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Adolescent Psychiatry (v.1, #4)

Preface by Lois T. Flaherty (pp. 264-264).

This issue of Adolescent Psychiatry spans the spectrum between evidence-based practice and practice-based evidence. Aspecial section on eating disorders in this issue summarizes current knowledge about these challenging, all-too-prevalent,disorders and their treatment. Included in this section is an article on eating disorders in males, which are often overlooked. Inthis article, Stewart points out that this is because of the popular assumption that eating disorders only affect females, and thefeminization of current diagnostic criteria. Anorexia nervosa, while among the most serious illnesses affecting adolescents, witha high rate of fatality, is treatable. However, the treatment must aggressively challenge the adolescent's extreme level of controlover the family.Two reviews deal with bipolar disorder and marijuana dependence. In the first review, Bernstein has provided an update oncurrent knowledge and best practices for treatment of bipolar disorder. She emphasizes a rational treatment approach that mayinclude alternative and complementary medications. Jaffe summarizes his long experience with treating adolescents who usemarijuana, pointing out the many myths that such teenagers use to justify their use, and giving suggestions for how to counterthese beliefs. He believes that marijuana use is particularly pernicious for adolescents as they do not recognize the impairmentthat their use is associated with. He underscores his points with neurobiological evidence, showing the significant and longlastingeffects that marijuana has on the brain.The perspectives section contains three thought-provoking articles. Aggarwal and Pumariega discuss the many issuesrelated to minors who were held at the U. S. naval base in Guantanamo in the aftermath of the terrorist attacks on the U. S. onSeptember 11, 2011. As has been pointed out many times, detainees at Guantanamo lacked many of the legal protectionsavailable to prisoners on U. S. soil and this was no less true for adolescents than adults. It is clear that the base was not wellequipped to provide adequately for their needs, with adverse consequences. Also in this section is a paper by MichaelKalogerakis, which summarizes his thinking about what needs to be done to promote mental health in children and adolescents,focusing on the role of families. The World Health Organization defines mental health as- a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stressesof life, can work productively and is able to make a contribution to his or her community. In this positive sense,mental health is the foundation for individual well-being and the effective functioning of a community.(http://www.who.int/mediacentre/factsheets/fs220/en/).Two articles focus on the psychiatric inpatient treatment of adolescents. The authors-one group from Greece and anotherfrom the U. S.-describe how they have dealt with the challenges of limited resources in the face of unmet needs. Zilikis andcolleagues describe the development of an adolescent inpatient program in which adolescents were hospitalized with adults andpoints out that there are some advantages to this arrangement. Shen, Dhillon, and McCarthy use the case of an adolescent withnon-suicidal self-injury to discuss the role of the hospital as part of a continuum of care.Duric and Elgen present findings from their research on Norwegian children and adolescents with ADHD who presented fortreatment in a clinic after having been referred from community sources. Their findings confirm that these youngsters have highrates of comorbid psychiatric conditions and often suffer from cognitive impairment, mandating careful evaluation of allaspects of their functioning. They add to the world-wide perspective on this common disorder.We are indebted to Glen Pearson who was able to obtain and edit -Embracing Spitfires,- a presentation given by James L.Cox at an ASAP meeting several years ago on his approach to adolescents who are difficult to engage in psychotherapy. Likeothers who have devoted their lives to psychotherapy with adolescents, Cox reminds us that this work is not for the faint ofheart.Finally, a new section, Letters to the Editor, appears in this issue, with two letters on Dwyer and Jarrel's article, the -Use ofMental Health Services By Youths Who Have Sexually Offended,- which appeared in the last issue (2011, pp. 240-250). I hopethat this is the start of an ongoing dialogue between Adolescent Psychiatry and its readers.

Editorial [Hot Topic: Eating Disorders in Adolescents (Guest Editors: Julie Lesser and Kathleen Kara Fitzpatrick)] by Julie Lesser, Kathleen Kara Fitzpatrick (pp. 265-266).

The idea for a special section on eating disorders in adolescents emerged from the collaborative conversations andenthusiasm for learning that characterized the March 2011 ASAP meeting in New York City: 9-11 to 2011, A 10-year updateon Adolescent Psychiatry. The focus of the conference and this special section is on the bridge from research to clinicalpractice. We stand at a unique moment in time with the treatment of eating pathology. For the first time since the codificationof these illnesses in the medical literature (Gull, 1874), the treatment literature has made strides to provide clinicians with aclearer path on the ways to manage these disorders. Nowhere has this advancement been as great as in the treatment of childrenand adolescents. Fortunately, we stand in a position today to assist our youngest patients make strides toward recovery, evencure.Despite advances in treatment, the dissemination of these strategies to front-line clinicians and care workers continues to lagbehind. Clinicians must flexibly attend to the needs of individual patients and families in a multitude of settings, while aplethora of available treatment options compete for attention. Effective clinical practice rests on the clinician's desire andability to seek out support for nascent skills and new learning opportunities. Studies of dissemination and implementation, suchas the work of Beidas and Kendall, 2010, outline important questions about how to bring information from research centers toclinicians and about how the training experience and organizational factors impact the implementation of interventions. Whilethe gold standard for evidence- based practice in psychotherapy remains a scientifically evaluated protocol with a treatmentmanual, training workshop and supervision, it is clear that active learning is essential for clinicians to be able to deliver keyinterventions and develop the level of competence and skill required to improve outcomes for patients.Adolescent psychiatrists are uniquely positioned to take a leadership role in implementing effective treatments for patientswith eating disorders. Clinical expertise in working with teens and families with comorbid disorders including anxiety,depression, and substance use disorders, combined with a flexible, positive attitude toward taking on challenges in treatment isa natural fit for training in eating disorder treatment protocols. Many clinicians are already familiar with training formatsavailable for cognitive behavior therapy through places such as the Beck Institute, where Dr. Judith Beck uses role-plays andother techniques to promote active learning, and Dr. Aaron Beck demonstrates goal setting and other interventions during aclinical interview, followed by an open format for questions from workshop participants. Treatment manuals, intensive trainingand regular consultation are elements of an adherent protocol in dialectical behavior therapy. In the treatment of eatingdisorders, clinicians now have ready access to treatment manuals, workshops and supervision for two main empiricallysupported treatments: Lock and LeGrange's Family Based Treatment (FBT or Maudsley at http://www.Train2Treat4ED.com)and Fairburn's Cognitive Behavior Therapy-Enhanced: (http://www.psychiatry.ox.ac.uk/research/researchunits/credo/forthcoming-training-workshops).Learning from mentors and gaining new skills informs not only specific areas of expertise but provides skills that may begeneralized and applied across a wide range of disorders and practice settings. Perhaps training is best thought of as a parallelprocess to the treatment alliance, with bonding (maintaining an atmosphere of mutual positive regard), goals, and steps toachieving goals. Representing one such alliance, we (Drs. Kara Fitzpatrick and Julie Lesser), the two guest editors of thisspecial section on eating disorders, worked together first as supervisor and supervisee in the training program for Family Basedtherapy for eating disorders. In putting together this special section on eating disorders in adolescents, the ingredients were inplace for a synthesis and collaboration that spans disciplines, institutions, health care settings and generations. The aim was tobring together articles that inform the treatment of eating disorders from various perspectives, building upon current knowledgeand interpreting well-known techniques in the treatment of eating disorder symptoms. The broad clinical utility of these skillsare presented with a goal of encouraging clinicians to consider the significant rewards of working with eating disorder patientsand their families.Fitzpatrick leads the section with an overview of FBT for children and adolescents with eating disorders. She gives anupdate on the clinical outcomes and research findings with this approach. In the paper, she outlines the forms of family basedtreatment and key interventions. Strategies to help empower families in refeeding while learning to separate the eating disorderthinking and illness from the child are described. Family based treatment has been successfully implemented in youngerpatients and in eating disorders with comorbid conditions. Despite the empirical support for the approach, there is still ashortage of trained clinicians.In the second paper, Dr. Beth Brandenburg and colleagues discuss the approach to psychopharmacological interventions inadolescents with eating disorders, an area where the research findings are sparse. The adolescent psychiatrist must draw uponclinical expertise in treatments for adults and adolescents with comorbid disorders. Special attention is directed to coordinatingcare with a primary medical physician, and other members of a multidisciplinary team. The paper presents guidelines formonitoring medications, the medical and safety status, and nutritional needs of the patient. The authors discuss the treatmenttargets, and potential side effects, risks and benefits of psychotropic medications in this population. Medication use is integratedwith the primary psychotherapy treatment, with a careful eye on maintaining the treatment alliance, and knowing when torecommend a higher level of care......

Family-Based Therapy for Adolescent Anorexia: The Nuts and Bolts of Empowering Families to Renourish Their Children by Kathleen Kara Fitzpatrick (pp. 267-276).

Family-based therapy or Maudsley has increasing evidence for its efficacy in the treatment of child andadolescent eating disorders. Available in manualized form, widely available, and supported by an ever-increasing researchliterature, the application of this outpatient treatment continues to be challenging for many front-line clinicians and is afairly significant departure from previous treatment methods. The current article explores the research supporting thismethodology and the iterations of this treatment, such as the use of multi-family groups, parent support groups or withnon-psychiatric comorbidities. Further clinical guidance is provided to assist the clinician in identifying tips, strategiesand techniques for success in implementation of these skills with families.

Psychopharmacological Interventions for Adolescents with Eating Disorders by Beth Brandenburg, Julie Lesser, Deb Mangham, Scott Crow (pp. 277-285).

The purpose of this article is to review evidence-based pharmacological treatments for eating disorders with aspecial focus on the adolescent population. Eating disorders commonly present in adolescence, yet little published data areavailable to guide the adolescent psychiatrist. The use of medications in the context of evidence-based psychotherapeuticinterventions and co-morbid psychiatric conditions will be discussed. Defined will be the unique role of the adolescentpsychiatrist in orchestrating treatment by a multidisciplinary team, determining the appropriate level of care, monitoringsafety, and evaluating treatment response. Risks and benefits of the use of pharmacological interventions in individualswho are malnourished or engaging in eating disordered behaviors, such as purging or laxative abuse, will be delineatedalong with proposed monitoring. Each potentially affected organ system will be addressed. Sequentially described is theexisting evidence for use of medications for anorexia nervosa, bulimia nervosa, and binge eating disorder in adults and,where available, adolescents. Atypical antipsychotics, particularly olanzapine, have shown promise for adults withanorexia nervosa. However, in a recent trial of adolescents, no benefit for olanzapine over placebo was found. Severalantidepressants have been shown to be effective treatments for bulimia nervosa, and fluoxetine has the FDA approval fortreatment of this disorder in adults. Although fluoxetine has been deemed safe and effective in an open trial of adolescentpatients, controlled studies in this population are lacking. Special considerations for the use of these medications inadolescents are discussed.

Addressing Low Self-Esteem in Adolescents with Eating Disorders by Kathleen Kara Fitzpatrick, Jennifer Lesser, Beth Brandenburg, Julie Lesser (pp. 286-295).

This article aims to provide background and theory supporting the use of a problem-solving, emotionregulation, and self-esteem module for children and adolescents with eating disorders. Eating disorders typically presentin adolescence, and low self-esteem and perfectionism are hallmark features of eating disorder pathology. We willexamine how low self-esteem and perfectionism interact and serve as risk factors as well as maintaining factors in eatingdisorders. Both features have distinctly been show to predict poor treatment response in eating disorders, as well as indepression and in certain anxiety disorders. We will review the limited existing models for treating low self-esteem andperfectionism in adults with eating disorders and potential problems of using these models with younger patients. Finally,we present a pilot intervention designed to be integrated into primary eating disorder treatments for patients where lowself-esteem, mood intolerance, and problem-solving deficits may present difficulties with eating disorder treatmentimplementation or risk for relapse. This intervention is based on principles from established treatments, includingChristopher Fairburn's cognitive behavioral therapy enhanced for eating disorders, Marsha Linehan's dialectic behaviortherapy, Melanie Fennell's and Leslie Sokol's guides to overcoming low self-esteem, Aaron and Judith Beck's cognitivebehavioral therapy, and anxiety and phobia treatments for children. We have used this 4 to 6 session interactive module inmulti-family groups, family and individual sessions. We believe this will be an important intervention in the treatment ofadolescents with eating disorders, and that it merits further study.

Difficulty with Uncertainty: How It Presents in Eating Disorders and What We Can Do About it by Maria-Christina Stewart (pp. 296-306).

Eating disorders (EDs) are serious illnesses whose treatment, particularly with children and adolescents,requires sophisticated integration of skills and techniques from the armamentarium of evidence-based treatments targetingEDs and associated symptoms. Especially difficult to treat are cognitive impairments, because they are both diseasespecific(e.g., cognitive distortions related to the body itself) and more general (e.g., difficulties with uncertainty). Thispaper discusses cognitive impairments in EDs that involve difficulty coping with uncertainty and the associatedimplications on emotional and behavioral functioning. A set of skills to assess and increase adaptive coping withuncertainty is discussed in depth. Clinicians are strongly encouraged to target cognitive difficulties such as intolerance ofuncertainty in ED treatment, as they can otherwise significantly interfere with one of the strongest predictors of successfuloutcomes - behavior change.

Eating Disorders in Adolescent Males: An Critical Examination of Five Common Assumptions by Alison M. Darcy (pp. 307-312).

Males have not received much attention in the eating disorders (ED) literature, and adolescent males havereceived even less. As a result, we have inappropriately extrapolated from the adult literature, and many commonly heldassumptions have gone unchallenged. This paper discusses some of the most common assumptions made about EDs inadolescent males, and reviews the evidence for those assumptions. Specifically, the assumptions that (1) males account for10% of ED cases; (2) ED behaviours are rare among adolescent males; (3) EDs are similar in males and females; (4)males are not subjected to media programming depicting physical ideals in the same way that females are; and (5) EDs areexclusively associated with female gender, are discussed. It now seems clear that while there are many more adolescentmales in the community with EDs than estimates from clinical samples would suggest, there are insufficient data to allowus to draw conclusions about the similarity between male and female EDs. Males are subjected to media programmingthat prescribe an equally unattainable physique as for females, however, it may affect them indirectly. Finally, contrary tobeing feminine issues, EDs in males are sometimes related to factors usually associated with extreme masculinity, such asmuscle mass and athleticism. While these opposing views are offered, in general, there are very little data from which toconclude and further research is encouraged.

Bipolar Affective Disorder in Young People: A Review by Bettina Bernstein (pp. 313-320).

Bipolar disorder (BD) is an uncommon, but not rare, psychiatric disorder, that often has its onset duringadolescence. This disorder is associated with a significant burden of illness both during adolescence and in subsequentadult life. Although a serious and persistent mental illness, it can be treated effectively so that functional impairment isminimized. Early diagnosis and prompt and effective treatment is important. This article provides a brief overview of thediagnosis and treatment of this disorder. In addition to the various medications (mood stabilizing, antipsychotic), andpsychosocial interventions that have demonstrated efficacy, the use of alternative forms of treatment, such as herbalsupplements, may have a role as adjuncts in helping with mood and with sleep architecture.

Marijuana and Adolescents: Treatment Strategies for Clinicians by Steven L. Jaffe (pp. 321-324).

Although marijuana dependency is probably the least severe of the drug dependencies in terms of acuity andseverity of negative consequences, it is one of the most difficult to treat. In this paper I propose that some of the difficultyin treating marijuana dependency in adolescence is due to the adolescent's impairment in recognizing the negative effectsof regular use. This impairment in recognizing impairment is the result of the combination of both the executive functioncognitive deficits and that everything is experienced in a mild high state. Adolescents then begin to lose the capacity tomake meaningful logical connections between their drug usage and its effects on their life. Understanding this processhelps the therapist to tolerate the frustrations in treating these adolescents. Suggested treatment interventions are to firstestablish an initial period of abstinence for 3-4 weeks. This can be done by utilizing one or more of the following: parentallimit setting with random urine drug screens, contingency management techniques, direct suggestions to try abstinence fora limited time, and/or positive program peer pressure that abstinence is necessary to be part of the group. After a period ofabstinence, the usual therapy approaches of motivational enhancement therapy, cognitive behavioral therapy, familytherapy, community reinforcement approach, 12-Step mutual help programs and pharmacotherapy of co-morbid disordersmay become more meaningful. Other practical clinical interventions with case examples are described.

Mental Health Services for Minor Detainees at Guantanamo by Neil Krishan Aggarwal, Andres J. Pumariega (pp. 325-332).

This article addresses the bioethical implications of child and adolescent mental health services forGuantanamo minor detainees, hitherto unexplored since the American War on Terror. First, the literature on child soldiersis reviewed as a standard to measure treatment of minor detainees. Next, frameworks for mental evaluations with childrenand adolescents are surveyed given the complexity of issues involved. Afterwards, the cases of Mohammed Jawad andOmar Khadr are analyzed through interviews with key informants. The article concludes that the American governmentcan improve future treatment of child soldiers by tailoring medical services for children and adolescents, providing regularaccess to caregivers and systematically obtaining informed consent, enforcing least restrictive environments, andemphasizing rehabilitation to punishment.

The Promotion of Mental Health: Role of the Family by Michael G. Kalogerakis (pp. 333-339).

Increasing awareness of the prevalence of mental illness in children and adolescents has been followed by anawareness of the global burden-economic and social, in addition to the suffering of individuals and their families. TheInstitute of Medicine recently acknowledged that insufficient attention has been paid to attempting to reduce the globalburden of mental illness. In light of what we know about development and the important role of the family in promotinghealthy development in children, it is crucial to support the role of the family. The author draws on his long career as atherapist, an administrator of clinical services, and a leader in mental health service agencies, as well as his personalexperience as a father and grandfather, to present a comprehensive overview of what we know and what we need to do topromote mental health in our children and adolescents.

Adolescent Admissions in Psychiatry: Reconsidering Clinical and Institutional Parameters on the Occasion of a Report of a Greek Experience by Nikos Zilikis, Grigoris Abatzoglou, Apostolos Iacovides, Charalambos S. Ierodiakonou (pp. 340-348).

More than half a century since the creation of the first specialized units in the USA and the U.K., inpatienttreatment of adolescents remains an illustrative example of the difficulties in integrating adolescent services in mentalhealth care systems. Through a literature review, the various parameters of adolescent hospitalization in psychiatry areexamined. Among the different solutions, admission to general (adult) psychiatry remains a realistic option, as long asthe gap between child and adult psychiatry perpetuates the difficulties of older and post-adolescents in having access toinpatient treatment facilities. The report of an experience from Northern Greece of 253 admissions in a general psychiatricward at a university general hospital gives the authors of this paper the opportunity for a discussion on this particularpractice, and for reconsidering the main questions on adolescent hospitalization in general.

Norwegian Children and Adolescents with ADHD - A Retrospective Clinical Study: Subtypes and Comorbid Conditions and Aspects of Cognitive Performance and Social Skills by Nezla S. Duric, Irene B. Elgen (pp. 349-354).

Objective: To retrospectively evaluate comorbid conditions including cognitive and social performance in acohort of ADHD referred children and adolescents.Method: A population of 187 children and adolescents was referred to an outpatient clinic for Child and AdolescentMental Health in Norway regarding attention deficit hyperactivity disorder (ADHD). Examinations of the population weredone using interviews and questionnaires with parents, teachers, children and adolescents regarding ADHD. After areview of all the assessments, the children and adolescents were classified as ADHD (96) and non-ADHD (91). Inaddition, when available, cognitive performance was registered.Results: Seventy-one (74%) children and adolescents met the criteria for combined type ADHD (ADHD-C, bothinattention and hyperactivity-impulsivity symptoms) and 21 (22%) predominantly hyperactive-impulsive type ADHD(ADHD-HI, hyperactivity-impulsivity). Referral age was from 6 to 18 years; 82% were boys. Nearly all of the ADHDgroup (93%) had comorbid conditions compared to half of the non-ADHD group (OR: 14; 95% CI 5.6 to 36, p=0.001).Disruptive behavior disorder, anxiety/stress related disorder and encopresis/enuresis were the main disorders. One out ofthree ADHD children had a low IQ, almost double as many as in the non-ADHD group (OR: 1, 5; 95% CI 0.5 to 3.9,p=0.5). Social dysfunctions were found in four out of five ADHD children. In an explorative binary logistic regressionanalysis with social dysfunction as the dependent variable and IQ, gender and ADHD/non-ADHD group as independentvariables, a low IQ was the only predictable factor contributing to social dysfunction.Conclusions: The study provides evidence for ADHD children and adolescents with combined ADHD type(predominantly hyperactivity and impulsivity) associated with comorbid conditions being relevant to low cognitiveperformance and low social skills.Trial registration: Current Controlled Trials NCT01252446.

Non-Suicidal Self-Injury in an Adolescent: A Case Report and Discussion of Treatment by Hong Shen, Preneet Kaur Dhillon, Malia McCarthy (pp. 355-361).

The recurrent nature of non-suicidal self-injury (NSSI) and its frequent association with multiplepsychopathological conditions makes it a challenge for assessment and treatment. While the behavior can often beeffectively addressed in a hospital setting, the short term stays that are typical in the current environment make it unlikelythat therapeutic gains will be maintained following discharge. The result is often therapeutic nihilism, and a revolvingdoor phenomenon, which can become a pathway to chronic psychiatric disability. However, if the hospital can be viewedas part of a continuum of community-based care, rather than a retreat from the community, it can play a valuable role instabilization and improvement in adaptive functioning. The authors describe a hypothetical yet typical case of anadolescent admitted to the hospital for NSSI and review the clinical decision-making process that led to the developmentand implementation of an appropriate treatment plan.

Introduction to Facing and Embracing Spitfires by James L.D. Cox, Glen T. Pearson (pp. 362-368).

In this article, the author presents principles of psychotherapy with adolescents who present with rage andviolence. He contends that it is necessary to face and embrace the violent feelings these adolescents expereince. Hepresents three clinical illustrations from his psychotherapeutic work with adolescents to illustrate these principles. Theseadolescents were driven by rageful feelings to act in ways that had negative consequences for them-defiance ofauthority, and violent and suicidal behavior. In all three cases it was necessary to work intensively with the family as wellas with the adolescent. In order to meet the clinical needs of adolescents such as these, one must diligently seek outresources in the family, the school, the community, and within the patient him/her self. The family always has a criticalrole to play in the therapeutic task with their adolescent children. It is also essential to gain each adolescent's personalcommitment to some degree in the process, lest the possibility of therapeutic change be limited.

Substance Abuse Disorders Among Juvenile Offenders by David R. Sharer (pp. 369-369).

I was surprised to read that in the South Carolina cohort of youthful sex offenders described by Dwyer et al. (2011), nosubstance use disorders were noted. In my Colorado experience (albeit knowing that we are one of the states with the highestoverall incidence of substance abuse) with adolescent sex offenders in residential and prison settings, a high percentage havevarious substance abuse/dependence diagnoses. I suspect the original evaluators of this cohort either minimized or wereunaware of the worldwide extent of juvenile substance use/abuse. I sincerely appreciate the authors' efforts to call attention tothe preventative and community treatment needs of these youth. Because of my experience, I would include substance abuseeducation and treatment as an essential in these programs.

Response to Sharer Letter by R. Gregg Dwyer, Jeanette M. Jerrell (pp. 370-370).

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Adolescent Psychiatry (v.1, #4)