Adolescent Psychiatry (v.5, #1)

Editorial: Forty Five Years and Counting by Lois T. Flaherty (1-2).

Self-esteem of Greek Adolescents: Changes in a Decade of Socioeconomic Hardship# by Helen Lazaratou, Vasilis Stavropoulos, Dimitris Charbilas, Alexandra Soldatou, Dimitris Dikeos (3-11).
Purpose: The aim of the present study was to compare the self-esteem of two independent samples of high school students collected in Athens, Greece, at two points in time reflecting different socioeconomic conditions of the country.
Methods: At time point A (in 2002) we collected data from 713 adolescent students (age 15-18 years) attending Senior High School. At time point B (in 2010) we collected data from 1916 students (age 15-17 years) attending Senior High School. The questionnaires consisted of an introductory part in which personal and family data were recorded (school type, sex, family structure, and academic performance) and the Rosenberg Self-Esteem Scale (SES).
Results: Adolescents reported higher mean levels of self-esteem in 2002 compared to 2010. The main effect of sex, school type and academic performance on self-esteem was significant.
The effect of the interaction of time by school type on self-esteem was significant, with the self-esteem of students in technical education schools showing grater difference between time points than that of students in general education schools. Τhere was no effect of the interaction of sex, academic performance and family structure by time on self-esteem.
Conclusions: The financial standstill in Greece resulted in significantly lower levels of adolescent self-esteem. This effect is similar for both sexes and more accentuated among adolescents attending technical schools versus those attending general education schools.

Background: Both developmental and psychoanalytic theories stress the importance of romantic involvement for gaining autonomy from parents. It is, however, unclear whether the importance assigned to romantic affairs as well as the spill-over in parent-child relationships seen in Western countries can also be found in adolescents with other cultural backgrounds. In addition, the capacity to regulate distress in romantic encounters needs to be explored in adolescents from the majority world.
Method: In a cross-cultural study on adolescents from 20 nations (N= 12.075), coping with stress in the family and romantic encounters was assessed in adolescents from seven regions of the world. The adolescents filled in instruments to asses stress in both domains as well as their coping behavior when stress in the family and the romantic domain emerged.
Results: In general, levels of family-related stress as reported by adolescents were substantially higher than romantic stress in most regions. Particularly high were the family-related stress levels in adolescents from Southern Europe, Asia, the Middle East and South America. Adolescents from Central Europe and North America experienced lower stress with parents. As expected, adolescents were much more active in dealing with stress in the romantic domain than in the family domain, suggesting that differences in power balance did not allow for as much negotiating with parents as with the romantic partners.
Conclusions: The results highlight that increasing autonomy is still a stressful task in most adolescents all over the world, leading to comparably high levels of parent-related stress. Coping with stress related to family relationships and romantic partnerships is a major focus; the amount of energy focused on each domain varies in accordance with cultural norms.

Background: ADHD, a common childhood psychiatric disorder, is known to persist into adulthood. Gaps and needs in the care of adolescents having ADHD when moving on from Children's Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) exist and result in disruptions in care and lack of care. This report describes the outcome of a quality improvement project in Birmingham in the United Kingdom that focused on the patient journey and continuity of care.
Method: A CAMHS/AMHS transition (strategic) working group and a CAMHS ADHD transition (operational) team were set up. A validated dataset of those requiring transition was created and patient needs were reviewed. Planning and preparation for transition took place. The handover from CAMHS to AMHS was done at a joint clinic involving both services.
Results: Over a 12-month period, the number of patients on the waiting list for transfer from CAMHS to AMHS went from 134 to 14 and the waiting time for transition between the two services went from 12 months to four months. The referral rate for those in need of transfer from CAMHS to AMHS was optimised. The rate of successful handover (and transition) went from 18% to 55% after the introduction of the joint clinics.
Conclusion: A collaborative effort between CAMHS and AMHS, including the holding of joint clinics, ensured there was a comprehensive and effective transition care pathway in place for adolescents with ADHD.

Promoting Well-being and Resilience in Employing a Relationship Centered Approach: A Case Study of a Pre-adolescent Boy by Sharon M. Holder, Robbie Shoenleben, Robyn Ellison-Daigneault, Lori Smith, Amy Jones, Kenneth Rogers (31-39).
Background: Relationship Centered Care (RCC) is a term that originated in the field of primary care, with roots in Engel's biopsychosocial model and humanistic medicine. It focuses on understanding of illness from an intersubjective perspective, involving a dialogue between physician and patient, and a shared understanding of the patient's narrative. The principles embodied in RCC have not been well described with respect to psychotherapeutic care with children and adolescents and their families, or in residential treatment settings, which may be hierarchical in their approaches.
Methods: This paper will demonstrate how employing multiple treatment modalities including (1) patient/ family, (2) shared decision making (3) emotional connections and (4) community partnerships, in using the Relationship Centered Care (RCC) approach can lead to the promotion of well-being and resilience. The case of a pre-adolescent boy with multiple mental health and behavioral issues will be used to illustrate this approach.
Results: The case demonstrates the effective utilization of the relationship-centered approach in comprehensively addressing the complex needs of a child with mental health and behavioral challenges.
Conclusions: The RCC approach helps bridge the coordination of multi-system plan of treatment intervention for a pre-adolescent youth in a children's residential program yielding an optimal outcome for both the child and family.

Background: Violence among youth continues to be a serious public health concern across the nation. Researchers have increasingly argued that effective violence preventions efforts and practice must consider the lived experience of youth. Retaliatory violence (i.e., violence in response to a perceived attack or threat) is a major concern and risk issue for young people, and has been increasingly linked to lethal violence. Primary care and mental health practitioners can play a vital role in helping young people who struggle with retaliatory violence to understand the emotions and decisions associated with these situations. However, there is limited research advising clinicians on how to help youth negotiate these issues in treatment.
Methods: In this paper, we offer a brief review of the literature regarding youth and retaliatory violence, discuss the role of psychotherapy with this population using case reports, and offer clinical recommendations for clinicians working with this population. Clinical case reports from a community clinic in an urban neighborhood in the northeast are utilized to illustrate challenges and successes involved in psychotherapy aimed at helping youth manage retaliatory violence.
Results: Clinician responses that validate the complexity of threat and identity issues experienced by clients but also offer face saving non-violent options are beneficial. We also discuss gender and fighting behaviors that have implications for how girls learn to resolve conflicts in later life.
Conclusions: It is critical that clinicians use interventions that are grounded in the norms in which youth live and help them generate non-violent responses to perceived threats, but enable both parties to save face and therefore preserve a sense of identity and dignity.

Psychopharmacologic Treatment of Children and Adolescents with Bipolar Disorder: A Review by Dana Baker Kaplin, Alison Conca-Cheng, Robert L. Findling (50-63).
Background/Objectives: Pediatric bipolar disorder (BPD) is a serious, chronic psychiatric illness that impacts a substantial number of youth in the United States. Pharmacological treatments that are effective and safe, both acutely and over the long-term are needed.
Methods: A literature review pertaining to the pharmacotherapy of pediatric bipolar disorder was conducted on PubMed and Science Direct. This yielded a total of 65 publications that were subsequently examined. Nine of these were review articles. There were also two posters identified that were presented at the following meetings: the American College of Neuropsychopharmacology, Annual Meeting and the American Academy of Child and Adolescent Psychiatry Annual Meeting that were considered salient.
Results: Mood stabilizers (such as lithium), anticonvulsants and antipsychotics are the three primary classes of medication that appear to be most often prescribed for monotherapy in the treatment of youth with bipolar disorder. Aripiprazole, olanzapine, quetiapine and risperidone are all FDA approved for the treatment of youth with bipolar I disorder, with acute manic or mixed states. Lithium is also FDA approved for treating youths suffering from an acute manic episode. An olanzapine/fluoxetine combination (OFC) is currently the only medication approved by the FDA for the treatment of the depressed phase of bipolar disorder in youths.
Conclusions: A gap exists between the extant, evidence-based data and the necessities of clinical practice when treating youth with bipolar disorders. Consequently, there is need for pharmacotherapy research targeting children and adolescents.

Background: Self-inflicted eye injuries are not common but constitute one of the main forms of non-suicidal self-injuries (NSSI). They can be seen in a variety of psychiatric conditions.
Method: This article presents a case report of a 14 year old female patient with major depressive disorder, features of borderline personality disorder, and a history of trauma. We review the literature on self-inflicted eye injuries and non-suicidal self-injury and discuss the relevance to this case.
Summary: The patient sustained bilateral self-inflicted ocular perforation with leakage of vitreous humor. She denied any intention to commit suicide and had no clear immediate precipitant triggering the incident. The patient was hospitalized with a plan to transfer to a residential treatment center for intensive dialectical behavioral therapy (DBT).
Discussion: The case discussed here appears to fit best into the impulsive NSSI category of the medical descriptive model. The first line treatment for this condition is psychotherapy. Several psychodynamic and biochemical theories have been proposed to describe the mechanism of this psychopathology; however, none have been conclusive.