jact (abstr). Circulation 42 (suppi 3): a55, 1970 9. READER R: Incidence and prevalence of ischemic heart disease in Australia. Med I Aust (spec suppi) 2: 3, 1972 10. LEVEN5TEIN JH: Myocardial infarction and the evolution of the intensive coronary care unit. South Air Med 1 50: 918, 1976 11. O'RousKa MF, WALSH B, FLETCHER M, et al: Impact of the new generation coronary care unit. Br Med 1 2: 837, 1976 12. BLOOM BS, PETERsON OL: End results, cost, and productivity of coronary care units. N Engi I Med 288: 72, 1973 13. YANOWITZ F, FOZZARD H: A medical information system for the coronary care unit. Arch Intern Med 134: 93, 1974 14. ROBERTS WC: Relationship between coronary thrombosis and myocardial infarction. Mod Concepts Cardiovasc Dis 41: 7, 1972 15. ROBERTS WC, BUJA LM: Frequency and significance of coronary arterial thrombi and other observations in fatal acute myocardial infarction. Am I Med 52: 425, 1972 16. FRIEDMAN
M,
MANWARING
JH,
ROSENMAN
RH, et al: Instantaneous and sudden deaths. Clinical and pathological differentiation in coronary artery disease. JAMA 225: 1319, 1973 17. RAPAPORT E: Prehospital ventricular fibrillation (E). N Engi I Med 291: 358, 1974 18. BAUM RS, ALVAREZ H III, COBB LA: Survival
after resuscitation from out-of-hospital ventricular fibrillation. Circulation 50: 1231, 1974 19. LAWRIE DM, GREENW.D TW. GODDARD M,
et al: A coronary-care unit in the routine management of acute niyocardial infarction.
Lancet 2: 109, 1967 20. PANThIDGE JF: Mobile coronary care. Chest 58: 229, 1970 21. PRINEAS RJ, BLACKBURN H (eds): Sudden
Coronary Death Outside Hospital, Am Heart
Assoc monograph no 47, Dallas, 1975 22. LIBERTHSON RR, NAGEL EL, HIRscHMAN JC, et al: Pathophysiologic observations in prehospital ventricular fibrillation and sudden cardiac death. Circulation 49: 790, 1974
23. Coss LA, ALVAREZ H in, KoPAss MK, et at: A rapid response system for out-of-hospital
cardiac emergencies. Med Clin North Am 60: 283, 1976 24. LIBERTHSON RR, NAGEL EL, HIRSCHMAN JC, et al: Prehospital ventricular fibrillation. N Engi I Med 291: 317, 1974 25. ADGEY AAJ, NELSON PG. Scorr ME, et al: Management of ventricular fibrillation outside hospital. Lancet 1: 1169, 1969
26. ORCHARD TJ: Mobile coronary care (C). Lancet 1: 263, 1974 27. LUND I, SKLTLBERG A: Cardiopulmonary resuscitation by lay people. Lancet 2: 702, 1976 28. LEMIRE JG, JOHNSON AL: Is cardiac resuscitation worthwhile? A decade of experience. N Engi I Med 286: 970, 1972 29. GILLUM RE, FEINLEIB M, MARGOLIS JR, et al: Delay in the pre-hospital phase of acute myocardial infarction. Arch Intern Med 136: 649, 1976 30. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 227 (suppl 7): 833, 1974 31. NIE NJ, HULL CH, JENKINS JG, et al: SPSS: Statistical Package for the Social Sciences, 2nd ed, New York, McGraw, 1975
Health problems and health care for adolescents in residential facilities in Quebec J.Y. FRAPPIER,* MD; N. STEINMETZ, MD, CM, MPH, FRCP[C]
The health problems of 160 adolescents in four residential facilities of the Ouebec social welfare court were studied. At the time of admission 440/0 had at least one problem requiring consultation with a specialist and 800/0 had an average of two problems requiring primary care. The medical records of 106 youngsters in two re-education centres were also reviewed and similar results were noted. The health services available, particularly physical examination and laboratory testing at the time of admission and arrangements for referral and follow-up were judged to be insufficient in most centres. Although society has taken custody of these adolescents, no one is responsible for their health care. Since February 1976 the social welfare court residential facilities and the network involved in the care of socially disturbed youngsters have been undergoing reorganization. Health programs and services ought to be part of this reorganization, and private physicians, hospitals and government each should have a role in the establishment and functioning of these programs. Nous avons 6tudi6 les probl&mes de sant6 de 160 adolescents r6partis dans From the department of pediatrics, McGill University *Clinical scholar of the Robert Wood Johnson Foundation Reprint requests to: Dr. J.Y. Frappier, 3189 Lacombe St., Montreal, PQ H3T 1L6
quatre centres d'accueil au Ou6bec. A I'admission 440/o pr6sentaient au moms un probleme n6cessitant une consultation en sp6cialit6 et 800/o avaient en moyenne deux probl.mes necessitant Des soins d'un praticien general. Les dossiers medicaux de 106 autres jeunes ont 6te revises dans deux centres de re-6ducation et Des resultats etaient similaires a ceux mentionnes ci-haut. Les services de sant6 offerts ont et6 juges insuffisants en ce qul a trait, entre autres, aux examens physiques et aux analyses de laboratoire a l'admission ainsi qu'aux arrangements en vue d'une consultation ou d'un follow-up. Mime si Ia societe est responsable de ces adolescents, en fait personne n'est responsable de leur sant6. Depuis fevrier 1976 s'effectue une reorganisation des centres d'accueil et du r6seau qui Des entoure. Des programmes de soins de sante devraient faire partie de cette reorganisation, et Des medecins, Des h8pitaux et le gouvernement devraient tous avoir un r6le dans l'elaboration et le fonctionnement de ces programmes. In Quebec, children and adolescents with special problems and needs are seen, whenever necessary, by the social welfare court. Such youngsters are divided into two major groups. The first are those "under court protection", such as orphans and those removed from parental custody owing to abuse or neglect. The second includes those with psychosocial problems, either delinquents or socially disturbed young-
sters whose behaviour has brought them into custody. To accommodate both groups the province has established many residential facilities, so-called reception centres, which are related to the social welfare court and social agencies. Among these centres some are involved in the care of youths designated as being under court protection. Others, training schools or re-education centres, care for adolescents with psychosocial problems. A few centres are similar to halfway houses; adolescents can stay there while waiting for placement in a foster home or for a court decision. All of the above centres function in an open setting. Finally, there are also some detention centres that, paradoxically, are forced to admit delinquents as well as youngsters under court protection, in part because of a lack of resources for the latter. In 1975 the Batshaw committee was formed to study how reception centres function and determine the needs of the youngsters they served. This meant taking into account relations between the centres and the existing and proposed network comprising social agencies, hospitals and schools. The committee's report,1 published early in 1976, enumerated the rights of children and included 160 recommendations. Among these were a group dealing with the development by the reception centres of several services (group homes, foster homes and day-care centres) and a group emphasizing individualized intervention and continuity in care directed towards social rehabilitation. The right of the child to "physical
CMA JOURNAL/DECEMBER 17, 1977/VOL. 117 1403
Table Il-4.harspteristics of youngsters Iii four of the centres4'
Characteristic
A,B audD C (boys, (girls1 n = 120)n = 40)
38 60 16.-Il 62 40 Not going to school (for >4mo) 61 55 Alcohol Intake (. twice a week) 18 10 DruguseGi.twIce a week) Cigarette smoking (>I2fd) 68 65 Sexually active 55 80 History of fractures 20 41 HIstory of surgeryt 55 50 4'Data were unavailable for Lentres E and F excsptforag(93% were Ilto l5yearsold). tTonsillctomy and adenoldectomy In one half.
taut problems qf youngters (120 lii.) xamlned In frniruf lii. .erdres (Ato D %of ProbIen. youngsters Requiring referral Ear, nose and throat 11 Nasal esptwn deviation 3 Other (e.g., chronic otitis, hearing defect) 8 General urglcal 7 Asthma an4allrgy, severe 6 PsychIatric 6 lton1azl4*oml.prophylsxis 5 Pregnancy (4w) gIrls) 5 Heart murmur, sIgnificant 4 Orthopedic 3 EpIlepsy 3 Speech problems 2 Other (e.g, h.stltis, colla. gonosis, hypothyroidism, 3 strabismus) Requiring prl0ary care Need cohtraceptlon 50 (girls) Skli. Infection (e.g., tlnea CruriS, scablas) 17 Severe acne 4 Other (e.g., dermatitis, laceratIons) 15 Tine test positive 29 Genltourinary 22 Vaghijtls Conococcal 5 Other 13 Urinasy tract Infection, hemeturla 4 Ear, nose and throat 20 Acute tonsluitlsl Tos.1hypertrophy 7 Other (e.g., otitis) B Heart murmur, functional 12 Nutritional and growth retardation 8 Musculoskeletal I Allergy, mild 7 High blood pressure (>140/90mm Hg) 6 Bronchitis 6 ConstIpation (2/3 with blood In stools) 6 Gingivitis 5 Enuresis S Gynecomastia 4
the 1973 American Academy of Pediatrics' recommendations for health care in juvenile court residential facilities should serve as a guide. The application could differ for group homes, reception centres and foster homes, but the concepts should be respected in every facility. Social rehabilitation must be the ultimate goal for each youngster taken into court custody, and improvement of physical health is an important first step. In that sense private physicians, local community service centres (centres locals de services communautaires; CLSCs), hospitals and government may each have an important role. In 1971, after the reorganization of health and social services, CLSCs started to develop in Quebec. As part of their role they were to provide curative and preventive health services to reception centres in their district. At present there are too few CLSCs and inadequate collaboration has been established with their respective reception centres. A large proportion of youngsters in court custody will not be admitted to reception centres, especially after their first court appearance. Moreover, with the reorganization of the social affairs network, more and more of these ado-
lescents will be sent either back home with support and surveillance or to foster homes or group homes instead of being kept in large institutions. Accordingly, it would be more promising if .a coordinated program were to develop between probation officers, social workers, hospital clinics and other resources (e.g., CLSCs and private physicians). Adolescent clinics could be of great help in the development of this program by ensuring quality of care and the involvement of specialty clinics and private physicians. With such a program it should be possible to bring all youngsters to medical attention shortly after their first court appearance. They could be seen by interested general practitioners in a CLSC in their district or in a private office. Some could also be seen at adolescent clinics, depending on the resources available. With the cooperation of the court, social agencies and physicians we think that more of the remediable defects would be corrected sooner and that more of the chronic or serious problems would be identified and the adolescent referred to and followed up at the appropriate clinic. A program such as this is not easy to set up, and follow up of these adolescents is difficult. However, it is feasible and
it should start somewhere. Finally, and of greatest importance, government officials responsible for health matters must become more aware of and responsive to the special health needs of this population. Leadership and resources should be provided for social agencies, the court, reception centres and hospitals to ensure that they are able to respond appropriately to these needs. We are greatly indebted to Dr. I.B. Pless for his help in the preparation of this manuscript and to those working in the centres for their cooperation. References 1. BATSHAW S chmn): Report of the Commtttee for the Study on the Rehabilitation of Chtldrcn and A dolescents placed in Reception Centres, Quebec, .diteur officiel du Quebec, 1976 2. EISNER V, SHOLTZ RI: Health care for juvenile delinquents. Pediatrics 52: 434, 1973 3. Lirr IF, COHEN MI: Prisons, adolescents, and the right to quality medical care: the time is now. Am J Public Health 64: 894, 1974 4. American Academy of Pediatrics, committee on youth: Health standards for juvenile court residential facilities. Pediatrics 52: 452, 1973 5. National Center for Health Statistics: Examination and Health History Findings among Children and Youths, 6-17 Years, Public Health Service publ no 1000, ser 11, no 129, Washington, US Govt Printing Office, 1973 6. BRUNSWICK
AF,
JOSEPHSON
E:
Adolescent
health in Harlem. Am I Public Health 62 (suppi 2): 1, 1972
MEDICLINICS POSTGRADUATE MEDICAL REFRESHER COURSE
FORT LAUDERDALE, FLORIDA MARCH 6 - 17, 1978 PRE*REGISTRATION - $300.00 MEDICLINICS 832 Central Medical Building Saint Paul. Minnesota 55104
EXCELLENT FACULTY, FINEST HOTEL, PEAK OF WINTER SEASON 1406 CMA JOURNAL/DECEMBER 17, 1977/VOL. 117
M,
MANWARING
JH,
ROSENMAN
RH, et al: Instantaneous and sudden deaths. Clinical and pathological differentiation in coronary artery disease. JAMA 225: 1319, 1973 17. RAPAPORT E: Prehospital ventricular fibrillation (E). N Engi I Med 291: 358, 1974 18. BAUM RS, ALVAREZ H III, COBB LA: Survival
after resuscitation from out-of-hospital ventricular fibrillation. Circulation 50: 1231, 1974 19. LAWRIE DM, GREENW.D TW. GODDARD M,
et al: A coronary-care unit in the routine management of acute niyocardial infarction.
Lancet 2: 109, 1967 20. PANThIDGE JF: Mobile coronary care. Chest 58: 229, 1970 21. PRINEAS RJ, BLACKBURN H (eds): Sudden
Coronary Death Outside Hospital, Am Heart
Assoc monograph no 47, Dallas, 1975 22. LIBERTHSON RR, NAGEL EL, HIRscHMAN JC, et al: Pathophysiologic observations in prehospital ventricular fibrillation and sudden cardiac death. Circulation 49: 790, 1974
23. Coss LA, ALVAREZ H in, KoPAss MK, et at: A rapid response system for out-of-hospital
cardiac emergencies. Med Clin North Am 60: 283, 1976 24. LIBERTHSON RR, NAGEL EL, HIRSCHMAN JC, et al: Prehospital ventricular fibrillation. N Engi I Med 291: 317, 1974 25. ADGEY AAJ, NELSON PG. Scorr ME, et al: Management of ventricular fibrillation outside hospital. Lancet 1: 1169, 1969
26. ORCHARD TJ: Mobile coronary care (C). Lancet 1: 263, 1974 27. LUND I, SKLTLBERG A: Cardiopulmonary resuscitation by lay people. Lancet 2: 702, 1976 28. LEMIRE JG, JOHNSON AL: Is cardiac resuscitation worthwhile? A decade of experience. N Engi I Med 286: 970, 1972 29. GILLUM RE, FEINLEIB M, MARGOLIS JR, et al: Delay in the pre-hospital phase of acute myocardial infarction. Arch Intern Med 136: 649, 1976 30. Standards for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). JAMA 227 (suppl 7): 833, 1974 31. NIE NJ, HULL CH, JENKINS JG, et al: SPSS: Statistical Package for the Social Sciences, 2nd ed, New York, McGraw, 1975
Health problems and health care for adolescents in residential facilities in Quebec J.Y. FRAPPIER,* MD; N. STEINMETZ, MD, CM, MPH, FRCP[C]
The health problems of 160 adolescents in four residential facilities of the Ouebec social welfare court were studied. At the time of admission 440/0 had at least one problem requiring consultation with a specialist and 800/0 had an average of two problems requiring primary care. The medical records of 106 youngsters in two re-education centres were also reviewed and similar results were noted. The health services available, particularly physical examination and laboratory testing at the time of admission and arrangements for referral and follow-up were judged to be insufficient in most centres. Although society has taken custody of these adolescents, no one is responsible for their health care. Since February 1976 the social welfare court residential facilities and the network involved in the care of socially disturbed youngsters have been undergoing reorganization. Health programs and services ought to be part of this reorganization, and private physicians, hospitals and government each should have a role in the establishment and functioning of these programs. Nous avons 6tudi6 les probl&mes de sant6 de 160 adolescents r6partis dans From the department of pediatrics, McGill University *Clinical scholar of the Robert Wood Johnson Foundation Reprint requests to: Dr. J.Y. Frappier, 3189 Lacombe St., Montreal, PQ H3T 1L6
quatre centres d'accueil au Ou6bec. A I'admission 440/o pr6sentaient au moms un probleme n6cessitant une consultation en sp6cialit6 et 800/o avaient en moyenne deux probl.mes necessitant Des soins d'un praticien general. Les dossiers medicaux de 106 autres jeunes ont 6te revises dans deux centres de re-6ducation et Des resultats etaient similaires a ceux mentionnes ci-haut. Les services de sant6 offerts ont et6 juges insuffisants en ce qul a trait, entre autres, aux examens physiques et aux analyses de laboratoire a l'admission ainsi qu'aux arrangements en vue d'une consultation ou d'un follow-up. Mime si Ia societe est responsable de ces adolescents, en fait personne n'est responsable de leur sant6. Depuis fevrier 1976 s'effectue une reorganisation des centres d'accueil et du r6seau qui Des entoure. Des programmes de soins de sante devraient faire partie de cette reorganisation, et Des medecins, Des h8pitaux et le gouvernement devraient tous avoir un r6le dans l'elaboration et le fonctionnement de ces programmes. In Quebec, children and adolescents with special problems and needs are seen, whenever necessary, by the social welfare court. Such youngsters are divided into two major groups. The first are those "under court protection", such as orphans and those removed from parental custody owing to abuse or neglect. The second includes those with psychosocial problems, either delinquents or socially disturbed young-
sters whose behaviour has brought them into custody. To accommodate both groups the province has established many residential facilities, so-called reception centres, which are related to the social welfare court and social agencies. Among these centres some are involved in the care of youths designated as being under court protection. Others, training schools or re-education centres, care for adolescents with psychosocial problems. A few centres are similar to halfway houses; adolescents can stay there while waiting for placement in a foster home or for a court decision. All of the above centres function in an open setting. Finally, there are also some detention centres that, paradoxically, are forced to admit delinquents as well as youngsters under court protection, in part because of a lack of resources for the latter. In 1975 the Batshaw committee was formed to study how reception centres function and determine the needs of the youngsters they served. This meant taking into account relations between the centres and the existing and proposed network comprising social agencies, hospitals and schools. The committee's report,1 published early in 1976, enumerated the rights of children and included 160 recommendations. Among these were a group dealing with the development by the reception centres of several services (group homes, foster homes and day-care centres) and a group emphasizing individualized intervention and continuity in care directed towards social rehabilitation. The right of the child to "physical
CMA JOURNAL/DECEMBER 17, 1977/VOL. 117 1403
Table Il-4.harspteristics of youngsters Iii four of the centres4'
Characteristic
A,B audD C (boys, (girls1 n = 120)n = 40)
38 60 16.-Il 62 40 Not going to school (for >4mo) 61 55 Alcohol Intake (. twice a week) 18 10 DruguseGi.twIce a week) Cigarette smoking (>I2fd) 68 65 Sexually active 55 80 History of fractures 20 41 HIstory of surgeryt 55 50 4'Data were unavailable for Lentres E and F excsptforag(93% were Ilto l5yearsold). tTonsillctomy and adenoldectomy In one half.
taut problems qf youngters (120 lii.) xamlned In frniruf lii. .erdres (Ato D %of ProbIen. youngsters Requiring referral Ear, nose and throat 11 Nasal esptwn deviation 3 Other (e.g., chronic otitis, hearing defect) 8 General urglcal 7 Asthma an4allrgy, severe 6 PsychIatric 6 lton1azl4*oml.prophylsxis 5 Pregnancy (4w) gIrls) 5 Heart murmur, sIgnificant 4 Orthopedic 3 EpIlepsy 3 Speech problems 2 Other (e.g, h.stltis, colla. gonosis, hypothyroidism, 3 strabismus) Requiring prl0ary care Need cohtraceptlon 50 (girls) Skli. Infection (e.g., tlnea CruriS, scablas) 17 Severe acne 4 Other (e.g., dermatitis, laceratIons) 15 Tine test positive 29 Genltourinary 22 Vaghijtls Conococcal 5 Other 13 Urinasy tract Infection, hemeturla 4 Ear, nose and throat 20 Acute tonsluitlsl Tos.1hypertrophy 7 Other (e.g., otitis) B Heart murmur, functional 12 Nutritional and growth retardation 8 Musculoskeletal I Allergy, mild 7 High blood pressure (>140/90mm Hg) 6 Bronchitis 6 ConstIpation (2/3 with blood In stools) 6 Gingivitis 5 Enuresis S Gynecomastia 4
the 1973 American Academy of Pediatrics' recommendations for health care in juvenile court residential facilities should serve as a guide. The application could differ for group homes, reception centres and foster homes, but the concepts should be respected in every facility. Social rehabilitation must be the ultimate goal for each youngster taken into court custody, and improvement of physical health is an important first step. In that sense private physicians, local community service centres (centres locals de services communautaires; CLSCs), hospitals and government may each have an important role. In 1971, after the reorganization of health and social services, CLSCs started to develop in Quebec. As part of their role they were to provide curative and preventive health services to reception centres in their district. At present there are too few CLSCs and inadequate collaboration has been established with their respective reception centres. A large proportion of youngsters in court custody will not be admitted to reception centres, especially after their first court appearance. Moreover, with the reorganization of the social affairs network, more and more of these ado-
lescents will be sent either back home with support and surveillance or to foster homes or group homes instead of being kept in large institutions. Accordingly, it would be more promising if .a coordinated program were to develop between probation officers, social workers, hospital clinics and other resources (e.g., CLSCs and private physicians). Adolescent clinics could be of great help in the development of this program by ensuring quality of care and the involvement of specialty clinics and private physicians. With such a program it should be possible to bring all youngsters to medical attention shortly after their first court appearance. They could be seen by interested general practitioners in a CLSC in their district or in a private office. Some could also be seen at adolescent clinics, depending on the resources available. With the cooperation of the court, social agencies and physicians we think that more of the remediable defects would be corrected sooner and that more of the chronic or serious problems would be identified and the adolescent referred to and followed up at the appropriate clinic. A program such as this is not easy to set up, and follow up of these adolescents is difficult. However, it is feasible and
it should start somewhere. Finally, and of greatest importance, government officials responsible for health matters must become more aware of and responsive to the special health needs of this population. Leadership and resources should be provided for social agencies, the court, reception centres and hospitals to ensure that they are able to respond appropriately to these needs. We are greatly indebted to Dr. I.B. Pless for his help in the preparation of this manuscript and to those working in the centres for their cooperation. References 1. BATSHAW S chmn): Report of the Commtttee for the Study on the Rehabilitation of Chtldrcn and A dolescents placed in Reception Centres, Quebec, .diteur officiel du Quebec, 1976 2. EISNER V, SHOLTZ RI: Health care for juvenile delinquents. Pediatrics 52: 434, 1973 3. Lirr IF, COHEN MI: Prisons, adolescents, and the right to quality medical care: the time is now. Am J Public Health 64: 894, 1974 4. American Academy of Pediatrics, committee on youth: Health standards for juvenile court residential facilities. Pediatrics 52: 452, 1973 5. National Center for Health Statistics: Examination and Health History Findings among Children and Youths, 6-17 Years, Public Health Service publ no 1000, ser 11, no 129, Washington, US Govt Printing Office, 1973 6. BRUNSWICK
AF,
JOSEPHSON
E:
Adolescent
health in Harlem. Am I Public Health 62 (suppi 2): 1, 1972
MEDICLINICS POSTGRADUATE MEDICAL REFRESHER COURSE
FORT LAUDERDALE, FLORIDA MARCH 6 - 17, 1978 PRE*REGISTRATION - $300.00 MEDICLINICS 832 Central Medical Building Saint Paul. Minnesota 55104
EXCELLENT FACULTY, FINEST HOTEL, PEAK OF WINTER SEASON 1406 CMA JOURNAL/DECEMBER 17, 1977/VOL. 117
