Adolescent Psychiatry (v.2, #3)

Editorial: Risks and Opportunities in Adolescence by Lois T. Flaherty (209-210).

Research over the past decade indicates that adolescents who have experienced childhood maltreatment have more emotional and behavioural disturbances and less socially desirable or adaptive behaviours than typically developing adolescents. These difficulties are consistent with weaknesses in executive functioning skills. Executive functioning (EF), which involves higher order thinking and reasoning skills, is considered to be critically important for complex human behaviour. Adolescence is a period of marked neurodevelopmental change, particularly in the regions of the brain that deals with EF. During this period youngsters are in the process of acquiring higher-order, abstract cognitive skills as well as coping with the normal pressures of teenage life. EF skills may therefore be critical at this time and may explain the cognitive and behavioural difficulties that maltreated adolescents' experience. However, despite evidence to suggest that the overwhelming stress of childhood maltreatment leads to adverse effects on brain development, research into maltreatment and EF is still limited, particularly using adolescent samples. After a brief introduction to childhood maltreatment, an overview of recent findings will be provided, with first a consideration of the general effects of maltreatment on cognitive achievements and behavioural regulation, followed by an examination of the role of developmental period, severity and type of abuse. Theories about EF will then be outlined, concluding with a consideration of the effects of maltreatment specifically on EF.

Introduction: Although an important task of adolescence is to explore one's sexuality individually and in relationships, technology today has broadened the ways in which teenagers may engage in such exploration. In combination with lack of insight, poor judgment, and impulsivity, this can lead to sexually risky behavior on the Internet or cell phones, with unanticipated and unintended consequences, such as sexual predation, alienation from friends and family, or legal charges. Objective: The purpose of this paper is to provide information on the relatively new phenomenon of sexually risky use of technology and to offer suggestions for systematic evaluation and treatment of adolescents, with consideration into motivation for behavior, context, developmental age and insight, associated symptoms, and psychiatric history. Methods: Clinical case reports that illustrate examples of adolescents using technology, including the Internet and cell phone, in sexually inappropriate ways (sexting and online exposure) are used for discussion of diagnostic formulation. Conclusion: As treatment providers evaluate adolescents, they must be aware of the phenomena of sexually inappropriate behavior with social media and cell phones, ask their young patients about use of this technology, and strike a balance between normalizing behavior that could reflect an underlying or associated psychiatric disorder and pathologizing behavior that might be risky but peer normative. They must also be able to provide psychoeducation to adolescents and parents toward safe use of technology as adolescents develop into maturity and treat (or refer to treatment) as necessary for any underlying psychiatric disorders.

Interest in the effectiveness of psychological interventions in patients with psychosis has increased in the last 2 decades, and early intervention programs are increasingly common. PIENSA (Programa de Intervencion en Psicosis Adolescente; Intervention Program for Adolescent Psychosis) is a clinical program and pilot study based on previous research into the efficacy of early intervention in preventing relapse and improving outcome in patients with first-episode psychosis. We describe a psychoeducational intervention designed for adolescents with early-onset psychosis and their parents. The intervention is adapted from McFarlane's Multiple Family Therapy model to our setting and population (adolescents treated in the Spanish public health system). It consists of 2 stages: an individual stage comprising 3 sessions and a subsequent group stage comprising 12 sessions. The total program lasts for 1 academic year (9 months). We present the design of our program and our preliminary experience in a Child and Adolescent Unit in Spain.

Judging Children as Children by Michael A. Corriero (237-242).
The juvenile justice system's original focus on rehabilitation and avoidance of criminalization for youthful offenders has undergone dramatic changes in the U. S. Nowhere is this more dramatically illustrated than in New York, which is one of only two states that sets its age of criminal responsibility as low as sixteen. It is also part of the minority of states that require juveniles as young as 13 who are charged with certain serious crimes to be tried and punished as adults, and imposes mandatory sentences on them, regardless of their individuality, developmental differences, and extent of involvement in the underlying offense. Therapeutic interventions are more limited in the adult court, and the results of this can be seen in higher rates of recidivism. In this article, Judge Corriero argues that the courts should treat children as children. He makes the point that adolescents lack the maturity to make appropriate decisions, especially in groups, and should be treated differently from adults. Using case examples, he points to the damage that has been done by taking discretion out of the hands of judges to identify those individual children who are amenable to rehabilitation and to give them a second chance, even when they have committed violent crimes. Advocacy efforts underway to change the system to a more rational one are described.

Case formulation that incorporates cultural factors is an important clinical tool for use in initial and ongoing treatment with adolescents. Providing culturally-responsive psychotherapy to adolescents requires the therapist to understand the complex cultural context in which adolescents live. Adolescent identity development and psychological functioning are influenced by an evolving matrix of social identities (race, ethnicity, sexual orientation, spirituality etc.) that may shift and change at each stage of the teen's developmental life as well as within different contexts. This paper will compare and contrast the DSM-IV-TR Outline for Cultural Formulation with the ADDRESSING and RESPECTFUL mnemonic models of cultural formulation in the evaluation and treatment of teenagers. Case examples will illustrate how each model may be used to create a synopsis of the patient's experience in cultural context as well as how they are used to conceptualize change over time. The case examples will highlight the utility of cultural formulations in alliance building, in understanding the patient and parents' explanations of illness as well as in examining cultural transference issues in therapeutic work.

Objectives: The objectives were to estimate the prevalence of major depressive disorder in adolescent suicide attempters and to search adolescent suicide attempters' characteristics associated with severe depression. Methods: A cross-sectional comparative study was conducted on two groups of adolescents matched on age, sex and socioeconomic status, during a period of 8 months (April-November 2010). The first group included 30 adolescents admitted to the emergency department of Habib Bourguiba Sfax Hospital for suicide attempts. The second group included 30 adolescents examined in a community clinic in Sfax for a benign acute medical condition. The two groups underwent a semi-structured interview based on the DSM-IV-TR criteria, conducted by a child and adolescent psychiatrist. All adolescents completed the Child's Depression Inventory (CDI) and the Hospital Anxiety and Depression scale (HADS). Results: The diagnosis of major depressive disorder was significantly more frequent in adolescent suicide attempters than in the control group (23.3% against 3%). According to the HADS, 50% of adolescent suicide attempters exhibited pathological depression scores against 26.6% in the control group (p = 0.043). Adolescent suicide attempters' mean CDI score was significantly higher than the control group (28.56 versus 13.22). Higher levels of depressive symptoms on the CDI were significantly related to suicidal ideations during the past six months, previous suicidal attempts, impulsivity, a high intent to die and parent-adolescent conflicts. Conclusion: These findings provide support for suggesting a need for a systematic screening for major depressive disorder in adolescent suicide attempters to ensure early mental health treatment and prevent the recurrence of suicide attempts.

Objective: Anecdotally, we noticed an increasing number of adolescents evaluated in our psychiatric emergency room after sending an electronic communication (text message, instant message, email, social networking site posting) of suicidality. In this study we aimed to describe key similarities and differences among adolescents who communicated their suicidality to others via electronic versus other means. Methods: We reviewed consecutive adolescent psychiatric emergency room assessments over a 4-year time period conducted at Children's Hospital, Boston, a large tertiary care pediatric hospital, for the chief complaint of suicidality. We broadly defined suicidality as ideation, intent, plans, attempts, and other self-injurious behaviors. We ascertained how the patient communicated their suicidality, and to whom, and we obtained demographic and other pertinent clinical information. Results: There were a total of 1,350 psychiatric evaluations done at Children's Hospital, Boston for the chief complaint of suicidality during the study period. The vast majority (n = 1260) of patients communicated their suicidality verbally or via witnessed gesture. There were 54 who communicated suicidality via a hand-written note and 36 who communicated suicidality via electronic means. Patients in our comparison groups were demographically and clinically similar. One striking difference was to whom each group communicated their distress. Of those who communicated electronically, the majority, 67%, did so to a peer and only 33% to an adult, whereas those who communicated via written notes were more likely to do so to an adult. In the written note group, 7% communicated to a peer and 93% to an adult. Not surprisingly, the numbers of electronic communications of suicidality increased over the four-year study period from 2005 to 2009. Conclusions: The increasing use of technology for communication among adolescents may mean that a peer is the first recipient of a ‘distress call’. Therefore, differential patterns of communication among adolescents with suicidality may have implications for their clinical management and the timely provision of needed services. Our findings also point to the importance of taking a media use history, particularly for adolescent patients who are high media users, and psychoeducational prevention programs in schools concerning appropriate responses to such calls. Replication is needed using prospective designs to conduct systematic inquiry about modes of communication used by suicidal adolescents.

Objective: The present study aimed to examine the association between hospitalisation for physical disease during infancy, toddlerhood and childhood and risk of mental disorders during adolescence and early adulthood. Method: This was a population-based birth-cohort study of males born between 1980 and 1984 in Western Australia. The observation period began at the age of 12yrs, and lasted until the first diagnosis of mental disorder (since the age of 12yrs), death or Dec 30th 2009, which ever occurred first. Multivariate Poisson regression models were employed to estimate the association between hospital admissions for physical disease before the age of 12yrs and risk of mental disorder during adolescence and early adulthood. Results: Frequent hospitalisations during infancy, toddlerhood and childhood were associated with increased risk of mental disorders and risk of mood disorders during adolescence and young adulthood. The association remained when restricting the sample to those without physical disease hospitalisation after the age of 12. Conclusion: It is possible that chronic psychological distress associated with physical conditions requiring hospitalisation and medical treatments impair normal mental development during childhood and further increase the risk of mental disorders in later life.

Psychoanalytic understanding of normal adolescent development can contribute to our understanding of the psychoanalytic processes unfolding in adult treatment. Empathic understanding of transferences (and countertransferences) and other phenomena hitherto diagnosed as typically “borderline” is thereby facilitated. A brief review of reports specific to the developmental phase of adolescence precedes a clinical case example. The analytic process which recognizes developmental tasks is juxtaposed with descriptions of phenomena otherwise regarded as typical of adolescence. These “adolescent” developmental tasks or challenges can be seen as part and parcel of the therapeutic process in general if it is conceptualized and understood as a developmental process. Attention to those developmental steps which are typical of adolescence can inform analysts about some specific developmental challenges encountered also in the treatment of adults.