Adolescent Psychiatry (v.5, #3)

Diagnosis and Treatment of Common Sleep Disorders in Adolescence by Jess Parker Shatkin, Michelina Pando (146-163).
Background: During the past two decades, research has elucidated many aspects of sleep physiology and the importance of sleep in regards to physical and mental health. According to recent epidemiological studies, most adolescents report persistent sleep difficulties that interfere with their daily functioning. Sleep quality is an important public health issue that requires adequate attention from clinicians, parents, and educators.
Method: A comprehensive literature review was employed to establish the recommendations in this report. This article provides a review of adolescent sleep physiology and offers various tools to aid in the clinical assessment and treatment of common sleep disorders. It highlights typical sleep changes throughout adolescence and the impact that these changes have on the development of sleep pathology.
Results: Chronic sleep loss is commonly reported among teenagers. Understanding the relationship between pubertal development and sleep regulation is essential for establishing clinical guidelines regarding adequate sleep. Benzodiazepine-receptor agonists (BzRAs) and cognitive behavioral therapy (CBT) are the most widely studied treatments for insomnia. In addition, bright light therapy and melatonin administration are often effective in treating circadian rhythm disorders. Sleep hygiene techniques are recommended for individuals with various sleep difficulties, yet there is insufficient data to support them as an evidence-based, standalone treatment.
Conclusions: The physiological components of sleep during puberty provide insight into behavioral and psychological changes associated with healthy development. Chronic sleep deprivation, insomnia, and delayed sleep phase disorder are the most common sleep disorders during maturation. Chronic sleep problems during youth can cause an array of symptoms that impact behavioral and psychological functioning. Diagnostic tools are essential to properly detect sleep disorders at early stages. Detecting and treating sleep-related issues among youth can prevent deficits in daily functioning and may halt the progression of psychiatric pathology into adulthood.

Background: Adolescence is a crucial nexus for consolidation of either pathological defenses against loneliness or the constructive and creative capacity for solitude. In order to become adults, adolescents must make a transition to authentic autonomy.
Method: In this presentation the author discusses the life of the poet Leopardi and uses clinical material from the psychotherapy of an adolescent to illustrate the complexity and importance of closer examination of the phenomena of loneliness. The author examines various patterns in Anglo-American, European and Asian cultures as they evolve normally and pathologically.
Discussion: Culture plays a large role in both external and internalized attitudes to aloneness, a fact that is reflected linguistically and in defense styles in different countries. But this demand for acceptance and engagement with the reality of separateness has been complicated by social factors, including lack of employment opportunities, lengthy education and dependence, and ambiguity and ambivalence about what constitutes separation from parents and family of origin in different cultures.

Loneliness in Adolescence - A Two-Systems Approach by Kerry Kelly Novick, Jack Novick (174-186).
Background: Very little has been written in the analytic literature about loneliness, despite its ubiquity in human experience and its importance in development.
Method: In this presentation the authors share clinical material from intensive treatment of an adolescent to illustrate the complexity and importance of closer examination of the phenomena of loneliness. They suggest techniques that are relevant to studying and treating troubles that arise from difficult relationships to self and others, which eventuate in symptoms of isolation, withdrawal, failures in relationships and lack of developmental progression.
Summary and Conclusions: A two-systems approach makes sense of these phenomena and offers treatment techniques to address pathological defenses against loneliness and lend support for growth of enjoyment in both solitude and relationships with others. Shifting cultural norms have contributed to the pathologizing of solitude.

“The Right Questions”: Reflections on the Internal Setting of the Psychoanalyst and the Work of Interpretation in Working With Adolescents by Giancarlo Galli, Lucina Bergamaschi, Daniela Alessi, Francesca Codignola, Ivana Longo, Angelo Moroni, Flora Piccinini, Anna Viani (187-192).
Background/Goals: Mario, an eighteen year old patient, tells his therapist, “I like to talk with you because you ask me the right questions,” expressing the reasons for his interest in his own psychotherapy. What are “the right questions?”
Method: This paper explores the meaning of the questions that a psychoanalyst has to ask in his own mind and in the treatment dialogue to promote the subjectivation process of the adolescent. In it we describe some of the special features of the internal setting and mental attitude of the psychoanalyst working with adolescent patients in treatment. These features seem to be kindling in the adolescent's mind a thinking process that is necessary to allow him or her to bear the mental suffering related to the developmental tasks and to the search for one's own uniqueness. The achievement of one's own subjectivity is often mingled with the acceptance of schematic and adaptive ways of escaping the mental suffering and the grief related to the individuation process.
Results: In our work with adolescent patients we think of ourselves as researchers, not pretending to deny or suspend our internal emotional reactions. We try to work through these reactions in our mind, in a countertransference sense, and to use them consciously, assuming a position of active partnership as co-producers and co-writers of a text waiting to be recognized and interpreted. In other words, we work beginning with the first session to create the relational situation in which the adolescent patient feels that we are working together on her/his own “right questions”.
Conclusions: We conclude that such an internal setting is deeply and meaningfully related to the work of the interpretation function in the psychotherapy with adolescent patients.

Background: Psychoanalytic treatment has undergone vast shifts in the last few decades, significantly influenced by the proliferation of infant research and attachment theory; since Ainsworth's seminal work much research has focused on the components of or impediments to the development of secure attachment. Stern (1985) suggests that both underattunement and overattunement can lead to insecure attachment. Beebe and colleagues' research (2012) points to the correlation between mid-range contingent maternal responsiveness and secure attachment and lowered or heightened responsiveness as factors in the development of disorganized attachment. However, little has been written on the influence of the combination of underattunement (from early deprivation) and later overattunement and its impact on attachment and emotional development. Method: This paper will explore the attachment predicament of an adolescent girl whose developmental experience was informed by both underattunement and overattunement. It will further explore the therapeutic work with the adolescent and her parents, which focused on attachment issues and the maternal overattunement, which led to a particular attachment dilemma. The patient was adopted from an orphanage at the age of 6, after been removed from a situation of extreme maternal neglect. When she was 13 she developed symptoms that were repeatedly misdiagnosed as psychosomatic. However, the mother's intense vigilance over her daughter's life led her to pursue medical information, which ultimately uncovered a very serious illness. Thus, the over-responsivity of her mother, while recreating the girl's ambivalent attachment experience, simultaneously served to rescue her from early neglect as well as a potential debilitating illness. The girl's attachment was profoundly affected by this event and led ultimately, not only to a reemergence of the original ambivalent attachment, but to the girl's homosexual object choice. The mother's deep disappointment with this choice further exacerbated the girl's attachment anxiety. Discussion: Security of attachment allows a teen to engage in discussion of disagreements, and lessens dysfunctional anger. Thus, secure teens are able to assert themselves with their mothers in ways that support rather than rupture attachment. Research has further suggested a link between secure attachment and affect regulation in adolescence. In this case, the girl's attachment was both powerful and fragile and she was unable to assert herself sufficiently because of her terror of attachment; she continually raged against the constraints imposed by her mother but acted out in problematic ways when those constraints were loosened. Psychoanalytic practice has traditionally avoided involving parents in therapeutic work with adolescents, largely with the intention of promoting the adolescent's separation and autonomy. However, I will present, in this paper, an approach to analytic work that engaged these parents in reflective experience and helped them to fully appreciate their daughter's profound struggle with the early experience of rejection, her longing for and anxiety around autonomy, and her desperate search for connectedness and maternal acceptance.

The Use of a Video to Reduce Mental Health Stigma Among Adolescents by Marta Gonçalves, Carla Moleiro, Benjamin Cook (204-211).
Background: Childhood mental disorders are an issue of great public health significance given their impacts on education, family relationships, and other social outcomes. Mental distress and illness, especially emotional and behavioral problems and learning difficulties, are growing among youth, increasing the need for early recognition and treatment. Stigma has been shown to be one of the strongest barriers to access to mental health treatment among adolescents, but few interventions are available that focus on de-stigmatizing treatment for adolescents with mental distress. The aim of this paper is to present results from a pilot test of a video-based mental health de-stigmatization intervention administered in a school setting (N=207).
Method: Classrooms in the study school were randomly selected into the intervention or control group, with all students in each classroom belonging to the same group. Adolescents in the treatment group were shown the video and both groups were surveyed over three survey periods - pre, post and 1 month follow-up.
Results: The intervention significantly reduced scores on all three stigma scales for the treatment group at the post- time period. This decline in scores among the treatment group was significantly greater than the decline in scores observed in the control group. The decrease in perceived stigma remained greater for the treatment than the control group in the follow-up time period, though these results did not reach statistical significance. After adjustment for SES measures, grade, and sex, we identified significant intervention effects at the post time period on the Self-Stigma and Seeking Help Scale.
Conclusions: These preliminary results demonstrate that quick, low cost stigma reducing interventions can be successful in increasing access to mental health treatment for those in need.

A Mixed Methods Evaluation of the Effects of an Innovative Art-Based Rehabilitation Program for Youths with Stabilized Psychiatric Disorders by Kim Archambault, Isabelle Archambault, Sarah Dufour, Frederic N. Briere, Patricia Garel (212-224).
Objective: Art-based interventions are promising strategies to improve the well-being and adjustment of youths suffering from mental disorders, but rigorous evaluations of these interventions are scarce and warranted. This study reports on a mixed methods evaluation of the effects of All on Stage, an innovative artbased group program aimed at fostering the rehabilitation of adolescents and young adults with recently stabilized psychiatric disorders.
Method: Fifteen participants took part in the program and were included in the evaluation. At pre-program, post-program, and three-month follow-up, participants completed measures of social comfort and competence and self-perception. At the same time points, clinicians who referred participants to the program assessed their global functioning using standardized measures. Semi-structured interviews were also conducted with participants and clinicians.
Results: Post-program and follow-up improvements in the general functioning of participants were observed with clinician-rated measures (p < 0.01) and were largely echoed in interview material. Improvements in selfperception and social comfort and competence were not observed quantitatively, but were reported in interviews by half of program participants and the large majority of clinicians who referred them.
Conclusions: Findings suggest that All on Stage can be successful at improving the global functioning of youths with stabilized psychiatric disorders, as well as the self-perception and the social comfort and competence of a fair proportion of them. This preliminary evaluation supports the relevance and potential efficacy of the program All on Stage and of similar initiatives as approaches to foster the rehabilitation of youths suffering from mental disorders.