of his or her decisions if they wish to be treated as an adult.

We can promote and nurture this desire for independence by using the toolkit in the office setting.

It is truly remarkable watching the changes as our patients travel the path toward adulthood.

Related articles:

1. Keep a well-stocked teen toolkit (part 1)
2. Like, do you know where your teen is?

Originally published in The Medical Post, VOLUME 39, NO. 29, August 12, 2003

Understanding adolescent developmental hurdles can help you explain to parents how they can meet the challenges of guiding their sons and daughters

More than 80% of adolescents do not experience the stereotypic “hellion” lifestyle and behaviour portrayed in the media. There is indeed adolescent angst, but often there is an identifiable cause: parental strife, divorce, laissez-faire approaches to discipline, lack of parental involvement and support, lax enforcement of the rules of the house, poor sense of self and depressive illness, among others. And sometimes, there is no apparent explanation.

The “adolescent toolkit” —a term I use to help me with adolescent issues—is an open-source approach that can provide a foundation for discussion between parents and their teens by acting as a neutral bridging intermediary. Physicians can introduce the concepts within the toolkit to parents to help them with the day-to-day challenges of guiding their son or daughter toward independence.

The responses to the kit’s questions and concepts are age-dependent. During the development cycle, adolescents migrate from more risky “what-were-you-thinking” behaviours to reasoned responses to problems.

Recent evidence indicates ongoing development in regions of the forebrain (responsible for abstract thought and reasoning) that continue until about the age of 20. It is not surprising to see a myriad of responses to similar events and problems. We all encounter mature teens and immature adults.

Adolescents develop different areas of interests, life and educational goals, and a sense of self through the three stages of adolescence. A parent’s response and guidance strategies must adapt to keep pace with this development cycle.

In the early stage of adolescence (girls 11 to 13, boys 12 to 14 years of age), puberty’s rapid physical changes directly influence the teens’ concerns about body image and sexual changes in comparison to their peers.

They have to adapt to new school environments and social structures. Given their stage of forebrain development, they are concrete thinkers, living for the moment with little belief in their own mortality. Their normal egocentricity leads them to think everyone is watching their every action and activity.

Their dependence upon their parents conflicts with their desire to be independent. A battle rages within them between the safety of childhood and the need to enter the new adolescent world. Often parents lament, “Steve used to go out with us on family outings, but now he wants to spend time with his friends. He can be like his old self at times and then be just impossible to deal with!”

In the middle stage (girls 13 to 16, boys 14 to 17), there is a consolidation of body image and sexual identity. Peer groups become their new family and safe haven and are a form of tribalism with all its rituals, markings and lingo. Peer pressure is the dominant behavioural influence. In their quest for independence they test their limits and compare themselves to their friends. Paradoxically, they conform to their peer group in order to be more independent.

In the late stage (17 to independence), there is a crystallization of identity. Career choices and plans for the future become important. After graduation, friends head off in their own direction. Peer groups become less important as intimate one-on-one relationships develop. Indeed, when leaving the tribe, they return to their family.

Adolescents face a myriad of challenges and experiences. Although dating and social interactions are an important element of adolescent development, for some it can become an all-consuming, romanticized process. They can become stuck in a particular stage of development, progressing no further. Drug use poses a similar threat. Some teens lose themselves within destructive relationships, ignoring friends and family. The actions and behaviour of their boyfriend/girlfriend may have a dominant influence upon their own moods and actions because of this singular focus.

So what can we do? Children must inevitably break away from their parents. The challenge is to maintain good relationships and avoid festering conflicts. Teens need and want limits with well-defined, consistent positive and negative consequences. Without these limits, they are adrift without direction. They usually test the rules of the house. Nevertheless, rules that are reasonable, age-appropriate and consistently enforced have the best chance of guiding teens through these times. They build upon this foundation on their path to adulthood.

Teens have many friends. Parents cannot be their child’s friend. Physicians can play an important role promoting this critically important concept.

We can point out that inevitably, situations will arise when the parent, adopting the friendship role, will have to switch hats. Friends do not tell friends when to go to bed. Their teen will let them know this in no uncertain terms.

If a teen is willing to accept praise, then they must be prepared to face constructive criticism for negative or poor decisions and outcomes. Angst, anger and sorrow expressed by friends and family to poor behaviour and actions are just as valid a response as elation and pride when they accomplish their goals. Welcome to the adult world.

In the next issue we will review the contents of the toolkit.

Related articles:

1. Keep a well-stocked teen toolkit (part 2)
2. Like, do you know where your teen is?
3. Adapt parenting to your teen’s development

Originally published in The Ottawa Citizen June 17, 2003
Original Title: The Adolescent Toolkit: Part II

Last week’s column discussed the stages of adolescent development and the normalcy of many of the problems our children face as they progress towards adulthood. The Adolescent Toolkit’s design is to foster the development of age-appropriate behaviours and decisions and promote independence based upon respect, honour, dignity and integrity.

These staid qualities are not just words. Indeed, today they seem to be branded as quaint human qualities from an era long ago. It is this tangible loss of these important characteristics that contribute to the difficulties our children face. Witness the depravity and willingness to sacrifice self-respect for a chance at fame and fortune on the take-your-pick reality show.

The loss of the meaning of these words leaves many to act selfishly. The idea that we can do what pleases us as long as it does not harm others is first-order thinking. First-order thinking is the concrete, immediate response to a problem or situation with little consideration of the consequences.

For example, teen sexual activity while living at home does affect the rest of the family. It is the family that picks up the pieces if pregnancy or serious illness occurs. Drug and alcohol abuse acts like a virus, infecting everyone around it. The angst and stress due to illness, infection, surgery or depression is not borne alone by the individual.

The Toolkit contains six defining questions, two “life-rules”, the concept of true versus false-self and second-order thinking.

Adolescence is like a dictionary in need of definitions. It is these definitions that help the adolescent understand themselves. Indeed, many adults fail to define these terms and continue to commit the same mistakes within and without their relationships.

I usually give my adolescent patients some “homework” after the preliminary evaluation to better understand their concept of friendship, relationships and their self-image. These questions are:

“What do you like and dislike about yourself?” This focuses on personality and physical characteristics.
“What is good and bad about you?” What are their moral and ethical values and its effect on their behaviours and actions?
“What are your definitions of a friendship and relationship?” Many confuse the two or provide incomplete definitions. A starting point would include independence as a prerequisite in any relationship; two independent people contributing love, trust, compassion and support so that their union or bond exceeds the sum of each individual’s qualities but never losing their sense of self.
The definitions change over time. One can discern possible contradictions and congruencies in the answers and use them to help the teen discover broader, more reliable and consistent definitions to use in their lives.

The two life-rules focus upon two straightforward statements: “It is not what people say but rather how they act that reveals their true intent,” and “People always do things for a reason”. Many choose to ignore these rules for reasons of discomfort, lack of support and feelings of hopelessness among others. They do not hold others accountable for their behaviour in effect condoning it through their own inaction or denial.

For example, I frequent hear a spouse’s explanation of living with their alcoholic wife/husband as “He/she is great when they are sober,” and “I have tried to get him/her to stop but they always return to their old ways”. The alcoholic’s actions supercede any thing they promise.

The concept of the “true” versus “false” self defines who we are. The true-self can usually discern right from wrong. It is our conscience that sounds an alarm bell if confronted by something that threatens our commitment to be true to ourselves. People who follow their inner voice tend to respect themselves and their motives. They become more self-confident and self-reliant. They are not afraid to answer “no.”

The false-self is best described as ignoring the alarm bell. They know their actions are wrong but they do it anyway. Frustration with their contradictory actions, they direct their anger inward damaging their self-respect. Over time, this pattern of behaviour leads to a loss of independence. These people have difficulty answering “no”. They try to solve everyone else’s life problems except their own rarely experiencing similar acts of consideration from others.

Before using these tools parents must do their best to avoid first-order thinking. Visceral reactions (“Are you out of your mind? What were you thinking?”) rarely solve problems. Second-order thinking invites you to step back and ask a series of questions to uncover the true reasons behind a behaviour, action or thought.

For example, your 15-year-old daughter wants to go on the pill. Why? What does she stand to gain from a sexual relationship? Does she fear her boyfriend will dump her if she does not take this step? If so, what does this imply about respect and the state of their relationship? What will they do if she does become pregnant?

Adolescents strive for independence. Appealing to this desire is a pragmatic means of providing a solid foundation of rules, limits and encouragement. Mature and appropriate actions in response to the rules deserve respect: loosen the reins in an age-appropriate manner. Flouting the rules should have predetermined consequences. The adolescent bears the responsibility of their decisions if they wish to be treated as an adult.

[Originally published in the Ottawa Citizen]

Related articles:

1. What teens want to know
2. Discourage smoking by appealing to teens’ independent spirit
3. Teens and the weed issue

Originally published in The Ottawa Citizen June 10, 2003
Original Title: The Adolescent Toolkit: Part 1

More than 80 per cent of adolescents do not experience stereotypical “hellion” lifestyle and behaviour. There is adolescent angst, but often there is an identifiable cause, such as parental strife, divorce, laissez-faire approaches to discipline, lack of parental involvement and support, lax enforcement of the rules of the house, poor sense of self and depressive illness. Sometimes there is no apparent explanation.

Some Citizen readers have asked about The Adolescent Toolkit. This open-source toolkit provides a foundation for discussion between parents and their teens by acting as a neutral bridging intermediary. It is a malleable framework designed for each family to use for their particular circumstance.

An understanding of adolescent developmental hurdles will help you get the most benefit from the toolkit. The responses to the kit’s questions and concepts depend on age. During the development cycle, adolescents migrate from more risky “what-were-you-thinking” behaviour to reasoned responses to problems.

Recent evidence indicates ongoing development of regions of the forebrain (responsible for abstract thought and reasoning) continues until about the age of sixteen.

Adolescents develop different areas of interest, life and educational goals, and a sense of self through the three stages of adolescence. A parent’s response and guidance strategies must adapt to keep apace with this development cycle:

In the early stage of adolescence (girls, 11 to 13, boys, 12 to 14 years of age), puberty’s rapid physical changes directly influence the teen’s concerns about body image and sexual changes in comparison to their peers. They have to adapt to new school environments and social structures. Given their stage of forebrain development, they are concrete thinkers, living for the moment with little belief in their own mortality. Their normal egocentricity leads then to think everyone is watching their every action and activity.

Their dependence upon their parents conflicts with?their desire to be independent. A battle rages within them between the safety of childhood and the need to enter the new adolescent world. Often parents lament, “Steve used to go out with us on family outings but now he wants to spend time with his friends. He can be like his old self at times and then be just impossible to deal with!”

- In the middle stage (girls, 13 to 16, boys, 14 to 17), there is consolidation of body image and sexual identity. Peer groups become their new family and safe haven and are a form of tribalism with all its rituals, markings and lingo. Peer pressure is the dominant behavioural influence. In their quest for independence, they test their limits and compare themselves to their friends. Paradoxically, they conform to their peer group in order to be more independent.

In the late stage (17 to independence), there is a crystallization of identity. Career choices and plans for the future become important. After graduation, friends head off in their own direction. Peer groups become less important as intimate one-on-one relationships develop. Leaving the tribe, they return to their family.

Adolescents face a myriad of challenges and experiences. Although dating and social interactions are an important element of adolescent development, for some it can become an all-consuming romanticized process. They can become stuck in a particular stage of development, progressing no further.

Drug use poses a similar threat. Some teens lose themselves within destructive relationships, ignoring friends and family. The actions and behaviour of their boyfriend/girlfriend may have a dominant influence upon their own moods and actions because of this singular focus.

So what do we do? Our children must inevitably break away from us. The challenge is to maintain a good relationship and avoiding festering conflicts. Teens need and want limits with well-defined consistent positive and negative consequences. Without these limits, they are adrift without direction. They usually test your rules. Nevertheless, rules that are reasonable, age-appropriate and consistently enforced have the best chance of guiding your teen through these times. They build upon this foundation on their path to adulthood.

Teens have many friends. Parents can not be their child’s friend. Inevitably, situations will arise when the parent who adopts the friendship role will have to switch hats. Friends do not tell friends when to go to bed. Your teen will let you know this in no uncertain terms.

If teens are willing to accept praise, then they must be prepared to face constructive criticism for negative or poor decisions. Expressions of angst, anger and sorrow from friends and family because of behaviour and actions are just as valid a response as elation and pride when they accomplish their goals. Welcome to the adult world.

[Originally published in the Ottawa Citizen]

Related articles:

1. Keep a well-stocked teen toolkit (part 1)
2. Teens and the weed issue
3. Trust, teens and the family doc

Originally published in The Ottawa Citizen March 27, 2003
Original Title: What society has wrought

One of the more difficult aspects of answering teen questions is the degree of angst and pain that spills from them. Although the majority of our teenage children progress through adolescence to become well-adjusted, productive adults, a substantial minority is desperate for help during life’s stressful events.

A recent annual Academy of Child and Adolescent Psychiatry meeting supports this view. A U.S.-wide survey of 3,242 teens and young adults indicates one-third experience a bout of depression. Two-thirds of this group fail to seek professional help.

The survey indicates that 36.4 per cent of teens between 15 and 19 experience a bout of depressed mood lasting two weeks or longer, at least once in their lives. About seven per cent have symptoms that suggest a major depressive disorder. Depression is a major health risk to teens.

The incidence of teen suicide climbs. “Less than 20 per cent of teens will tell a doctor about their (depressive) symptoms,” reports Dr. Stephanie Riolo of the University of Michigan.

“Of those who tell, girls seek help more often than boys do.”

This is similar to my experience at Canterbury High School clinics. Many teens are reticent and intimidated from seeking medical attention; they fear their family doctor will breach confidentiality and inform their parents. Some seek solace from friends or acquaintances, only to find the support underwhelming or ineffective.

The teen years are a time for personal growth and development. Adolescents develop different areas of interests, life and educational goals, and a sense of self through the three stages of adolescence. Although dating and social interactions are an important element of adolescent development, for some it becomes an all-consuming process. They can become stuck in a particular stage of development.

Drug use poses a similar threat. One observation made by the guidance counsellors and our medical centre at Canterbury is that many teens become trapped within destructive relationships. Friends and family are forgotten.

Some lose themselves in the relationship; their moods and actions are influenced by the actions of their partner. The dynamics of their relationship change if they become sexually active. There is the anxiety of infidelity, sexually transmitted diseases, pregnancy and the consequences of any of these concerns.

There are many reasons why this occurs: parental strife, divorce, laissez-faire approaches to discipline, lack of parental involvement and support, lax enforcement of the rules of the house, poor sense of self and depressive illness among others. Sometimes, there’s no apparent explanation.

This is not an indictment of parents but based on direct observation and interviews with the students.

Here, the students have their say:

Grade 9

“What do you do when you get so upset that you think people would be better off without you?”

“If my boyfriend has slept with another girl before, is it best to have him tested? And why?”

“If I had a friend who I thought was being abused by her father, should I come to you or what should I do?”

“A friend of mine is really depressed. And, he wants to die although he said he could never go through with it. He says that he can’t live like this any more, and that he won’t tell anyone until OAC, when he won’t see any of us again. I hate to see him like this. How can I persuade him to get help?”

“Depression and suicide run in my family. I’ve heard that it can be caused by a chemical imbalance and is curable. Is that true?”

“A close friend of mine has had a hard life. She’s been anorexic and bulimic for eight years now. She’s 5-foot-2 and 75 pounds. I’ve tried to get her help but they say she’s not ready for a program yet. I’m really worried about her.”

“I have a lot of problems and things going on in my life and I don’t feel like I have anyone to talk to. I’m worried that my problems are going to start taking control of my life and I don’t know where to turn. How do I get help and who do I go to?”

Grade 10

“I used to trust everyone but within the past two years three guys (who I was serious about) cheated on me and friends have betrayed me. Now I can’t trust anyone at all. Even friends I’ve known since I was a baby. How can I get over this trust issue and trust again?”

“Is there such a thing as a social anxiety disorder — when you are so wrapped up in what other people think of you, you don’t enjoy your friends or whatever.”

“I have a friend who is a frequent self-mutilator. I’m afraid her cuts will get infected. I’m not worried about suicide because she only cuts her legs but I’d like to know what is the risk factor of infection. She uses razors mostly but scissors sometimes. What can I do?”

“I started having sex a year ago when I was 15, and my vagina was very tight. My boyfriend could not reach full penetration, and once I blacked out. Why is this and what can help?”

Grade 11

“For years, my dad’s girlfriend hated me. She used to insult me and tell me my real mother hated me. She tried to run me over with her car. I told myself I didn’t care but I guess I really did. This I guess went on for four or five years and I’ve never talked about it. My new stepmother says that because I was older (11+), it didn’t affect me, but it does.”

“I’m very shy and am always trying to make people happy. I want to talk to someone but I’m afraid. I find that I get excessively angry and violent at times. When I feel this way, I feel like hurting or destroying someone or something. Is there something wrong with me?”

One is struck by the concreteness of some sexuality questions. There is little emphasis on the appropriateness of the activities described. Should our children have to worry about these issues? How can we prevent this behaviour?

Many teens are adrift, lacking direction and focus. Once they find someone they trust, they tend to stick with them. Trust provides the ability to influence a teen’s life. The goal is to minimize and if possible eliminate behaviours that are inherently self-destructive.

Related articles:

1. How do you get herpes?
2. What teens want to know
3. Survey shows youth drug use up in past decade

Originally published in The Ottawa Citizen March 26, 2003
Original Title: What teens want to know: Drugs

In this continuing series based on teens’ questions asked at Canterbury High School, today’s column looks at the drug issue, which is all too often intertwined with the issue of sex among teenagers.

The 2001 Ontario Student Drug Use Survey, a study conducted by the Centre for Addiction and Mental Health (CAMH) every two years since 1977, looked at legal and illicit drug use by more than 4,200 students from Grade 7 to OAC.

“The 1980s were a period of decline of drug use, the ’90s had a resurgence and in 2001 the good news is that illicit drug use among youth isn’t growing — the bad news is it’s still higher than it was in the early ’90s,” according to Dr. Edward Adlaf, the senior scientist at CAMH and associate professor at the University of Toronto who conducted the study.

For the first time since 1991, the survey did not show any year-over-year increase in drug use. However, most measures continue to be significantly greater than the 1993 rates. Alcohol remains the top dog in this department. In 2001, 63 per cent of students drank, versus 57 per cent in 1993.

Further, binge drinking — defined as downing five or more drinks at one time — was reported by 25 per cent of youth in 2001, compared with 18 per cent in 1993. Inebriation rates increased from 17 per cent in 1993 to 27 per cent in 2001.

Between 1999 and 2001, cigarette use declined from 29 to 24 per cent, solvents from seven to six per cent and LSD from seven to five per cent.

The student drug-use survey highlights include:

Students today are not using alcohol, tobacco or cannabis at an early age.
The percentage of new users has not increased over time.
Although rates of drinking and driving among licensed students remained stable at 15 per cent, about 32 per cent of all students report being a passenger in a vehicle driven by someone who had been drinking, and 19 per cent of drivers reported driving after using cannabis.
Perceptions about the risks of using cannabis, cocaine and LSD seem to be weakening over time.
Toronto students use alcohol at a lower-than-average rate, while western Ontario students report above-average use of cannabis, heroin, methamphetamine, cocaine, crack, hallucinogens and ecstasy. Northern Ontario students have a higher rate of alcohol and binge drinking.
Females reported higher rates of non-medical stimulant use, while males reported higher rates of heavy drinking, cannabis, glue, methamphetamine, LSD and hallucinogens.
Drug use was lowest among 7th-graders and highest among 11th- or 12th-graders — with the exception of inhalants, that showed greater use among younger students.
These statistics correlate with the questions students pose in the classroom. Teens want to know what drugs will do to them. Their questions are to the point and reflect an interesting dichotomy between immediate versus long-term harm.

They seek a frame of reference to compare the risk by invoking another drug or activity for risk assessment comparisons.

These Grade 9 questions reflect a desire to understand the issues:

“What are the side-effects of the drug mescaline? What is it?”

“My best friend used to be anorexic and bulimic and now uses a whole bunch of drugs. Her parents know, but they refuse to take action. All of her friends are the same way. What do I do?”

“How fast will smoking kill you, ’cause I don’t want to die?”

“Is it true you lose brain cells if you do drugs? If so, what exactly do drugs do to you?”

“How do I tell my parents about my drinking problem?”

“My friend throws up every time she gets drunk. This is normal, but the same things happens when she smokes marijuana. Is she allergic? If so, how can she find out the consequences of trying acid or other drugs?”

“Does alcohol stunt the growth of your boobs or anything else? Also, if you drink a lot as a teen but stop after a few years, will you have liver problems?”

“I’ve been doing drugs for a while and probably done just about every drug you can think of. I also get depressed a lot and I find drugs help me to escape for a while. I don’t want to quit drugs, but I want the depression to go away. What should I do?”

“I heard that smoking pot does not harm you at all because it is a natural drug, but all that is harmful is the smoke. Is this true?”

“Is there such a thing as a weekend alcoholic?”

“If one of my parents is an alcoholic, what are my chances of being an alcoholic?”

“Some of my friends that smoke weed, their grade-point average is going down. I smoke about two to three times a week, but it hasn’t really affected my school work. Why is that?”

“If you do drugs and have a high tolerance level, does it have the same effect on the body and mind?”

“What effect does cocaine have on a person if they done it just once? Or more?”

“What would be the difference smoking weed or smoking weed laced with cocaine?”

“How long do drugs stay in your bloodstream? If the doctor takes a urine sample, can they detect drugs?”

“When my friends are talking about drinking or getting drunk, it makes me feel very uneasy. What should I say to them? I don’t want them to get drunk. I feel very scared about alcohol and what it can do to you.”

Our teens want our help. Their questions call out for guidance through the maze of half-truths and peer pressure. Most parents have the unique opportunity to guide their children through the morass.

Related articles:

1. How do you get herpes?
2. What teens want to know
3. Club Drug Use Carries Uncertain Risks

Originally published in The Ottawa Citizen March 25, 2003
Original Title: What teens want to know: Real Questions, Real Answers

How have society’s changing attitudes about sexual activity and responsibility affected our teenage children?

The Medical Institute for Sexual Health, a U.S. non-profit group promoting sexual abstinence outside marriage, lists the devastating toll laissez-faire attitudes have had on our teens.

Its data are supported by similar reports by the U.S. Centers for Disease Control.

The medical institute raises concerns that providing sexual health information without moral context and consequence is harming our children.

The institute’s review of the data indicates that our children’s emotional and physical health is at risk.

Half of all 13- to 17-year-olds will become sexually active. Twenty-five per cent of all sexually active teens have a sexually transmitted disease.

Over 20 years, the prevalence (number of existing cases in a given population) of genital herpes in children 12 to 19 years old increased by 500 per cent. Chlamydia, a leading cause of infertility in women, occurs in one in 10 teenage girls, half of all cases in 15- to 19-year-olds. Human papilloma virus, a leading cause of cervical cancer, is reaching epidemic levels in the teen and young adult age group. Teenage girls with the virus are more susceptible to cervical cell changes that lead to cancer, compared with adult women.

Oral sex is a means for some girls to maintain they are virgins. Many do not see oral sex as being sexually active. Many teens do not even have a definition of what “sexually active” means.

As many as one in five of our teenagers are clinically depressed. Suicides have increased threefold in 30 years.

After nine years of giving health clinics at Canterbury High School, thousands of patient visits and hundreds of handwritten anonymous questions answered during classroom visits, these reports and statistics lead me to accept them for what they are: the truth.

Before writing me off as alarmist, please read what your children have had to say:

Grade 9

“What happens if when you’re having oral sex, you swallow sperm?

“If a girl swallows my sperm, will she be pregnant?”

“How is abortion performed?”

“What is the average of females being raped and beaten in the ages 14 to 16?”

“How does Viagra work?”

“As a male, if I impregnate a girl, what are my obligations?”

“Can you get pregnant without having sex?”

“My friend used to have a boyfriend who hit her and treated her like crap. He even used to use her for sex. Now he wants to get back together with her and she hasn’t made up her mind. As a best friend, what should I say to her to make the right decision without hurting our friendship?”

“Do males have to ejaculate or is it something they choose to do?”

“Can you arrange an abortion without our parents knowing?”

“Can a girl get pregnant if a guy ejaculates in a pool and she is near him?”

Grade 10

“Are there any risks for girls under 14 years other than pregnancy and STDs?”

“If you have intercourse with someone who has an STD, are you guaranteed to get the STD?”

“What is herpes? How can you get it? And how do you get rid of it?”

“My friend might be pregnant but she doesn’t want to have it. She doesn’t want to go to the doctor. She wants her friend to punch her in the stomach to kill the baby. I don’t think it’s right. What can I do to convince her to not do this?”

“Does the size of a man’s penis affect his personality?”

Grade 11

“Would it be safer to have sex now while we are younger, considering that the number of people who have AIDS is rising very quickly?”

“Is it illegal for a 15-year-old girl to be having sex with a 20-year-old guy? What if she’s 16?”

“Can you have an abortion when you are 16 without letting your parents know?”

“I just can’t handle it with the workload any more. I’ve had it trying to balance out school, homework, work, sports, friends and a boyfriend and especially parents. I’ve gotten to the point of nervous breakdown. I don’t sleep, hardly eat. I feel helpless. What can I do? P.S. What is hepatitis B and how do you catch it?”

These questions cut across all socio-economic and cultural strata. We must face this growing trend. We cannot ignore what is happening to our children. Many parents come into my office gravely concerned about their teen’s behaviour.

Teenagers, despite their protestations and efforts to act as adults, need guidance and support to become mature, caring adults.

The guidance centres on responsibility, respect, sexual behaviour and following the rules of the house.

Many parents try to be their children’s friend. The idea is the child will be more likely to accept you into their life. Parents hope they will have more influence on their child’s life decisions and actions.

This strategy, well-meaning and caring as it is, will not stand the test of time.

Friends do not tell friends when to go to bed. At some point, circumstances will dictate that parents will have to switch hats from friend to parent. Viva la revolucion!

Despite their challenges to your authority, teens do need their parents to be a foundation for morals, limits, rules, understanding and love, regardless of what the teens might say or do. Too many feel adrift in a sea of confusion. They need to know they can return safely to port.

As the questions above show, what possible benefit is it to a 15-year-old to have to worry about whether their boyfriend or girlfriend is cheating on them?

Why should they have to deal with the complications inherent in a sexual relationship on top of their educational, social and family responsibilities?

Why should they have to come into the office freaking out over whether they are pregnant or have an STD? Why are they worried about the effects of swallowing sperm? What can parents do? Quite a bit, but it is not an easy road.

Tomorrow night, Dr. Joanne Tannenbaum and I will present at the Citizen conference centre a forum for parents and teens called “What your teens want to know: Real answers to real questions.”

Sign up by e-mail at dworkinforum@thecitizen.canwest.com . Please include your name and phone number.

——————————————————————————–

Tomorrow’s column will look at teens and drugs.

Dr. Barry Dworkin is a family physician and an assistant professor of family medicine at the University of Ottawa.drbdworkin@hotmail.com

Read previous columns at members.rogers.com/barrydworkin/

Web Sites:

Medical Institute for Sexual Health: www.medinstitute.org

Centers for Disease Control: www.cdc.gov/nchstp/od/news/RevBrochure1pdf.htm

National Mental Health Association: www.nmha.org/infoctr/factsheets/24.cfm

Teen Sex: What You Need to Know

Saturday: The demise of dating: Why school kids have ‘buddysex.’

Sunday: In their own words: Students talk about hooking up.

Monday: In search of guidance: Health educators try to guide students through the morass and attempt to curb date rape by teaching the dangers of mixing alcohol and sex.

Today: Sex ed: What are they teaching our kids in elementary and high school? And Dr. Barry Dworkin on what teens really want to know about sex.

Tomorrow: High-school confidential: the Canterbury health clinic. And Dr. Barry Dworkin on kids and drugs.

Thursday: A look at what parents and teens have to say in Wednesday night’s public forum. And Dr. Barry Dworkin on the angst teens are dealing with on the subject of sex.

Friday: The consequences of the hooking-up culture: Where will society and divorce rates be in 20 years if we continue in this direction. And a reality check — teens are not the libertines they are portrayed as.

Public Forum on the Culture of Teen Sex

Parents, teens and others interested in the culture of ‘hooking up’ are invited to a Citizen-sponsored public forum held by Drs. Barry Dworkin and Joanne Tannenbaum, tomorrow at 6 p.m., at 1101 Baxter Rd. Register by e-mail at dworkinforum@thecitizen.canwest.com or by phone at 596-3664. Please include your name, phone number, and the number of people who plan to attend.

Related articles:

1. Students stressed, desperate for help
2. What teens want to know
3. Survey shows youth drug use up in past decade

Originally published in The Medical Post, VOLUME 39, NO. 4, January 28, 2003

Before she can improve relations with her divorced and feuding parents, a young woman must get to know her true self

As adolescents progress through their teenage years we bear witness to their emotional and cognitive development. Some sprout early and surprise us with their clarity of thought and insight. Others remain stuck in neutral for long stretches of time. This is one of the challenges of providing adolescent care.

Fifteen-year-old Caitlin falls into the former category. The reason she came to the high school clinic was her concern about the risk of an eating disorder relapse. About a year ago, she cut breakfast and lunch out of her diet. She did not binge or purge her meals. She did not have a distorted sense of body image or depressive illness. Her behaviour continued for several months then abruptly stopped.

She now remains stable and of normal weight. Her goal was to find out how she could prevent future recurrence.

Adolescent behaviours do not come vacuum-packed. When they seek help, an earnest empathetic approach creates an atmosphere of trust. Let them know you may be asking potentially charged or pointed questions. They need to understand that its intention is to help, not harm or anger them but to draw a clear understanding of their problem. For Caitlin, it turned out her eating disorder arose due to her parents’ post-marital strife.

Caitlin’s parents divorced when she was nine years old. Her father suddenly left the family to marry another woman. Her mother did not establish any new relationship and remains bitter and angry with her father. Many unresolved issues remain between them.

Both parents use Caitlin as a sounding board to snipe and criticize one another. They reveal marital details that she does not want to hear. Caught in the middle, she resents both for their actions.

She is angry with her father for breaking up her family yet still tries to maintain a father-daughter relationship. She tries to support her mother but is uncomfortable with being her mom’s confidant. This stress and worry consumes her. She bears the burden of being the intermediary for a situation she cannot resolve; her frustration grows. She has no control over her parents’ behaviour.

Further, her mother perceives that she is in competition for Caitlin’s love and attention. Tearfully, Caitlin recounted how her mother made it clear that she will not attend her graduation (two years hence) if her father brings his wife.

Instead of looking forward to one of the milestone days in her life, she faces two years of its use as a weapon to control her actions. Her mother, unwilling to resolve the issue herself, transfers the responsibility onto her daughter’s shoulders.

This is a fork-in-the-road life moment. How she handles these relationships and their inherent difficulties can affect the rest of her life and future relationships.

Already seeking solace from within her peer group she takes on the role of therapist solving their personal problems. Yet when she needs their support, they beg off with excuses that they have homework or are busy. Her response is to redouble her efforts, further ensnaring her in an unequal relationship situation: a response akin to her family dynamics.

The goal for Caitlin is to develop the tools to counter the guilt and manipulation on the part of both parents. Given her insight, it is necessary to provide a plan and establish short- and long-term goals.

Clearly, she desires a normal adolescence without the aforementioned burdens. She wants her father to treat her with respect and to spend time with her. Her love for her mother, cognizant that she is alone and now increasingly dependent upon her, hinders her ability to act. She needs a method to approach her parents to discuss these issues. She also needs someone in her corner to support her efforts.

Introducing the concept of true and false self, respectively listening to or ignoring one’s inner voice or conscience, adds another dimension to cognitive therapy. The true-self usually can discern right from wrong. It is akin to an inner voice trying to keep us true to our morals and beliefs. People who follow this inner voice tend to respect themselves and their motives. They become more self-confident and self-reliant. They are not afraid to say “no.”

The false-self follows a path or decision contrary to doing the right thing. The person knows their actions or decisions are wrong but they follow through with them anyway.

Sometimes others try to draw a person away from their true-self using guilt and manipulation, as in Caitlin’s situation. Other times it is the person himself or herself listening to an addictive or self-deprecating thought. The result is anger, frustration and loss of self-respect.

One approach is for Caitlin to write down and organize her thoughts. She has to define what friendships and relationships mean to her. She needs to identify and explore her good and bad qualities and her likes and dislikes. Helping her define these concepts gives her the initial foundation to confront present and future issues that will challenge her sense of self. Once this process is under way, she can focus on her parents.

Caitlin has difficulty discussing her concerns with her father. He consistently interrupts her train of thought. He will twist her words to suit his argument: an irritating and frustrating situation. Her goal is to get him to listen to her.

She is afraid of telling her mother it would be best if she talked about her issues with a friend instead of her. Caitlin needs to grow and develop her own sense of self. She cannot accomplish this goal if her mother becomes increasingly dependent on her for her emotional stability. Yet, she does not want her mother to feel rejected or abandoned.

The beginning of dysfunctional patterns between her mother and herself has grave implication for the future. Caitlin is aware that her future relationships and friendships will naturally move her away from her mother. Requiring more attention, her mother has already shown she is insecure with Caitlin’s foray into adulthood. Caitlin does not want to face the choice of moving away in the future to avoid her mother’s intrusions into her life.

The emotional challenge is overwhelming from Caitlin’s standpoint to talk to her parents face-to-face without some preparation. Caitlin can write letters to her mother and father in a non-confrontational manner explaining how their behaviour affects her. Writing it down reduces the argumentation inherent in parental discussions fraught with emotion.

One way is to look at her relationships as a series of contracts. Every relationship has a contract of needs, expectations and consequences. She should define her needs and wants and ask her parents to define theirs. They should meet to clarify and honour them. Enlisting the support of a counsellor as mediator could support Caitlin’s efforts.

Early to mid-adolescence is fraught with healthy and damaging events that define a person’s future interactions. Offering them the basic tools and support to use in these instances, combined with appropriate followup, can serve them well.

Related articles:

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