Adolescent Psychiatry (v.6, #2)

Editorial by Lois T. Flaherty (87-88).

Background/Objective: The most prevalent cause of youth (aged 16-25) fatalities is high risk driving behaviors (HRDB) leading to motor vehicle crashes (MVCs). We examine: first, whether youth drivers diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) may manifest an increased HRDB compared with Non-ADHD drivers of a similar age and driving experience, and second, if, and to what degree, does compliance with prescribed ADHD medications affect rates of HDRB.

Method: A systematic literature review was conducted for HRDB, MVCs, citations, and violations in youth age 16-25 years old diagnosed with ADHD using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve out of fiftynine papers met the search criteria.

Results: The diagnosis of ADHD is associated with increased rates of HRDB. Inattention is a significant predictor of driving problems and reduced driving safety (P<.05). The relationship between hyperactivity/impulsivity and self-reported violations showed a trend towards poor driving behaviors (p=.08). Youth with ADHD who are treated with stimulants have statistically significant improvements in simulated driving performance compared to those treated with placebo (P=.005).

Conclusion: Treatment of attention deficit hyperactivity disorder in affected youth reduces the risk for HRDB. Continued examination of safety, legal and ethical implications of obtaining a driver license and operating a vehicle by youth with ADHD is necessary in order to reduce HRDB and MVCs in this high risk population.

Background and Objective: Negative parent-child interaction patterns have been linked to youth depression, with a causal influence being assumed. However, the majority of empirical studies examining this issue have used self-report methods to assess parent-child relationships, which cannot capture the temporal dynamics of dyadic interactions and may be subject to reporting bias. This review considers the association between parent-child interactions and youth depression with a specific focus on observational methodology.

Method: A literature search was conducted including studies that investigated the association between observed parent-child interactions and youth depressive symptomology. Literature was obtained using database searches, citation searches and screening of recent reviews.

Results and Conclusion: Maternal disengagement, reduced adolescent autonomy granting, adolescent maladaptive emotion regulation, parental suppression of adolescent positivity and incongruent parent-child communication styles were relatively consistently related to youth depression. Nonetheless, there were conflicting findings and several studies demonstrated little or no contribution of parent-child interaction factors to youth depression. Overall, the evidence suggests that causal influences are likely to be modest. The majority of studies relate to maternal versus paternal interactions. Furthermore, the factors that mediate the association between parent-child interactions and youth depression remain largely unknown. Implications for future research and clinical practice are discussed.

Background: In addition to well-known cognitive impairments, there are disruptions in processing emotions in individuals with substance dependence and in those predisposed to drug abuse. Neurofeedback training-based intervention is one of the potentially efficacious nonpharmacological treatment options for substance use disorders. Several neurofeedback protocols which reported success in treating addictive behaviors have been employed. However, there are no studies on the use of neurofeedback in occasional drug users who have a drug use history have not yet developed substance use disorder or substance dependence.

Method: We tested a protocol that may be useful to prevent drug abuse through self-regulation training aimed at enhancing EEG measures of positive emotional states. One of the aims of this pilot case series study was to determine the dynamics of self-reported perceived positive emotional state rating before, during and after twelve 25-minute long neurofeedback training course in two groups of subjects. One group of subjects (N=6) had a documented drug use history, most of them referred from the local metro operated mental health community center for adolescents; and the other group were drug-naïve subjects (N=5), recruited mostly from undergraduate students. Our hypothesis was that learning to increase the prefrontal 40 Hzcentered EEG band (a gamma frequency) power over 12 training sessions is possible and will be accompanied by increased ratings of positive affect. We trained subjects to increase a 40 Hz gamma measure (i.e., a “clarified 40 Hz-centered gamma” index termed “Neureka!”) at a prefrontal site above FPz, in the middle of the forehead, referenced to the left ear.

Results and Discussion: Neurofeedback training was accompanied by a highly significant linear increase of the “40 Hz gamma” measure and a less significant change in the relative power of the gamma activity in 35-45 Hz range. Individual reports of self-recorded happiness scores assessed during each neurofeedback session using the Continuous Response Digital Interface (CRDI) showed a linear increase both during and across training sessions. Both posttraining evaluations and 3.9 months follow-ups showed increased happiness ratings in both groups of subjects in this study. Neurofeedback training also resulted in better performance on the MicroCog and IVA+Plus neurocognitive tests.

Conclusion: This proposed neurofeedback training method is promising for increasing both present happiness and future health. It needs further research and clinical trials to be validated as a method of positive emotion self-regulation in adolescents, particularly those predisposed towards drug abuse.

Background: Suicide attempts are a significant public health problem, especially among adolescents. They are associated with psychiatric morbidity and result in significant use of health care resources. Systematic study of suicidal behavior among Greek adolescents remains limited.

Objective: The purpose of this study is to examine the clinical, psychosocial and family characteristics of adolescent suicide attempters within the rapidly changing socio-cultural context.

Method: This is an ongoing cross-sectional study conducted since 1990 at the Adolescent Unit of the AHEPA General Hospital, the oldest and one of the major teaching hospitals of the School of Medicine of the Aristotle University of Thessaloniki.

Results: Of the 182 cases reviewed, 84.1% were females and 15.9% were males aged 12 to 19 years (M=15.24 years, SD = 1.74). Most attempts occurred in adolescents living in intact biological families (59.9%), and medication ingestion was the most predominant method (83.5%). Nearly one-fifth of the adolescents had previously attempted suicide. There was a family history of suicide in 5% of cases. Severe dysfunction or impairment of family context was the most frequently recorded parameter (59.9%), followed by various school difficulties (54.9%), and adolescent-parent conflict (53.3%). In a clinical perspective, active psychopathology was found in 56.1%, with depressive disorder ranking first (30.8%), followed by personality disorders characterised by acting out behavior (19.2%), and substance-related disorders (9.3%).

Conclusions: Findings from this research enable us to gain a greater understanding of suicidal behavior among adolescents, thus contributing to a better clinical and psychosocial approach, and, consequently, more effective prevention and care.

Background: Psychotherapy and counseling traditionally relies on a conversational mode involving processing of information that requires attention, concentration, and working memory, all of which may often be somewhat impaired in may people with psychiatric symptoms, thus limiting the optimal effect of “conversational based therapy.” In routine classroom learning situations and in professional presentations for seminars, workshops, and meetings, some forms of visual modality (e.g., blackboard, easel, or PowerPoint slides, printed handouts, etc.) are often used to enhance communication and to limit interference of any “intrusive associations” that many people in general may experience. With the availability of computer technology, the possibility of accompanying oral communication supplanted with visual representation of conversational dialogues in psychotherapy has not yet been recognized or appreciated.

Method: There have been some publications on the computer-facilitated therapy by the author and his colleagues primarily based on author's work with persons with schizophrenia, and one with behavior disordered adolescents, but this article presents specific case samples detailing more extensively on the use of computer facilitated dialogue techniques from author's personal experience in working with adolescents.

Discussion: The article highlights how personal goals, problem issues, and steps that one needs to take to reach goals, which can be developed with computer word processor with active client participations. Clinicians can also use the technique to capture the main themes of any counseling or assessment sessions. This technique can be adopted by mental health clinicians from different disciplines, including by the medication practicing clinicians in working with adolescent or adult psychiatric patients.

Schizophrenia in an Adolescent with Complex Co-morbidity by Hena Jawaid, Tania Nadeem (148-153).
Background: The peak age of onset of schizophrenia is during late adolescence and young adulthood. Early onset schizophrenia—that which occurs prior to age 18—is more likely to be treatment resistant. The management of schizophrenia in the adolescent patient poses many challenges.

Methods: We present a complex case of a patient diagnosed with schizophrenia when she was 16 years old. The patient initially developed symptoms of depression and obsessions after stressful life events. The OCD and depressive symptoms remitted partially with medications. She also had short stature and delayed puberty, possibly related to growth hormone deficiency.

Results: The patient's psychotic illness did not respond well to typical and atypical antipsychotics, but she improved dramatically on clozapine. Treatment was augmented with estrogens. However, she had persistent cognitive deficits that were quite disabling and interfered with academic functioning.

Conclusion: The case illustrates how multiple factors - psychosocial and hormonal -- might have been involved in the development of schizophrenia in this adolescent and the challenges of treatment resistant schizophrenia. In particular, we discuss the possibility of a link between delayed puberty and schizophrenia and raise the question of whether growth hormone deficiency could make adolescents susceptible to early-onset schizophrenia.