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Tuesday, April 25, 2006

An Appeal for Funds 2006

RURAL HEALTH CENTRE

REQUEST FOR FUNDING 2006

This is an appeal for funding for the health centre. This document should be read in conjunction with the Annual Report of 2006

SALARIES

Position

Monthly

Yearly

Yearly

INR

INR

$

1

Doctor (1)

10000

120,000

$2,727

2

Doctor (2)

10000

120,000

$2,727

3

Optometrist

3000

36,000

$818

4

Microbiology Technician

3000

36,000

$818

5

Laboratory Technician

2500

30,000

$682

6

Radiographer

2500

30,000

$682

7

Administrative Assistant

2500

30,000

$682

8

Dispensary Assistant

1700

20,400

$464

9

Sweeper

1500

18,000

$409

TOTAL SALARIES

36,700

440,400

$10,009

1

Building Maintenance

3,000

36,000

$818

2

Ambulance Maintenance

1000

12,000

$273

3

Equipment Maintenance

1000

12,000

$273

4

Printing & Stationery

500

6,000

$136

5

Telephone/Internet

1500

18,000

$409

TOTAL ADMINISTRATIVE

6500

78,000

$1,773

Patient Care Costs

PATIENT CARE COSTS

INR

$ Equivalent

1

Cost of treating one OPD Patient:

45

$1.02

2

Cost of treating one Cataract Patient with IOL:

1500

$34

3

Cost of treating one TB Patient:

2000

$45

4

Cost of treating and following up one Antenatal:

1500

$34

5

Cost of one Domiciliary Delivery

1000

$23

6

Cost of one Hospital based delivery

3000

$68

7

Annual requirement of Drugs

300,000

$6,818

8

Annual requirement for meeting costs tertiary care centres:

250,000

$5,682

TOTAL - Patient Care

559045

$12,706

CAPITAL EXPENDITURE

INR

$

Waiting room for patients (priority)

200,000

$4,545

Modifications to existing building for catering to patient load (priority)

200,000

$4,545

Generator 7.5 kva

150000

$3,409

Semi Auto Analyser for Laboratory.

300,000

$6,818

ELISA Reader for Laboratory:

200,000

$4,545

PC with LAN

100,000

$2,273

Housing for paramedical staff@ 600 sft/person. Total 1800 sft @ Rs 450/sft:

810,000

$18,409

1. All cheques/drafts to be drawn in favour of Rishi Valley Rural Health Centre. IT exemption u/s 80 G is available.

ADDRESS:

Rishi Valley Rural Health Centre
Krishnamurti Foundation India
Rishi Valley PO
Madanapalle 517352
AP, India
Tel: 08571 280622/280582 (Office)
08571 280573/280850 (Clinic)
Fax: 08571 280261

2. The RHC also has a tie up with ASHA for Education in USA, which will route cheques for us.

ADDRESS FOR SENDING CONTRIBUTIONS IN USA

Srijan Chakraborty
Asha For Education
Seattle Chapter
PO BOX 2407
Redmond WA 98073-2407

The cheques should be in the name of ASHA for Education. In the memo line please mention Rishi Valley Rural Health Centre. TAX ID NO: ASHA 77-0459884

NB. The RVRHC functions under the administrative control of Executive Committee of RVREC

Thank you for having taken the time and patience to go through this appeal. I do hope that you will consider our appeal favourably. Please feel free to revert to me with any questions.

Thanking you

Kartik Kalyanram MD

Coordinator Rural Health Centre

Email: rvsrhc@yahoo.co.in, kartik.kalyanram@gmail.com

Tuesday, April 18, 2006

BETWEEN ANGST AND SEXUALITY

ADOLESCENCE AND ADULTS

By

Dr Kartik Kalyanram MD

Rishi Valley School

Introduction

As a teacher, house parent and a parent, not necessarily in that order, I have often wondered at the seemingly irreconcilable differences between an energetic, impulsive, complaining, “immature” angst ridden adolescent and the staid, “mature”, orderly adult. Both adolescents as well as adults also quite unconsciously nurture this difference. We were once the same confused adolescent and now we are quite confused adults. Where do our sympathies lie – with the adolescent, without actually realising what the adolescent is going through (a harking back to the carefree youth) or with the ‘adult world/society” we are very much part of.

In this article I have attempted to probe questions of Angst, Sexuality and Substance abuse, which seem more worrying in today’s youth than at any time in the past.

Normal Adolescent Development

There have been many theories put forward to try and explain adolescent development. Many of them believe that there are definite predetermined, sequential steps through which all human beings pass through – be it physical, moral or psychosocial. Some of these theories and their relevance in today’s understanding of adolescent growth are discussed below.

Piagets theory:
Jean Piaget[1], a Swiss Psychologist, challenged a widely held theory that Children and adults actually think alike. This was based on the premise that children are physically just “miniature adults”, ergo they should be the same mentally and that the cognitive [2] processes of the two were similar.

Piaget’s Theory is a stage theory – suggesting that all human beings move through an orderly and predictable series of changes. However this assumption has been questioned in recent times simply because of the wide variability in individuals, which precludes such orderliness in human development.

Central to the Theory is Constructivism, which assumes children are learning all the while being active thinkers, constantly, trying to construct a more advanced and accurate understanding of the world around them. Children build this new knowledge by two ways – Assimilation and Accommodation. The former involves the incorporation of new ideas/knowledge into existing SCHEMA, a kind of a cognitive scaffold, a framework for holding knowledge and organising it. The latter involves modification of existing schemas as a result of exposure to new information or processes.

As with all theories, Piaget’s Theory has been the subject of careful assessment and a number of revisions suggested particularly in the context of cognitive abilities of preschoolers and infants (which is much greater than what Piaget believed) and most importantly for this article the importance of social interactions between children and caregivers in this process of cognitive development.

Kohlberg’s [3]Stages of Moral Understanding[4]

Kohlberg suggested that humans move through three distinct levels of moral reasoning, each divided into two separate phases. Kohlberg placed a series of moral dilemmas in front of individuals, e.g stealing food if one is impecunious and very hungry. Based on the reasoning and not the decision he placed individuals in a particular stage of development. An overview of Kohlberg’s Moral Development is given below:

Level/Stage

Description

Preconventional Level

Stage 1: Punishment and obedience orientation

Stage 2: Naïve hedonistic orientation

Morality judged in terms of consequences

Morality judged in terms of what satisfies own needs or those of others.

Conventional Level

Stage 3: Good boy – good girl orientation

Stage 4: Social order – maintaining orientation

Morality judged in terms of adherence to social norms or rules with respect to personal acquaintances.

Morality judged in terms of social rules or laws applied universally, not just to acquaintances

Post conventional level

Stage 5: Legalistic orientation

Stage 6: Universal ethical principle orientation

Morality judged in terms of human rights, which may transcend laws.

Morality judged in terms of self-chosen ethical principles.

Most adolescents will switch between Stages 2 &3, depending on what sort of dilemmas they were confronted with. Though Kohlberg stated that individuals do move through these se stages as they advance in years, in reality, we find that in real life situations, individuals could and will exhibit different behaviour patterns, which need not be commensurate with their age/maturity. However Kohlberg’s stages of Moral Development do help in identifying a particular set of responses to real life situations.

Erikson’s Eight Stages of Psychosocial Development

Erik Erikson’s[5] theory deals with development across the entire life span. He believed that each stage of life is marked by conflict or specific crises between competing tendencies. Only if individuals succeed in negotiating each of these stages successfully will an individual develop in a normal healthy manner. The table below summarises the eight stages of development.

Crisis/Phase

Description

Trust versus Mistrust

Infants learn to trust the environment (if needs are met) or to mistrust it.

Autonomy versus shame and doubt

Toddlers acquire self-confidence if they learn to regulate their bodies and act independently. If they fail or are labelled as inadequate they experience shame and doubt.

Initiative versus Guilt

Preschoolers (ages 3-5) acquire new physical and mental skills but must learn also to control their impulses. Unless a good balance is struck, they become either unruly or too inhibited.

Industry versus Inferiority

Children (Ages 6 – 11) acquire many skills and competencies. If they take pride in these, they acquire high self-esteem. If they compare themselves unfavourably to others they may develop low self-esteem.

Identity versus Role Confusion

Adolescents must integrate various roles into consistent self-identity. If they fail to do so they may be experience confusion over who they are.

Intimacy versus Isolation

Young adults must develop the ability to form deep, intimate relationships with others. If they do not, they may become socially or emotionally isolated.

Generativity versus Self-Absorption

Adults must take an active interest in helping and guiding younger persons. If they do not, they may become preoccupied with purely selfish needs.

Integrity versus Despair

In the closing decades of life, individuals ask themselves whether their lives had any meaning. If they can answer YES they attain a sense of integrity. If they answer NO they experience despair.

Adolescents adopt many different strategies to help them resolve their own personal identity crises. They try out many different roles, the good girl/boy, the rebel, the super cool, the dutiful child, the athlete etc. They may also try their hand at many diverse activities as they role-play through these various phases. They may also identify strongly with social groups and at times seem to flit from one to the other – much to the annoyance of us adults who feel that they cannot make up their minds. They consider many social selves and from all this form a self-schema. Once formed, this framework remains fairly constant and serves as a guide in many contexts.

Marcia[6] in 1991, suggested that adolescents can be categorised in terms of whether they have explored alternative selves and whether they have actually chosen one. Four patterns emerge:

a) Identity Achievement: Those who have gone through their crisis and made a commitment to one clear alternative.

b) Identity Moratorium: Those who are still searching for their identity

c) Identity Foreclosure: Those who have chosen an identity suggested by their parents or other authority figure

d) Identity Diffusion: Adolescents’ who have not yet begun their process.

Healthy Adolescents

At the risk of stating the obvious, one can see that adolescents are, developmentally, morally and psychosocially, in a turmoil. This turmoil plays itself out in front of our eyes. Yet we need to recognise the fact that these young adults are actually in the throes of growing up, akin to the labour pains a mother experiences as she is delivering. The pain is worth the end result, in most cases!

Adolescence Angst

Adolescent angst[7], an acute feeling of anxiety or apprehension that is often accompanied by depression, is a frustrating, painful, and occasionally frightening dilemma for teens and parents alike. One needs to be aware of the difference between potentially harmful behaviour patterns and normal mood swings, which are so much a part of adolescent life.

The Norms of Adolescent Angst[8]

There is a wide difference in normal behavior at ages 12 or 16 or 21. Broadly speaking adolescence covers three stages each with its own variations in moodiness and parental interaction.[9]

Early Adolescents. (females: 11-13 years; males: 12-14 years) Many children experience transient wide mood swings moving from euphoria to sadness in minutes. In most cases there are no predisposing factors. These changes could last for hours or days and are characteristic to this stage of development. [10]

This is the age where the peer takes on an overwhelmingly important role. Friends are in and parents/teachers – Forget it. Quite often argumentative with a disregard for rules, they challenge parental authority and tend to try out the different values systems of society and school. The importance of the school as a place where value systems originate cannot be underestimated. Same-sex best friends are crucial, and some early teens may engage in transient harmless homosexual experimentation. Sexual feelings develop in general, creating desires to watch sexually explicit movies or televisions shows, read sexually explicit magazines, tell sex-related jokes, and use foul language.

Teens are preoccupied with their selves and are intensely concerned with “being normal". They are also chalking out their own spaces and quite jealously guard their own privacy. Young teens spend hours in front of mirrors scrutinizing their appearance and grooming. The changes of puberty cause them to become extremely body conscious, creating worries about
acne, menstruation, nocturnal emissions, and body size. They become hypercritical of themselves as they compare themselves to friends and the unrealistic images portrayed in the media. Emotional reactions may overwhelm the early adolescent's ability to understand and cope. Young teens can easily become confused and frightened by the changes they are experiencing. They look for role models and it is not uncommon to find them in a fantasy world - daydreaming about unrealistic goals, being a hero, a pilot a fireman doing all sorts of saving the world stuff. Celebrities are often the focus of their fantasies whether sexual or as a role model. In fact it is a common sight to see adolescents walking around wearing T-Shirts with Che Guevera written on it. Most have no idea of what this iconic cult figure of the 60s/70s stood for. Football stars, Hollywood and Bollywood beauties and hulks could actually cover bedroom walls much to the disgust of the adult community. This interest, as well as their preoccupation with peers, may result in a temporary drop in academic performance in classes 5-8.

Middle Adolescents.[11] (females: 13-16 years; males: 14-20 years) : At this stage rules get rewritten as never before. Adolescents start asserting their authority, their feelings of self, identity etc. Naturally this brings them into conflict with the “regulated” adult world. Parental conflict peaks, authority is consistently challenged and they are forever arguing and attempting to negotiate/renegotiate rules. The Peer is the most important and all strive to conform though in their minds they are “rebelling” against authority and conformity! Designer gear, outlandish hairstyles and a weird dress sense leaves many an adult gasping. The peer group dictates communication style and conduct and nothing can be done without the peer accepting or okaying it. In fact many children find it difficult to stand up against the enormity of the peer pressure and though they would like to be different they buckle to the pressure.

This is also the age when sexual drives peak leading many into dating and sexual experimentation, with intercourse starting at earlier ages. In India, statistics are hard to come by but a WHO document puts the age of first sexual contact (about 16 – 20%) at 15-16 years and sexual intercourse at between 16 – 18 years (about 20 – 30%).[12] The latter figure includes those adolescents who have been married of, as is the case in Rural India. Recent surveys of city schools tend to confirm this picture of early experimentation with sex. Risk-taking behaviors like experimentation with sex, drugs, and dangerous activities occur more often at this stage of adolescence than the other 2 stages. These behaviors result from feelings of omnipotence and infallibility and the fact that they believe that "no one understands them."

On the positive side middle adolescents demonstrate increased thinking ability and creativity; however, they can also demonstrate "pseudostupidity" by overthinking. Overthinking can lead to lack of decisiveness and the assigning of complicated explanations to simple situations. They may even distort a parental suggestion into an intention to undermine their independence or competence.

Late Adolescents. (both sexes: 17-25 years) [13]are on the verge of adulthood. Their level of peer relationships changes, and they rekindle their relationships with parents in a more adult-like manner. Many establish their sexual identity and commit to an intimate relationship.

Reasoning skills are at an adult level, allowing them to understand the consequences of their actions, make sophisticated judgments, and comprehend inner motivations. Late adolescents are future oriented. They enter careers, start families, and pursue education or other higher goals. They thus tend to complete their developmental tasks in a supportive, structured environment.

When Angst Becomes a Serious Concern

Adolescence has periodic roadblocks, but the route is generally smooth and successful. Since there is a fine line between angst and problems like violence, depression, and substance abuse, we have to be careful and should suspect problems when any of the following occur:[14], [15]

  • Lack of peer group or best friend (confidant);
  • Moodiness that persists more than a couple of days;
  • Extreme mood swings;
  • Constant complaints of boredom or being treated unfairly;
  • Spending prolonged periods of time in their rooms or withdrawing from social contacts;
  • Lack of concern over appearance;
  • Decreased energy levels or fatigue;
  • Persistent defiance; lying; stealing, and other delinquent behaviours;
  • Gang membership;
  • Diminished ability to think clearly and make decisions;
  • Feeling worthlessness or hopelessness;
  • Self-destructive behaviours;
  • Unreciprocated romantic obsession;
  • Signs of substance abuse (paraphernalia, secretive peers, school failure or absence, aggression, apathy);
  • Preoccupation with violence or death themes (thoughts, music, art, movies, television shows, video/computer games);
  • Animal cruelty;
  • Reliance on violence to solve problems; or
  • Fascination with weaponry or explosives.
Adolescent Sexuality

There is a very large body of evidence, which has unequivocally proved that today adolescents engage in out-of-control, dangerous, and immoral sexual behavior. The age of first sexual contact (kissing, necking, non penetrative sex) is about 15 years (down from 16-18 a decade ago) and age of first sexual intercourse itself is at around 17 years (down from 18 - 20 a decade ago). This hangs, as a specter, over all of us and should provoke a debate and formulations of policy to deal with this sociological change, which, seems to be sweeping the world. There is a fallacious notion amongst Educators, parents as well as Public Health Personnel that pregnancy and disease are unavoidable aspects of teenage sex and this is integral to the abstinence-until-marriage message, which often constitutes the main, and sometimes the only, tenet of sex education. [16],

Statistics pertaining to the Indian context are minimal. But few of the studies which have been done in India, one in Andhra Pradesh, the other in UP and the third in Mumbai all unequivocally point at a early age of sexual intercourse, a large number of teenage pregnancies and complications arising from these pregnancies.[17], [18],[19],[20] Some of these studies have shown that up to 50% of these pregnancies is due to premarital sex, at times involving multiple sex partners. Also in many of the cases, particularly for the female, the first sexual partner is an older male and in the case of males, an older “aunty” provides the first initiation. [21]To reiterate a point there is very little data available except for the odd “sex survey” which crops up in our magazines. For example, the magazine India Today [22]is quoted as saying that 33% of college girls are sexually active in Chandigarh and that 38% of the respondents did not respond to this question. That leaves us with the question whether sexually active adolescents are actually more than 33%?

Though this survey seems a bit far fetched/ not scientific, it is an indication that times are changing. I would look at it as a wake up call to look at this whole issue of Adolescent Sexuality in a different light.

Two constructs of Adolescent Sexuality

Would you permit X to spend the night with a girlfriend or boyfriend in his or her room at home? With this provocative question, researchers worked with parents of adolescents in the Netherlands and in USA. Both societies are “advanced” and “sophisticated”, with the mean age of first intercourse being 17 years. The study threw up some startling results. The number of teen pregnancies, abortions and incidence of Sexually Transmitted Infection (STIs) in the Netherlands was negligible as compared to data from America. A pregnancy rate of 54.9% in America compared to just 9% in the Netherlands. [23]

What were the Dutch doing, which the Americans were not?

The answer seemed to lie in the Dutch Approach.

Describing the "Dutch approach" to adolescent sexuality, authors for the government-funded Dutch NGO Youth Incentives write, "Parents, educators, and other professionals rarely tell young people to stay away from sex, or to say no to sex. Dutch policy is aimed at assisting young people to behave responsibly in this respect. The Dutch approach means spending less time and effort trying to prevent young people from becoming sexually active, and more time and effort in educating and empowering young people to behave responsibly when they do become sexually active.”

Dramatizing vs Normalizing Adolescent Sexuality

The 3 themes that guide American constructions of adolescent sexuality and explain their near-universal strong opposition to the sleepover: (a) the perils of raging hormones, (b) the costs of the battle between the sexes, and (c) the logic of "not under my roof." By viewing the sexual maturation of teenagers through these 3 cultural lenses, American parents dramatize adolescent sexuality -- they highlight the dramatic and conflicted aspects of sexuality, forces that overwhelm the individual, conflicts that put girls and boys at odds, and the radical break between parents and teenagers that is required before parents accept their children's sexual relationships as legitimate.

Three different themes guide the Dutch constructions of adolescent sexuality: (a) the importance of self-recognition and self-regulation, (b) the embedding of sex in relationships, and (c) the celebration of normal and non-secretive sexuality. By viewing adolescent sexuality through these 3 cultural lenses, Dutch parents, normalize teen sexuality -- they emphasize teenagers' capacity to determine their own pace of sexual development and to prevent adverse consequences, their proclivity to want sex in the context of relationships that are mutual and loving, and the ease with which sexuality can be discussed, and adolescent relationships integrated, within the parental home.

The table below gives an idea of the opposing viewpoints of Dutch and American parents.

Dramatization of Adolescent Sexuality

Normalization of Adolescent Sexuality

Raging Hormones Out of Control

Self-Regulated Sexuality

The Battle Between the Sexes

Relationships Between the Sexes

"Not Under My Roof"

"Normal and Not Secretive"

Normalization in Context

Family cultures do not operate in a social or political vacuum. Instead, the tools that parents have available as they figure out how to guide their children through adolescence depend, in large part, on the larger society and on the position of different professional groups within it. This at least is the premise. Indeed Dutch healthcare professionals, sex educators and policy makers have, throughout the last 2 decades of the 20th century, supported the 3 components that constitute the normalization of adolescent sexuality in Dutch middle-class families -- namely, the emphasis on the self-regulatory capacities and responsibilities of adolescents; the norm that sex should take place in intimate relationships of mutual respect; and, finally, the desire to have sex be a normal topic of discussion between parents and teenagers, and not a cause for anxiety and deception.[24]

Understanding Adolescent Minds

Over the past few years there has been a tremendous amount of research into the adolescent brain. Much of this research has overthrown long held paradigms of why adolescents are so much more prone to “risk taking behavior” as compared to adults? In the following paragraphs I will try to outline some of the research work that has taken place.

Psychological Perspective

Sense of Invulnerability: People in general and adolescents in particular, quite often make incorrect judgments regarding risk. [25] Burger and Burns[26] quite convincingly demonstrated that sexually active women, who did not use contraceptives, rated themselves as least vulnerable for an unintentional pregnancy. This cognitive bias was found in early adolescents too and in part may explain why statutory warnings do not carry the weight that they should.[27] Adolescent’s today are probably far better informed than what we were at a similar age. However, adolescents tend to think, for example, Unprotected sex is dangerous in general but not for me.”[28]

Temporal Influences. Adolescent’s may actually have a limited capacity to understand what they are doing, particularly the connection between present actions and long term complications, or they simply may not place any value on these long range outcomes.[29]

When we consider sexual intercourse, long term consequences of unwanted pregnancies, sexually transmitted infections, HIV etc probably do not even enter the consciousness as at that time they are probably more strongly influenced by the anticipated positive outcomes of pleasure, sexual gratification, self worth etc. It must also be understood that long term risks are at best nebulous and the only reality is the present.

Relationships in Adolescence: The normative influence of peers cannot be underestimated. When an adolescent has a strong attachment to a group, they tend to blindly follow the norm that is emanating from that group. [30] Surprisingly (but not actually so) parents have a strong influence on adolescent behavior. An authoritative parent is likely to produce offspring have lower rates of risk taking behavior than say an authoritarian or neglectful parent. [31]

The Developmental or Biological Perspective.

Almost overnight a sweet cheerful obedient child mutates into a churlish monster, prone to recklessness and unpredictable mood swings. This statement reflects a sense of hopelessness and despair in understanding adolescent growth. Thus far “raging hormones” have been blamed for this change. Technological advances in imaging, for example Functional MRI (Magnetic Resonance Imaging) (F MRI), Structural MRI (S MRI) and Positron Emission Tomography (PET), are tools which have helped in understanding brain growth during the adolescent years. Conventional teaching, which is still in vogue, is that maximum brain growth occurs in the first year of life (true) and that by age three all that has to happen in the brain in term s of growth has happened (false). There is now evidence that brain growth continues till well into adolescence. This neurodevelopment is to an extent modified by previous and current learning, environmental and social factors. At the risk of stating the obvious Adolescence is a period characterized by increased risk taking. Coincidentally and not surprisingly, this is the period where there is a significant increase in mortality, which then tends to even out till the 5th decade of life. “Although it is not a disorder, adolescence can be a disorderly transition between child hood and adult hood.”[32]

Corticostriatal systems:[33] [34]Adolescent brain systems shows lower levels of Neurotransmitters, primarily Dopamine and Serotonin 5 Hydroxy Tryptamine (5HT). A lower level of these hormones makes them more impulsive, choosing smaller immediate rewards over larger delayed rewards. Deficiency of these hormones have also been linked to Impulsivity, Attention Deficit Hyperactivity Disorder as well as Drug Addiction. Finally Impulsivity itself has been linked to damage to the Nucleus Accumbens and Amygdla.[35]. There is also evidence that exposure to Nicotine and Substance Abuse Drugs leads to permanent damage to these areas, which ultimately leads to adult addiction. Adolescents have a poorly developed sensitivity to rewards. This prompts them to seek higher levels of novelty and stimulation to achieve the same results. They also find it difficult to Self regulate – i.e. Interrupting a risky behavior pattern, thinking before acting or choosing a different course of action. This is primarily due the fact that neuronal networks, which govern self-regulation, are not mature, possibly maturing only in late adolescence (> 21 years)[36]. When teens are given a task in which they perform poorly the Amygdla (fear center) lights up. However as one grows older, this activity shifts to the frontal and prefrontal cortices. This might also explain as to why teens are much more sensitive to emotion altering recreational drugs.[37]

Brain Development: In the course of early adolescence, the gray matter thickens, peaking at 11 years for girls and 12.5 years for boys. Many new neuronal pathways open up, in a sense reflecting the influence of multiple environmental cues and also the choices that adolescents face. However, more pathways need not necessarily be more efficient, in fact it actually slows brain functioning. As the adolescent grows, these pathways prune down and the grey matter approaches adult size by about age 20 years. As the grey matter is lost, there is a simultaneous strengthening of connections (synapses) within the brain. There is also deposition of Myelin around those neuronal networks, which have been most active.[38] This important stage of brain development in which teens do or not do affects them for the rest of their lives. If a teen is doing music, sports or academics, these are the cells and connections that last. If on the other hand they are couch potatoes, playing video games or watching MTV, then these are the cells and connections that will survive.[39]

The prefrontal cortex has been another area of intense research. This part of the brain (situated just above the eyes) has also been called the “Area of Sober Second Thought”[40]. Stress in any form during adolescence – particularly domestic, familial or social leads to a great loss of excitatory synapses in the forebrain. This has been linked to high levels of the Neurotransmitters – Dopamine and Norepinephrine. (A tenuous link between these neurotransmitters and hormonal surges during adolescence is also being investigated.) These neurotransmitters are known to cause a dramatic dysfunction of the Prefrontal Cortex.[41] Investigating causes of addiction, researchers found that Adolescents routinely chose a nicotine patch over a placebo. The conclusion reached was that “Susceptibility to Drug Abuse is related to impaired functioning of the Prefrontal Cortex. Whether these changes are the cause of such behavior or the result is being investigated.[42] Another piece of evidence which points to the almost frenetic activity taking place in the adolescent brain is that the ability to recognize other peoples emotions simply nosedives in early and middle adolescence simply nosedives, returning to normal only between ages 18 – 21.[43].

Corpus Callosum[44] and Cerebellum[45]. Waves of growth have been recorded in the Corpus Callosum. Fiber systems influencing Language, learning and associative thinking grow more rapidly than surrounding regions grow more rapidly than surrounding regions before and during puberty. This finding reinforces the belief that language acquisition decreases after age 12[46]. There is hope that further research in this direction will shed light on the nature vs nurture debate.

MRIs of corpus callosum in twins show that they are absolutely identical. In fact a lay person would be able to spot the similarities. However, the Cerebellum is a different story altogether. The cerebellum seems more vulnerable to Environmental factors while the Corpus Callosum seems to be influenced by genetics.

The Cerebellum continues to change well adolescence. The cerebellum was initially thought to be only involved in coordination of fine movements and balance. No it seems to work more like a math co processor making any activity better. Maths, Music, Philosophy, Decision making, and Social Skills are all dependent on the Cerebellum showing the way.

Drug, alcohol abuse and Aberrant Behaviour.

We have seen that there are changes in the Prefrontal and meso Limbic cortex[47]. These ares support and and are subject to the reinforcing effects associated with alchohol and drug abuse. “The younger one starts, the more likely one is to become addicted”. [48] Hormones also play a role. The neuromotivational process reflects the effect of gonadal hormones on these brain structures.[49]

When we look at Motivation in adolescents, these same findings repeat themselves. There is massive development in areas associated with motivation, impulsivity and addiction. Adolescent impulsivity and/or novelty seeking can be explained as a transitional trait behaviour, which, can be partly explained by changes in the frontal, cortical and neurotransmitter systems. These developmental processes may advantageously promote learning drives for adaptation to the adult role but on the same hand may confer a greater vulnerability to the addictive action of drugs.[50] There seems to be a self-perpetuating cycle associated with addictions. With exposure to recreational drugs, the brain undergoes some changes, which in turn make the brain more susceptible to addictive drug use. This developmental plasticity[51] seems to make the adolescent at a greater risk for addiction.

Similarly if the environment provokes or encourages aberrant behavior then these behavior patterns become the norm. This may, in some part why one sees waves of bullying occurring in a residential school setting. Youngsters who have been bullied tend to become fearful and more aggressive with younger ones, retreating when faced with an adversary of equal size.

Caution

Though all this research points to the fact that adolescent brains mature much later than thought and that they seem to follow stages in growth as laid down by Kohlberg and Ericson, yet how can one explain a youngster with sophisticated thought, maturity in a person whose brain is still “immature” and also a brash risk taking adult whose frontal lobes are “mature”.

There does not seem to be any single way in which to explain why adolescents are more prone to “poor” choices than adults. Personality, Cognitive Style as well as social settings all seem to play a part. Adolescents do not use active cognitive reasoning. They go with things that feel intuitively right[52]. As we have seen that these “gut reactions” may themselves be fallacious because of the “immature” adolescent brain.

It is important to try and understand the mechanisms underlying adolescent judgment, decision-making and risk perception. Recent theorizing, for example, proposes that risk perception and decision-making are dependent on two information-processing systems: I) Analytical, normative decision-making is consciously controlled, effortful, accessible and deliberate. This system is rule-governed and flexible. ii) Heuristic decision making, by contrast, is preconscious, rapid, inaccessible and effortless: This latter system relies on an assortment of judgmental heuristics. It is slow to learn and it is sensitive to emotional state. The two systems are interdependent, but contextual variables and age determine which will be predominant in a given situation[53]. The challenge it seems is to help adolescents regulate such gut responses and work towards the first of the two information processing system.

Conclusion

In this rather lengthy article, I have tried to weave in many threads which may further understanding of adolescence and the beauty of this fascinating stage of growth. Where does all this leave us (a) Confused – quite possibly so, (b) Somewhat better informed – hopefully so and (c) Nothing new – hopefully not. In spite of everything or probably because of the amount of information one is still left in a quandary on how to deal/handle adolescents. I have put together a series of “tips” which have always worked and these are given as an afterword.

Secondly and probably more important than Tips is the recognition of the fact that brain changes can be subtly but definitely altered by the environment to which the adolescents are exposed to. Here I would make a strong case for the opening up our Schools to various external influences. Adolescents need a strong supportive yet flexible framework within which to grow up in. I am concerned about the fact that our schools are “intellectual”. This for most adolescents is just verbiage, which, in most cases is hot air rather than anything of substance. I would look at improving our Dramatics, Fine Arts, Music and Dance to counter the MTV onslaught. I would also look at the very important place of rigor and excellence in our schools. I am sure that we all would like our children to be “wired correctly” and not go out with empty heads. The Krishnamurti ethos, which guides our schools, puts us in a unique position to do such things. Let us not get caught in inventing and reinventing the wheel. Let us move forward towards helping children grow healthily allowing them to explore their limits through education.

Afterword

This is more in the nature of tips to parents/house parents on how to “handle” adolescents – particularly in the context of risk taking behaviour. Children do internalize that parental watchfullnes.

Some questions which could be asked (indeed need to be asked)

1. Where are you going to be?

2. Who are you going to be with?

3. Will there be an adult present?

4. When will you return? Please inform me of any changes.

Helping Parents Manage Adolescent Angst

  • Stay calm.
  • Praise more than criticize.
  • Overlook little mistakes.
  • Use "I" statements -- "I feel angry when you..."
  • Listen carefully to opinions and foster decision-making skills by providing opportunities and choices, but set limits. Oppositional behaviors may relate to egocentrism and independence seeking, but they are not socially acceptable. Despite protest, most adolescents recognize discipline as a sign of caring.
  • Respect privacy needs.
  • Take their teens' concerns seriously, no matter how trivial they sound.
  • Encourage interaction with friends and get to know their teens' friends and parents.
  • Tolerate peer-imitating behaviors within reason. Behaviors should be safe and permissible under family/house rules.
  • Nurture independence and self-esteem by encouraging responsibilities, such as chores and volunteering.
  • Spend time with their teens. Engage in mutually enjoyable activities. Have frequent heart-to-heart talks, letting their teens know that they're always there when needed.

Teen pregnancy: Cause factors

The ultimate "cause" of teenage pregnancy is unprotected intercourse. A sexually active teenager who does not use contraception has a 90% chance of becoming pregnant within one year. Potential behaviour patterns for a teenage girl becoming pregnant include:

* early dating behaviour
* high-risk behaviour (smoking, alcohol and substance abuse)
* lack of a support group or few friends
* Unhealthy environment at home
* stress and depression
* delinquency / criminal behaviour
* living in a community where early childbearing is common and viewed as the norm rather than as a cause for concern
* exposure to domestic or sexual violence
* and most important, financial constraints

Advice for the adult[54]

Changing Risky Sexual Behavior: Advice for the Clinician

The research literature offers a number of direct implications for how clinicians may want to manage their interactions when encountering adolescents who they suspect are engaging in risky sexual behaviors. This is equally applicable to counselors, teachers who at most times are the first point of contact with a trouble adolescent.

· Be empathic first and foremost. It is extraordinarily difficult for adolescents to behave in ways that adults deem to be "rational" given the number of cognitive biases at work; indeed, our own behavior as adults could be described as similarly "irrational" at times. Frustration would be a natural emotional response for the clinician when an adolescent fails to follow through on a commitment. However, frustration can also be taken as an internal cue signaling that there has been a failure of empathy. Taking the perspective of the patient (ie, understanding the nature of the cognitive biases at work) will help to reduce the frustration of the clinician and set the stage for a more positive relationship that may be conducive to disclosure about risky sexual behaviors/aberrant behaviour, and ultimately encourage positive behavior change.

· Support autonomy when possible. Adolescents, by definition, are not yet adults. For this reason, clinicians (like parents) may feel obliged to make decisions for them and implore them to change behaviors that they find unacceptable. The common experience of those who try this directive approach is that it generally does not work. Adolescents have a difficult enough time making rational decisions without motivations being unduly influenced by their need to assert their budding autonomy by doing exactly the opposite of what is recommended by authority figures. Numerous studies support the contention that perceived autonomy is conducive to healthy behavioral practices.

· Identify and own your values. It is important for all health professionals working with an adolescent to both identify their own values/attitudes toward sexual/aberrant behavior, and to take ownership of them. These values should be differentiated from the values owned by the adolescent. Attempts to impose one's values and attitudes are likely to result in frustration for the clinician and no change in behavior on the part of the adolescent (or perhaps even an increase in motivation to perform the very behavior that is disdained by the clinician). Asking adolescents about their values is a good starting point. Some adolescents believe that adults are not interested in what they value in their life; asking them in an in-depth and interested way about their values is an opportunity for clinicians to demonstrate that they are different from other adults who have not done this. It is fine to value abstinence, for example, and to convey this to an adolescent patient; however, one should not do this in a way that makes the adolescent feel coerced.

· Refer to mental health practitioners as appropriate. Promiscuity is sometimes indicative of something more complex than a simple, isolated behavioral tendency. Sexual behavior characterized by large numbers of partners, increased frequency of sexual behavior, and repeatedly engaging in sexual behaviors in unsafe environments may be a sign of an underlying psychiatric disorder such as attention deficit disorder, conduct disorder, bipolar disorder, or personality disorder. High-risk sexual behavior may also stem from a history of sexual abuse. By treating the underlying disorder, risky sexual behavior may be reduced or discontinued in some cases.

Table. Internet-Based Resources for Parents, Teens, and Primary Care Practitioners



Resources in the United States

Resources in Canada

Final Comment

In the domain of parenting research, it has long been understood that parents who are (1) clear about rules around acceptable behavior but (2) accepting and responsive to the child are likely to raise children who are more psychologically healthy and socially competent. This parenting style characterized by clear structure and high responsiveness is known as the "authoritative" parenting style. This contrasts with parents who are "permissive" in parenting style (low expectations; high responsiveness), parents who are "authoritarian" in parenting style (high expectations; low responsiveness), or parents altogether unengaged (low expectations; low responsiveness).

Although both authoritative and authoritarian parents are likely to be clear about their values and beliefs about acceptable and unacceptable behavior, the authoritarian parent is more likely to engage in efforts to control the behavior of the child through psychological techniques (eg, guilt, shame, coercion). Authoritative parents, on the other hand, are clear about their values and beliefs, but do not attempt to engage in psychological control. It may be increasingly important as children move into their teen years for parents to be respectful (even encouraging) of autonomy, given that an important developmental task for the adolescent is to achieve individuation from the parent.

kartik



[1] Jean Piaget: 1896 – 1980. Born in France and served in Universities of Lausanne, Geneva and Sorbonne.

[2] Cognition: n. The mental action or process of acquiring knowledge through thought, experience and the senses.

[3] Lawrence Kohlberg: Professor at Harvard. Strongly influenced by psychologist Piaget, Philosophers John Dewey and James Mark Baldwin, all of whom felt that humans develop philosophically and psychologically through clearly identifiable stages.

[4] Moral Development: Changes in the capacity to reason about the rightness or wrongness of various actions that occur with age

[5] Erik Erikson: 1902-1994. A developmental psychoanalyst. Famous for coining the phrase “Identity Crisis”. Born in Germany of mixed parentage – was teased in school by the Germans as a Jew (for his birth) and by the Jews for being Nordic (he was tall blonde and blue eyed). He did most of his work in USA at Harvard, Yale, Berkley and Michigan.

[6] Marcia JE.1991: Identity and Self Development. In RM Lerner, AC Petersen & EJ Brooks. Encyclopaedia of Adolescence (Vol 1) (pp 527 – 531) New York, Garland

[7] Concise Oxford English Dictionary

[8] Mary E Muscai, PhD RN. When should we worry about Adolescent Angst? 2005 Univeristy of Scranton www.Medscape.com

[9] Dunn A, Fisher J: Developmental Management of Adolescents. In: Burns C, Dunn A, Brady M etc. Paediatric Primary Care Handbook, 3rd Ed. Saunders 2004

[10] Kohlberg’s Stages 1,2 and Erikson’s Industry versus Inferiority

[11] Kohlberg’s stages 2-3 and Erikson’s Identity vs Role Confusion.

[12] Sarah Bott and Shireen J Jejeebhoy. Adolescent Sexual and Reproductive Health in South Asia. Proceedings of a Conference in Mumbai, 2004.

[13] Kohlberg’s stages 3-4 and Erikson’s Identity vs Role Confusion; Intimacy versus Isolation

[14] Castiglia P. Depression in Adolescents. J Pediatr Health Care. 2000:14: 180 - 182

[15] Muscari M. Not My Kid 2: Protecting Your Children from the Threats of the 21st Century. Scranton Pa.University of Scranton Press 2004.

[16] Andrew L Cherry, Mary E Dillon, Douglas Rugh. “Teenage Pregnancy – A Global View”. Greenwood Publishing, 2001

[17] Society for the Protection of Unborn Children – Report 2004

[18] SNDT Women’s University, Mumbai, Internet Archives

[19] Duru S Shah. “Teenage Pregnancy in India – Education and Prevention. Oct 2005

[20] Bhattacharya ML, Joshi PL: Strategy Formulation to reduce Teenage Fertility. 1995

[21] A more sexually experienced partner may also expose an individual to a wider spectrum of infection,

particularly gonorrhoea, trichomoniasis, genital ulcer disease and HIV. Adolescent females may encourage

relationships with older partners, not only out of economic necessity, but also for obtaining simple

luxuries such as cosmetics and similar gifts.

[23] Must we fear adolescent sexuality? Amy Schalet, PhD Medscape General Medicine 6(4), 2004. © 2004 www.Medscape.com

[24] Must we fear adolescent sexuality? Amy Schalet, PhD Medscape General Medicine 6(4), 2004. © 2004 www.Medscape.com

[25] Weinstein ND. Unrealistic optimism about susceptibility to health problems: conclusions from a community-wide sample. J Behav Med. 1987;10:481-500.

[26] Burger JM, Burns L. The illusion of unique invulnerability and the use of effective contraception. Pers Soc Psychol Bull. 1988;14:264-270.

[27] Whalen CK, Henker B, O'Neil R, Hollingshead J, Holman A, Moore B. Optimism in children's judgments of health and environmental risks. Health Psychol. 1994;13:319-325.

[28] Author’s Italics

[29] Fong GT, Hall PA. Time perspective: a potentially important construct for decreasing health risk behaviors among adolescents. In: Romer D, ed. Reducing Adolescent Risk: Toward an Integrated Approach. Thousand Oaks, Calif: Sage Publications; 2003:106-112

[30] Kirby D. Risk and protective factors affecting teen pregnancy and the effectiveness of programs designed to address them. In: Romer D, ed. Reducing Adolescent Risk: Toward an Integrated Approach. Thousand Oaks, Calif: Sage Publications; 2003:265-283

[31] Steinberg L, Fletcher A, Darling N. Parental monitoring and peer influences on adolescent substance use. Pediatrics. 1994;93:1060-1064.

[32] Anne Kelly PhD, University of Wisconsin – Proceedings of a conference on Neurodevelopment, 2004.

[33] Corticostriatal systems connect the cerebrum or conscious brain with the deeper layers particularly the limbic system.

[34] Rudolf N Cardinal PhD, University of Cambridge - Proceedings of a conference on Neurodevelopment, 2004

[35] These structures are part of the Limbic System, probably the oldest part of the brain, considered to be the fount of all emotions. The Amygdla is also known as the “Fear Centre”.

[36] Laurence Steinberg PhD, Temple University. Risk Taking in Adolescence – What changes and Why? - Proceedings of a conference on Neurodevelopment, 2004

[37] Michelle Ehrilich MD. Adolescent Vulnerabilities and Development, New York Academy of Sciences.

[38] Jay N Giedd MD. Adolescent Brain Development: Views from Structural MRI. National Institute of Mental Health, Bethesda, USA.

[39] Authors Emphasis.

[40] The forebrain is associated with goal setting, priority setting, planning, organisation and Impulse inhibition.

[41] Amy Amsten PhD, Yale University Medical School: Cognitive Development, Decision Making and Behavioural Changes. Proceedings of a conference on Neurodevelopment, 2004

[42] Frances M Leslie PhD, University of California at Irvine: Adolescent Development of Forebrain Stimulant Responsiveness. Proceedings of a conference on Neurodevelopment, 2004

[43] Robert McGivens PhD, San Diego State University: Brain and Cognition, Vol 50, p 173.

[44] Corpus Callosum: The bundle of fibres that connect the two brain hemispheres.

[45] Cerebellum: A small potato shaped structure in the hind part of the brain. Evolutionarily an ancient structure.

[46] Paul Thompson, MD PhD, McGill University: Nature Volume 404, 2003.

[47] Also called the LIMBIC SYSTEM – consisting of the Amygdla, Hippocampus, Para hippocampus and various collections of nerve cells called as Nuclei – considered to be evolutionarily an ancient part of the brain and strongly associated with all emotions be it fear, pleasure, satiety or hunger.

[48] Linda Specs MD,PhD, Bingham University; What is it that predisposes the initiation of drug and alchohol abuse? Adolescent Vulnerabilities and Development, New York Academy of Sciences

[49] Elaine F Walker. Adolescent Neurodevelopment and Psychopathology. Current Directions in Psychological Science, Vol 11, No 1 Feb 2002, pp 24 – 28.

[50] Andrew Chambers MD, Jane Taylor PhD, Marc N Potenza MD, PhD: Developmental Neurocircuitry of Motivation in Adolescence. A CriticalPeriod of addiction vulnerability. Adolescent Vulnerabilities and Development, New York Academy of Sciences

[51] The ability of neurones to rewire/alter existing connections.

[52] Daniel P Keating PhD. Adolescent Cognitive and Brain Development. University of Toronto. Adolescent Development and Vulnerabilities – New York Academy of Sciences.

[53] National Institute of Health, Bethesda Maryland USA – Background Document for proposal for Adolescent Neurodevelopmental Research. 2000

[54] Peter A. Hall, PhD; Maxine Holmqvist, BA; Simon B. Sherry, MA. Risky Adolescent Sexual Behavior: A Psychological Perspective for Primary Care CliniciansTopics in Advanced Practice Nursing eJournal 4(1), 2004. © 2004 Medscape