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Teenager with cystic fibrosis

has now started smoking

Three GPs share their

approach to a

practice problem

Case history

Tom is 14 and has cystic fibrosis. His parents have been diligent about his care and can take much of the credit for the fact that his lung function is relatively good. They have also encouraged him to participate as fully as possible in school and scouting activities.

But today Tom's mum is in tears. They have been having increasing problems with Tom's behaviour. He has become rude and aggressive and spends a lot of time in his room. He refuses to co-operate with his physiotherapy saying he would rather be out with his mates.

Tom's mum thinks they are a 'bad influence' and was appalled to discover that not only had he bunked off from school this week, but that he had been smoking cigarettes.

Dr Rachel Pryke

'Could his parents bargain from a more cool position by offering him limited alcohol ­ or even a tattoo?!'

Who can blame Tom for testing the bounds of his parents' control? Most parents find pubescent youths tricky to juggle, but it is often the most controlling parents that create the most rebellious kids. For Tom, his protective parents need to discover ways to allow Tom some freedom in his normal adolescent experimentation without, in the process, causing damage to fragile lungs.

The parents would benefit from reassurance that short-term experimentation with smoking is likely to be harmless, but overreaction on their part may result in defiant risk taking. Conveying this gently and positively would be stretching a 10-minute consultation, but I would try to explore the following factors, which might help the transition from being protective parents to supportive but respectful onlookers, as Tom begins to make his own decisions in life.

Mentoring. Parents may fail, but a respected outsider to the family might knock some sense into Tom, if they have a strong relationship with him.

Challenging Tom's friends. If Tom's friends are good mates they may be happy to modify their own experimenting in order to lessen peer pressure on Tom. While not applying common-sense to themselves, they may respond to the idea that they could be worsening their friend's health by their own behaviour.

Swapping to a lesser evil. Smoking for Tom is clearly a significant risk, but could his parents bargain from a more cool position by offering him limited alcohol, or glibly suggesting he gets a tattoo?

Back off with the physio for a while. Deteriorating symptoms might help Tom focus on the practicalities of his inescapable condition so that he is happier to comply.

Showing respect. Respecting other decisions that Tom is engaged in, such as GCSE course choices, could build his self-esteem, lessening his need to rebel.

These issues won't be solved overnight, so I would offer to refer Tom to a child psychologist, and explore what sort of support is available through organisations such as the Cystic Fibrosis Society.

If given the opportunity I would offer to see Tom alone to give him a voice. And I would try hard to listen rather than spout.

Rachel Pryke completed her VTS in 1993 ­ she is now a part-time principal in Redditch, Worcestershire

Dr Peter Moore

'I must resist the temptation to give the problem a medical label'

It's distressing to have a child with serious medical problems. Parents often become protective and find it difficult to set clear boundaries. It's not easy trying to enforce discipline on a child when life expectancy is limited. This can lead to behavioural problems in the child and an increased rate of marital break-up in the parents. Other children in the family can also be affected.

Teenagers will try to push at the boundaries. If there are no clear boundaries then the behaviour problems will become more extreme.

Tom is behaving as a typical teenager. Many children of his age will smoke because, unfortunately, it still carries a macho image. For most it's a phase they will grow through without too much harm. But for Tom the consequences of smoking and refusing physiotherapy could be serious. Bunking off school is also a part of normal teenage rebellion, although at the more extreme end.

I need to listen to Tom's mother without turning the normal adolescent problems into a medical illness. I must resist the temptation to prescribe psychotrophic medication or give the problem a medical label.

There's a danger that she will act from emotion and fear, imposing unrealistic rules and creating further conflict. Shouting and refusing to allow him to see his friends will only make him more rebellious. She may also try to bring me into the conflict with leading comments about his behaviour and friends. If I nod, she might use this in any future conflict: 'You shouldn't see your friends, and the doctor agrees.'

It's not clear how Tom's mother found out about his recent behaviour, but this could affect her response. If the school or physiotherapists contacted her, she may be feeling guilty and a failure. This will add to her anger and increase the conflict with Tom.

There needs to be an 'honest broker' who will allow Tom to talk. This could be a specialist health visitor, a school nurse or a drop-in centre for teenagers. With support for Tom's parents and family and space for Tom to express his feelings it should be possible to control the situation until Tom grows through his normal teenage rebellion.

Peter Moore completed the VTS in 1979 and is a partner in Torbay ­ he is also senior police surgeon for the area

Dr Prashini Naidoo

'This normal stage of development could have

grave consequences for Tom'

The temptation to intervene in Tom's best interests is huge, but it may compound the problem by giving the impression that 'we know best, you silly child'. Tom may be rebelling against authority and exerting his right to decide for himself, a perfectly normal stage of development but one, in his case, that could have grave consequences.

So, I have a moral dilemma. I need to weigh up respect for his autonomy, acting in his best interests, acting for the benefit of worried carers and doing what's best in a difficult and complex situation.

I have various options. I could just wait for something to happen, in which case Tom will eventually present to the medical services. But he may be gravely ill, and his parents may well feel betrayed by this course of action.

I could speak to Tom, but this may antagonise him and incite him to further rebellion. At least I would have done my duty and preserved my relationship with his parents.

A better option ­ and the one I would take ­ is to write to Tom.

I'd outline his parents' concerns but explain that I am also his doctor and respectful of his wishes. I'd tell him that I would like him to make decisions about his health, provided these decisions are made in consultation and with knowledge of the consequences.

Finally, I'd tell him that I'd like to speak to him about what sort of treatment he would find acceptable. By allowing Tom to choose, I may increase his commitment to future treatment.

Prashini Naidoo completed the VTS in August 2002 and is a GP in south Oxfordshire ­ she recently completed a diploma in occupational medicine and is now studying for a Masters degree in primary care development

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