Adolescent Psychiatry (v.4, #3)

As I looked for a unifying theme in the articles published in this issue, it occurred to me that all of the articles deal withbridging the gap between research and clinical practice.As Camille Wilson and colleagues point out in the lead article in this issue, there has been a longstanding debate over the relationshipbetween autism spectrum disorders and schizophrenia. Both of these disorders are now understood to be neurodevelopmentalin origin. They have overlapping features—both involve difficulties in social interactions and information processing.Both have demonstrable brain abnormalities that are distinct in some ways but similar in others. Whether these disorders are infact variants of the same condition or two separate disorders has clinical implications, especially in terms of early intervention.Wilson and colleagues have carefully reviewed the history of thinking about these disorders and have summarized recent researchand hypotheses. Conversely, adolescents who appear to have childhood or adolescent onset schizophrenia may alsoshow autistic features. They point out that clinicians may miss signs of autism in adolescents with psychotic symptoms, or failto detect the onset of schizophrenia in teenagers with autistic features.Beginning in 1970s with the work of British psychoanalyst John Bowlby, attachment research has steadily progressed andled to a substantial body of knowledge that has bridged the gap between theory and empirically based knowledge. Originallyfocusing on infant studies, attachment research was subsequently extended to adults, and finally, to adolescents. Enrico de Vito,a psychoanalyst who has carried out research on attachment in adolescents in Italy, describes how he began to incorporate asystematic approach to assessing attachment in his clinical work with adolescents.In their article, “Stress-related Risk Factors for the Maintenance of Major Depression in Adolescent Girls” Ulrike Schmidt-Gies and Reinhold Laessle present the results of their research in Trier, Germany on a community sample of adolescent girlswith major depressive disorder. They found avoidant coping, stress vulnerability and stress related psychic symptoms to becorrelated with the presence of symptoms of major depression 6 months later. Their results have implications in terms of intervention,especially school-based interventions

Blurred Edges: Evolving Concepts of Autism Spectrum Disorders and Schizophrenia by Camille Wilson, Emily Kline, Gloria M. Reeves, Laura Anthony, Jason Schiffman (133-146).
Background: Adolescents who have autistic features, such as social communication deficits, as well as disorganizedthinking and bizarre behavior, present diagnostic challenges for clinicians as well as for researchers. Autism andschizophrenia are both neurodevelopmental disorders; they have an interconnected history that has diverged diagnostically,but retains many shared characteristics. Once conceptualized as a type of schizophrenia, autism has separated into adistinct disorder, yet similarities are evident between the two. Recent research has called into question the complete dichotomousseparation of these two disorders.;Methods: This review covers the history, as well as the shared phenotypic and genotypic characteristics of the disorders,including genetics, imaging, language development, and social functioning. We present possible theoretical constructs toframe the nature and extent of the overlap given the available research.;Results: Adolescents who have childhood histories consistent with autistic spectrum disorders can present with psychoticsymptoms in adolescence. Conversely, adolescents who appear to have childhood or adolescent onset schizophrenia mayalso show autistic features. Various hypotheses have been proposed to explain the overlap between these two heterogeneousconditions.;Conclusions: We believe that the overlaps between autism and schizophrenia represent an important and rich area of researchin order to better understand the unique characteristics of each disorder that may help to aid understand mechanismsof development, refine models of prediction and risk, as well as to understand common characteristics that may helpshape entry points for future intervention.

Background: In the last twenty years interest in the clinical implications of attachment theory has greatlygrown. The perspective of attachment seems to be particularly relevant with regard to the study of adolescence, insofar asthe restructuring of the self that occurs during this developmental phase can lead to different outcomes in accordance withthe different attachment organizations. Also the psychotherapeutic process with the adolescent can be enhanced by theunderstanding of the adolescent's development with respect to attachment, and therapy can be adjusted according to theattachment models of the adolescent's relationships.;;Method: In this paper I discuss the significance of this attachment- oriented approach to psychotherapy in adolescence,starting from utilizing an “attachment-based” model for the assessment of the adolescent. The administration of the AdultAttachment Interview (AAI) forms part of the assessment process.;;Results: Such an assessment, focusing on the dimension related to the attachment patterns of the adolescent, highlights theconversational and narrative features, the prevailing defenses and the availability of reflective functioning in order topromote individuation. This methodology implies a focus also on the way attachment patterns operate in activating, fromthe very beginning, specific types of unconscious responses in the therapist.;;Conclusion: The AAI is useful in the evaluation phase of clinical cases, before initiating therapy. In many cases the interviewitself activates a process of reflection and reinterpretation of their past within the adolescent, which in turn that allowsthe establishing of a preliminary working alliance.

Background: Major depressive disorder is a highly prevalent disorder in adolescence that entails significantlifetime risk for repeated episodes of depression and other disorders Furthermore, it can have a negative impact on academicand psycho-social functioning with long-lasting effects. Thus, identification of the most relevant risk factors for thecontinuation of major depressive disorder is important.;Method: Seventy one female adolescents between 10 and 18 years who were identified from a community sample as havingmajor depressive disorder were assessed regarding stress vulnerability, stress symptoms, coping behavior and physicalcomplaints. These variables were tested as risk factors for the persistence of major depression six months later.;Results: Factors having the highest predictive power for the continuation of major depression were avoidant coping, stressvulnerability and stress related psychic symptoms.;Conclusions: Stress symptoms, stress vulnerability, and a strategy of avoidant coping behavior are risk factors for the prolongedexistence of major depression and should particularly be considered in prevention of major depression and interventionfor depressive symptoms.

Fostering Resilience: Protective Agents, Resources, and Mechanisms for Adolescent Refugeesµ Psychosocial Well-Being by Stevan Merrill Weine, Norma Ware, Leonce Hakizimana, Toni Tugenberg, Madeleine Currie, Gonwo Dahnweih, Maureen Wagner, Chloe Polutnik, Jacqueline Wulu (164-176).
Background: Adolescent refugees face many challenges but also have the potential for resilience. The purposeof this study was to identify and characterize the protective agents, resources, and mechanisms that promote theirpsychosocial well-being.;Methods: Participants included a purposively sampled group of 73 Burundian and Liberian refugee adolescents and theirfamilies who had recently resettled in Boston and Chicago. The adolescents, families, and their service providers participatedin a two-year longitudinal study using ethnographic methods and grounded theory analysis with Atlas/ti software. Agrounded theory model was developed which describes those persons or entities who act to protect adolescents (ProtectiveAgents), their capacities for doing so (Protective Resources), and how they do it (Protective Mechanisms).;Protective agents are the individuals, groups, organizations, and systems that can contribute either directly or indirectly topromoting adolescent refugees' psychosocial well-being. Protective resources are the family and community capacitiesthat can promote psychosocial well-being in adolescent refugees. Protective mechanisms are the processes fostering adolescentrefugees' competencies and behaviors that can promote their psychosocial well-being.;Results: Eight protective resources were identified that appeared to promote psychosocial well-being in the adolescentrefugees. These included 1) finances for necessities; 2) English proficiency; 3) social support networks; 4) engaged parenting;5) family cohesion; 6) cultural adherence and guidance; 7) educational support; and 8) faith and religious involvement.Nine protective agents were identified. These included: 1) friends and peers; 2) parents; 3) older siblings; 4)extended family members; 5) school teachers, staff, and coaches; 6) church staff and congregants; 7) resettlement agencycaseworkers and activity leaders; 8) volunteers, and 9) health and mental health providers.;Conclusions: To further promote the psychosocial well-being of adolescent refugees, targeted prevention focused policiesand programs are needed to enhance the identified protective agents, resources, and mechanisms. Because resilienceworks through protective mechanisms, greater attention should be paid to understanding how to enhance them throughnew programs and practices, especially informational and developmental protective mechanisms.

Being or Feeling the Right Weight: A Study of Their Interaction with Depression among Adolescents by Caroline Huas, Mario Speranza, Caroline Barry, Christine Hassler, Marie-Rose Moro, Bruno Falissard, Anne Revah-Levy (177-184).
Objective: High and low body mass index (BMI) values and inaccurate body weight perceptions (BWP) (i.e.:mismatch between BMI and BWP) are known risk factors for depression/suicide. However, the relationships betweenBMI, BWP and depression are still insufficiently understood in adolescents, and data are lacking concerning the entirerange of BMI in either gender. This study aimed to investigate how BMI and BWP are related to depression in adolescents,exploring the entire range of BMI in both genders.;Method: Observational cross-sectional survey of a representative sample adolescents aged 17 from metropolitan France. Atotal of 39,542 subjects responded to a self-administered questionnaire between March 15th and March 31st 2008. Theywere classified according to their BMI (WHO thresholds: underweight/normal/overweight or obese), their BWP (five responsechoices from "too thin" to "too fat") and their depression levels (measured with the Adolescent Depression RatingScale).;Depression scores were calculated for each group defined by crossing the 4 classes of BMI and the 5 categories of BWP.The interaction between BMI, BWP and depression was investigated using variance analysis. Results were secondarilyadjusted to control for home environment and socioeconomic status. Analyses were performed separately for boys andgirls.;Results: An interaction was observed between BMI, BWP and depression. Irrespective of BMI and gender, adolescentswho felt they were almost the right weight had low depression scores. The greater the discrepancy between BMI andBWP, the more likely were adolescents to show high depression scores.;Conclusions: From a clinical perspective, asking adolescents about their BWP could help to better identify those at riskfor depression.

The Bullying Prevention Plan: An Approach to Youth who Bully Others by Anat Brunstein Klomek, Barbara Stanley, Andre Sourander (185-193).
Background: Bullying among adolescents has increasingly been recognized as a highly prevalent problem thathas long lasting consequences for both bullies and victims. Numerous school-wide interventions have been developed butthere is a need for interventions that can be implemented by clinicians working with individual clients and patients whobully others.;Methods: This manuscript describes a safety plan for youth who bully others which aims to prevent future bullying/cyberbullying behavior. The ultimate goal of the Bullying Prevention Plan (BPP) is to stop bullying before it starts.;Results: The (BPP) is a written plan of action created by the clinician and the youth involved in bullying that essentiallycharts the course of what the youth should do if he/she begins to experience bullying urges or even starts to bully others.The plan includes hierarchical steps including the identification of warning signs for bullying behavior, use of internalcoping strategies, use of external coping strategies, involvement of an adult or professional provider etc. The plan shouldbe periodically reviewed, discussed and possibly revised by the clinician and youth. It is recommended that the youthlearn new skills and therefore the bullying prevention plan should be expanded.;Conclusions: The bullying prevention plan offers a promising intervention that is directed toward youth who engage inbullying behaviors. Further research should study its efficacy in a systematic way.

Maryland's Evolving System of Social, Emotional, and Behavioral Interventions in Public Schools: The Maryland Safe and Supportive Schools Project by Catherine P. Bradshaw, Katrina J. Debnam, Sarah Lindstrom Johnson, Elise T. Pas, Patricia Hershfeldt, Andrea Alexander, Susan Barrett, Philip J. Leaf (194-206).
Background: Schools serve as an important context for the prevention of behavioral and mental health problems.There is growing interest among educators in the application of a three-tiered public health prevention model to preventa range of behavioral and mental health concerns, and in turn, improve academic and social-emotional outcomes forstudents. One such multi-tiered system of supports framework used by schools is called Positive Behavioral Interventionsand Supports (PBIS). This model has been widely disseminated in over 20,000 schools across the U.S., with the goal ofimproving social, emotional, and behavioral outcomes among youth. Yet, most of the implementation efforts and researchon PBIS have focused on elementary schools.;Method: This paper describes a collaborative state-wide effort, called Maryland Safe and Supportive Schools, to disseminatethis model in high schools and conduct a randomized trial to determine the impact of PBIS on adolescents. Themodel uses a collaborative, team-focused coaching framework and draws upon school climate data to implement a continuumof evidence-based prevention programs. The goal of this effort is to reduce behavioral, academic, and mental healthproblems among adolescents. This paper summarizes the design, implementation, and lessons learned through this uniqueschool/non-profit/university partnership-based approach to implementing a comprehensive three-tiered model of supportwithin the state of Maryland.;Results: A relatively large and diverse sample of 58 schools voluntarily participated in the school-level group randomizedcontrolled trial. Annual measures of school climate were collected via self-reports from over 25,000 students and throughobservations across 25 classrooms per school. Fidelity of tier 1 and 2 supports was generally high among the interventionschools. Preliminary findings from the randomized trial testing the impact of MDS3 suggest a positive impact on schoolclimate and other safety related concerns following the first year of implementation.;Conclusions: The MDS3 project promoted a framework for helping the school leadership teams develop data-based decision-making skills, generate data reports to establish need, optimize evidence-based program implementation, and usedata to monitor progress toward goals and celebrate successes. Lessons learned include the importance of 1) obtainingdata at the student and school levels; and communicating and sharing data with the schools in a way that makes sense tothem and is consistent with the school's mission.

Fulminant Somatization: Medical Investigation in Trauma Survivors by Gordon Harper, Oommen Mammen (207-211).
Background: Somatic symptoms are common in trauma survivors, including those who have experienced sexualabuse. These symptoms sometimes continue or get worse during the course of medical investigations, provoking evenmore investigation, and leading to a vicious circle involving invasive medical procedures and frustrating attempts at diagnosisand care. In such cases, the symptoms may be considered fulminant.;Method: This article presents a review and analysis of three cases of adolescents presenting with fulminant somatic symptoms.;Results: In each case, the patient's symptoms resolved when the focus of care shifted from investigation to support forcoping. Sexual abuse history had been overlooked during the acute phase.;Conclusions: In such patients, somatic investigation may evoke past trauma. Management should consider a shift in emphasisfrom investigation to promoting adaptation.