Stormy adolescence

  

 

“I am having severe neck pain doctor. I have taken all home remedies that were suggested to me. But it is not going away,” said a demure young woman. She was the 68^th patient of the day. The complicated and memorable patients always seem to come to the clinic towards the fag end. Is it a pattern? Or am I vividly remembering them because they came last? The brief interaction with her left a deep impact. I was thinking about her for a long-time last evening. 

 

Mrs. L must be all of 24-25 years of age. She must be about 5 ft 4 inches tall, thin built, pitch-black hair well oiled, parted in the middle and worn as a plait. She also had a bright kumkumam dot on her forehead, it was not the typical dark maroon color that most women in the area wear. It was a light red to orange colour dot, commonly worn by women belonging to the Irula tribal community. We have a practice of routinely collecting information about caste in our clinic case records. It has been a contentious issue and many outsiders who visit our clinic have asked us, “Why do you collect caste information?” “What do you do with the caste information?” “Aren’t you creating unease by asking about caste during registration?” “Don’t people misunderstand you?” We collet caste information to ensure that we continue to serve the marginalized caste groups such as scheduled castes and scheduled tribes. We do periodic assessments of our clinic attendees profiles and if we notice that we have lesser attendance by SC and ST, we immediately meet, discuss about it, and reach out to the communities and check what is happening. This helps us stay true to our mission and vision, which is to serve the most marginalized communities. So, I looked at the case record where we note down the caste, and she was indeed belonging to the tribal community. A young boy, her same height, must be around 13-14 years, accompanied her. Irula men and women are characterized by a dark skin tone. In fact, the etymology of the word Irula comes from the tamil word Irul which means darkness and refers to their skin complexion apart from the nature of their work which is hunting for snakes and rats in the fields at night. The teenager was in the precipice of adulthood with good height for his age, broad shoulders, and the wispy fuzz over his upper lip, but what was most interesting was the bright and constant smile on his face. 

 

I asked Mrs. L for other symptoms associated with her neck pain. She had nothing else. No pain radiating to her arms and hands, no weakness of her hands, no dizziness on changing the neck posture. I examined her neck and her upper limbs, and everything seemed to be normal. In primary care one of the common dicta is that neck pain and low back pain are often indicators of unresolved psychological conflict and stress. Often people go to various spine surgeons, orthopedic surgeons and other specialists and get all kinds of scans like the MRI for the spine. Sometimes the scans even show problems in the spine. Despite presence of these lesions, the most common cause for neck and low back pain in primary care practice is psychological. I routinely ask for any causes of psychological problems when patients come to me with these complaints. I gently treaded into that line of conversation. As though she was waiting for me to get into this, Mrs. L started talking about her son. 

 

“I brought this boy with me today, mainly for that doctor. I told him I am not well and I asked him to accompany me. Otherwise, he wouldn’t have come. But it is him that I want you to see.” 

 

I looked at the boy and smiled at him.  “Enna da? What is the problem?” I asked. He returned the smile, but did not say anything. 

 

“Tell sir. Don’t keep quiet like that. Open your mouth and speak.” This was Mrs. L. He stayed silent and the typical smile lingered on his face. But now he broke eye contact with me and was looking at the roof, the fan and all around. 

 

“Sir, he is using ganja (cannabis), smoking beedis and even drinking alcohol. He is bunking school and hanging out with older men in the village. The teachers are coming and complaining to me. The parents of other children are also shouting at me to correct him, otherwise their children will also get spoilt.” Mrs. L was very much agitated when she had the outburst and said this. 

 

It was unbelievable. The teenager looked happy, cheerful and there were no signs of any substance abuse. I looked at the boy and asked him, “Thambi, look at me. Can we talk about this?” He refused to look at me and turned to the other side. His back was facing me. But I could see that he continued to smile. His mother pushed him and made him physically turn towards me. He was facing me now, but he was looking outside the window which is just behind my seat. I was trying to establish eye contact, but he wouldn’t. The smile remained on his face, but its nature had changed by now. What was initially a cheerful smile, was now a fake smile. It had the contours of a smile, but the spirit of the smile was missing.

 

By now, Mrs. L started crying. “I am struggling with this boy doctor. I have 3 more children all younger than him. Now they will also see him and get spoilt. I have told him kindly, I have cried to him, I have scolded him. Yesterday I even took a stick from the nearby tree and beat him blue and black. But he is just not listening.” 

 

I could not break the ice with this young man. I was clutching at straws trying to get a breakthrough with him. Maybe taking his side will help. “Amma, please don’t cry. He seems like a nice boy. We can talk to him and make him understand.” I am sure he heard the words, but he completely ignored them. He wouldn’t look at me. “Hey, Thambi…come on. Just look at me once. Shall I ask amma to leave the room? Shall we talk in private?” I asked. Still no response. By now I could see that he was struggling to maintain the fake smile on his face. The small muscles of his face below the eyes and around the mouth and nose started twitching with the effort of maintaining the smile. 

 

By now Mrs. L’s condition was very bad and she was crying. I also had to handle her emotion. So, I told the boy, “Look at amma. She is so worried about you. Look at how she is crying. Please allow me to help you and help her.” I don’t know what happened, the boy suddenly turned to see her, glared at her, then he turned to me, he did not speak anything by started laughing. It was a loud guffaw and his whole body was shaking as he laughed. I was confused. I did not say anything funny. Why is he laughing? I was too confused to think and I smiled at him. He did not stop laughing and slowly his eyes became red, and tears started streaming down his cheeks. That was the saddest emotion I had seen. The teenager was laughing out and crying inside. I just wanted to rush to him, hug him tight and console him. I could hear the cry for help. Mrs. L was also crying and she said, “This is what he does doctor. He laughs whenever he wants to cry and hides his crying. Everyone thinks he is laughing, but I know he is crying. Please help him.” 

 

I placed a hand on his shoulder and drew him closer to me. He struggled and fought against me and released himself. He was not ready to talk. He did not want to be consoled. I told him, “I won’t judge you, I won’t ask you to do anything. I won’t give you any treatment. I just want to listen to you. You can think of me as a friend and talk to me. I just want to help you.” But he continued to laugh, got up and left the room. Mrs. L got up, thanked me and started walking away too. I called out to her and said, “Please bring him back whenever you can. I want to keep trying to talk to him” She nodded and left. 

 

I am sure there is something complex going on in that young boy’s mind. I felt extremely helpless after he left. Adolescence can be such a confusing time. I remembered my own stormy adolescence, how I felt extremely lonely, unsupported, misunderstood, angry with the whole world around me. The young boy is probably going through something like that. I felt unprepared to help him. I felt helpless! I was asking myself, if I had been a parent, if I had handled adolescents in my own family, maybe I could have handled this boy better. But then I realized parents are probably not the best people to support and help adolescents going through hard times. They need teachers, they need friends, they need mentors. I will keep trying to see what I can do to help him. A primary care physician must be an astute clinician, and at other times a good teacher, a good mentor and friend. I have a long way to go.