ALL THIS AMOUNTS TO POORER HOUSING, UNSAFE LIVING
ENVIRONMENTS. ..... POORER HEALTH FOR AMERICA’S
ADOLESCENTG......

MORE STRESS ON FAMILIES.

AND THIS COMES AT A TIME WHEN FAMILIES ARE LESS ABLE TO

BEAR STRESS.

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THERE ARE SIGNIFICANT CHANGES IN TRADITIONAL FAMILY
STRUCTURES AND ROLES.

THE AMERICAN FAMILY, AS WE HAVE KNOWN IT EARLIER IN THIS
CENTURY, HAS FALLEN APART.

IN 1965 11.3% OF AMERICAN CHILDREN LIVED IN SINGLE-PARENT
HOMES. BY 1987 21% OF AMERICANS UNDER 18 LIVED IN HOMES

WITH A SINGLE PARENT.

52
DIVORCE, REMARRIAGE, DESERTION BY ONE PARENT OR THE
OTHER.... ALL THIS HAS TORN FAMILIES APART, AND LEAD TO THE
RESTRUCTURING OF FAMILIES IN NEW, SKELETAL, AND OFTEN

DYSFUNCTIONAL FORMATIONS.

GENERATIONAL LINES ARE BLURRED BECAUSE GRANDMOTHER,
MOTHER AND GRANDCHILD ALL HAVE CHILDREN BEING RAISED

TOGETHER.

53
PARENTS INCREASINGLY DON’T ASSUME PARENTAL FUNCTIONS.
IN SOME CASES THIS IS BECAUSE THEY ARE TOO YOUNG, ~
CHILDREN HAVING CHILDREN, BUT IN OTHER CASES THE
PARENTS MANIFEST ILL-HEALTH, PERSONAL EMOTIONAL

TRAUMA, AND THE INABILITY, OR EVEN UNWILLINGNESS TO COPE.

54
AS THE MIDDLE CLASS #@ SHRINKS, LARGER NUMBERS OF

FAMILIES HAVE FEWER RESOURCES FOR SURVIVAL.

AND AS NUCLEAR FAMILIES BREAK DOWN, THE NEXT LEVEL OF
SUPPORT --EXTENDED FAMILIES AND NEIGHBORHOODS--
SUFFER SIMILAR DISINTEGRATION IN A MORE URBANIZED, MORE

MOBILE, MORE ANONYMOUS AMERICAN CULTURE.

55
THIS MEANS THAT WITH EACH PASSING YEAR, AMERICAN
CHILDREN AND ADOLESCENTS HAVE LESS AND LESS CONTACT
WITH ADULTS.

PARENTS WORK, RELATIVES AND NEIGHBORS MOVE AWAY OR

ARE DISINTERESTED, YOUNGSTERS ARE LEFT ALONE.

THE AVERAGE CHILD SPENDS LESS THAN AN HOUR A DAY WITH
HER OR HIS MOTHER, AND LESS THAN 5 MINUTES WITH THE

FATHER. AND MANY DON’T HAVE ONE PARENT AROUND AT ALL.

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within WACH ae Diy eet ac é eof SRAWOPAREP

56
EVEN WHEN BOTH PARENTS ARE PRESENT WE SEE AN ALARMING

TENDENCY TO PASS THE BUCK OF PERSONAL RESPONSIBILITY.

PARENTS LEAVE TO THE SCHOOLS THE ENTIRE TASK OF
EDUCATING THEIR CHILDREN, WHEN NOT LONG AGO PARENTS
CLAIMED THE EDUCATION OF THEIR CHILDREN TO BE THEIR
PRIVILEGE AND OBLIGATION, EVEN IF SHARED WITH THE

SCHOOLS.

57
CHILDREN LIVE IN THEIR OWN CULTURE, REMOTE FROM ADULTS,
DOMINATED ONE YEAR BY TRANSFORMER TOYS, THE NEXT BY
CABBAGE PATCH DOLLS, THE NEXT BY TEENAGE MUTANT NINJA
TURTLES.

THEY LEAD LIVES DETACHED FROM PARENTAL CONCERN OR
INTEREST, TURNING TO PEERS FOR THE GUIDANCE OR EVEN
PLAYFUL COMPANIONSHIP THAT PARENTS AND GRANDPARENTS

USED TO PROVIDE.

58
INTO THE VACUUM CREATED BY THE ABSENCE OF ADULTS HAVE
MOVED TELEVISION, RADIO, MOVIES, AND VIDEOS, OFTEN WITH A
CONSTANT MESSAGE OF SEX, VIOLENCE, AND GREED.
RELIGIOUS TEACHING AND ETHICAL VALUES, IF THEY ARE
INSTILLED AT ALL, ARE NOW LEFT TO CHURCH OR SYNAGOGUE. .

. OR MTV.

59
AS WE MOVE INTO THE LAST DECADE OF THE TWENTIETH
CENTURY, OUR NATION HAS YET TO ENACT A NATIONAL YOUTH
AGENDA THAT

ADDRESSES THE NEEDS OF ADOLESCENTS COMPREHENSIVELY.
EXISTING SERVICE DELIVERY SYSTEMS DO NOT FUNCTION IN
WAYS THAT CHERISH AND PROVIDE FOR ADOLESCENTS AND
THEIR FAMILIES. IT IS TIME TO RE-EXAMINE THE WAYS IN WHICH
WE LOOK AT ADOLESCENTS AND THEIR SPECIAL HEALTH
PROBLEMS —- TO REALLOCATE RESOURCES AND TO REDESIGN
SERVICE DELIVERY SYSTEMS IN WAYS THAT HELP ALL OF OUR
YOUNG PEOPLE, AND THEIR FAMILIES, COPE WITH THE
CHALLENGES ASSOCIATED WITH BECOMING WELL-EDUCATED

AND HEALTHY CITIZENS.

60
WHAT CAN WE DO?

WELL, I’VE GIVEN THIS A LOT OF THOUGHT, ESPECIALLY IN THE
LAST FEW WEEKS WHEN I HAVE SPENT SO MUCH TIME WITH
ADOLESCENTS, INTERVIEWING THEM IN CONNECTION WITH MY

COMING NBC TV PRIMETIME SPECIAL ON ADOLESCENT HEALTH.

61
’LL MAKE A FEW SUGGESTIONS, BASED UPON THE EYE-OPENING
FILMING OF THE LAST FEW WEEKS, BASED UPON MY YEARS AS A
SURGEON OF CHILDREN AND ADOLESCENTS, AND BASED UPON

MY EXPERIENCE AS YOUR SURGEON GENERAL.

62
IN THAT LAST CAPACITY, ALTHOUGH I MAY HAVE RECEIVED
PUBLIC ATTENTION FOR MY EFFORTS AGAINST AIDS, SMOKING,
AND DRUNK DRIVING, | TAKE THE GREATEST SATISFACTION FOR
AN INITIATIVE | WAS PRIVILEGED TO LEAD THAT REDESIGNED THE
WAYS IN WHICH CHILDREN WITH SPECIAL HEALTH NEEDS --
SOME CALLED THEM HANDICAPPED CHILDREN-- COULD TAKE
ADVANTAGE OF THE TANGLED WEB OF HEALTHCARE AND SOCIAL

SERVICE AGENCIES THAT MIGHT HELP THEM.

63
THOSE OF US INVOLVED IN THIS INITIATIVE FOR SPECIAL NEEDS
CHILDREN WANTED TO MAKE SURE THE SERVICES WERE
PLANNED AROUND THE NEEDS OF THE PEOPLE WHO NEEDED
THEM, RATHER THAN FORCING THE PEOPLE TO ADAPT TO THE

SERVICES.

WE NEED THE SAME APPROACH FOR ADOLESCENT HEALTH

PROBLEMS.

64
A FEW SIMPLE CONCEPTS SHOULD GUIDE US.

ALL OUR EFFORTS SHOULD BE:

FAMI LY-CENTERED
COMMUNITY-BASED
CULTURALLY SENSITIVE
COORDINATED
CONFIDENTIAL

ADEQUATELY FINANCED.

65
FIRST, FAMILY-CENTERED:

EVEN THOUGH THE BELEAGUERED AMERICAN FAMILY IS OFTEN
UNLIKE THAT IDEAL FAMILY OF THE STORY BOOKS, WE NEED TO
DEAL WITH THE FAMILIES OF ADOLESCENTS, IN THEIR VARIOUS
PERMUTATIONS, THE WAY WE FIND THEM, NOT THE WAY WE
WOULD WISH THEM TO BE.

EVEN THOUGH FRAGMENTED, THE FAMILY IS THE CONTINUOUS

PRESENCE IN THE LIFE OF THE ADOLESCENT.

66
FAMILIES, EVEN IN UNUSUAL FORMS, SHOW A STEELY
RESILIENCE. IN WHATEVER SERVICES WE OFFER THE

‘Mw
ADOLESCENT, WE MUST INCLUDE THE FAMILY,THE
DEVELOPMENT AND APPLICATION OF POLICIES THAT AFFECT
ADOLESCENT HEALTH CARE. SERVICES MUST BE FLEXIBLE AND

RESPONSIVE TO FAMILIES.

WE NEED TO VIEW FAMILIES AS PRIMARY CARE PROVIDERS, AND

GIVE THEM THE INFORMATION AND SUPPLIES THEY NEED TO DO

THIS JOB.

67
WE NEED TO PAY HEED TO THE SINGLE PARENT FAMILIES OR

AGGREGATE FAMILIES.

IF WE FIND FAMILIES WEAK, WE NEED TO STRENGTHEN THEM.
WE NEED TO STRENGTHEN PARENTING SKILLS, REMEMBERING
THAT IN SOME DYSFUNCTIONAL FAMILIES THE PARENT ROLE MAY
BE ASSUMED BY AN OLDER SIBLING OR EVEN A SURROGATE

ADULT.

68
FURTHERMORE, OUR CONCERN FOR FAMILIES MUST ENCOMPASS
AN AFFIRMATION OF BASIC VALUES. HEALTH IS A MATTER OF
THE SPIRIT AS WELL AS THE BODY. PROVISION OF A SPIRITUAL,
A RELIGIOUS DIMENSION AMONG THE SERVICES OFFERED
ADOLESCENTS AND THEIR FAMILIES WILL REAP LASTING

REWARDS.

69
OUR CONCERN FOR ADOLESCENTS MUST BE

CULTURALLY SENSITIVE:

SERVICES NEED TO BE SENSITIVE TO DIFFERENT CULTURAL
VALUES AND CUSTOMS. FOR EXAMPLE, MORE THAN 80% OF
CHILDREN WITH HIV INFECTION ARE BLACK OR HISPANIC.
SERVICES MUST FOCUS ON THE STRENGTHS AND NEEDS OF
THESE GROUPS. MINORITY LEADERS SHOULD BE CENTRAL IN
PLANNING AND STARTING SYSTEMS OF SERVICES FOR CHILDREN

AND THEIR FAMILIES,

70
EVEN AFTER A GENERATION OF LEGISLATIVE, JUDICIAL AND
PERSONAL EFFORTS TO ELIMINATE RACIAL INEQUALITY, AMERICA
IS STILL PLAGUED BY RACISM, AND THERE ARE MANY WHO SEE
ETHNIC HOSTILITY AND DISCRIMINATION ONLY INCREASING IN

THE YEARS IMMEDIATELY BEFORE US.

DESPITE THE FACT THAT OUR COMMUNITIES ARE MORE
CULTURALLY DIVERSE, SOCIAL INSTITUTIONS HAVE NOT ADAPTED
TO THESE CHANGES. PROFESSIONAL INSENSITIVITY TO
CULTURAL DIFFERENCES AND LANGUAGE

BARRIERS IMPEDE ACCESSIBILITY TO SERVICES FOR

CULTURALLY DIFFERENT FAMILIES AND ADOLESCENTS.

71
AS WE KEEP OUR FINGER ON THE PULSE OF THE FAMILY, AS WE
ARE SENSITIVE TO CULTURAL DIFFERENCES, WE NEED TO

GROUND OUR SERVICES IN THE COMMUNITY.

COMMUNITY-BASED SERVICES ARE THE KEY TO WINNING THE

STRUGGLE AGAINST ADOLESCENT HEALTH PROBLEMS.

72
OUR COUNTRY IS RECOGNIZED INTERNATIONALLY FOR
SOPHISTICATED TERTIARY CARE AND TECHNOLOGICAL
ADVANCES; YET WE LACK ACCESS AND EQUITY FOR BASIC
SERVICES AT THE FAMILY AND COMMUNITY LEVEL. WE ARE THE
ONLY DEVELOPED NATION THAT DOES NOT GUARANTEE HEALTH

CARE TO EVERY CITIZEN, i777" E ER CEP Few 0

Sov7w AFRICA,

‘SERVICES NEED TO BE PROVIDED IN OR NEAR THE HOME
COMMUNITIES OR NEIGHBORHOODS OF CHILDREN AND THEIR
FAMILIES. FAMILIES SHOULD NOT HAVE TO TRAVEL LONG
DISTANCES FOR SERVICES. AND WHENEVER POSSIBLE,
CHILDREN SHOULD BE CARED FOR AT HOME RATHER THAN INA

HOSPITAL.

73
| HAVE BECOME CONVINCED THAT FINDING THE RIGHT PLACE

FOR ADOLESCENT HEALTH CARE WILL WIN HALF THE BATTLE.

EVEN WHEN ADOLESCENTS DECIDE TO SEEK A PHYSICIAN,

FINDING A DOCTOR IS USUALLY A LOST CAUSE FOR MANY OF

THEM.

| SPENT MUCH OF MY PROFESSIONAL LIFE MAKING SURE THAT
CHILDREN WITH SURGICAL PROBLEMS CONTINUED TO RECEIVE
GOOD COMPREHENSIVE CARE IN THE ADULT WORLD, SO I KNOW
THAT ONE OF THE PERSISTENT PROBLEMS OF AMERICAN
MEDICINE IS THE DIFFICULTY OF TRANSITION BETWEEN ~

PEDIATRIC AND ADULT MEDICAL CARE.

74
SOME ADOLESCENTS DON’T LIKE TO KEEP GOING TO THEIR
PEDIATRICIANS, THE "BABY DOCTOR”, AND SOME PEDIATRICIANS
' ARE GLAD, FROM A PROFESSIONAL IF NOT PERSONAL POINT OF
VIEW, TO SEE THEM MOVE ON.

OTHER ADOLESCENTS ARE RELUCTANT TO CHANGE, WHILE SOME
PEDIATRICIANS FEEL TOO MUCH OF A PROPRIETARY INTEREST IN
THEIR GROWING PATIENTS, AND CLING TO ADOLESCENTS WHO

WOULD BE BETTER SERVED IN AN ADULT PRACTICE.

75