Adolescent Psychiatry (v.1, #2)

Editorial by Lois T. Flaherty (94-96).
The lead article in this issue is an essay by Joseph Noshpitz on the Shakespeare play and#x201C;Love's Labor's Lost,and#x201D; in which Noshpitz analyzes the play in terms of what it reveals about pubertal development. Although written sometime before 1997, when Noshpitz died, it was never published. In it Noshpitz also reminds us of how endlessly fascinating normal pubertal development is. I won't say more here, other than to say how enjoyable it was to read and edit Noshpitz's work (and remember that he was my first editor) as I have a commentary on this article immediately following it. Several articles in this issue deal with substance abuse related disorders and treatment in adolescents. According to the American Psychiatric Association, 7and#x25;-10and#x25; of adolescents are in need of treatment for substance use disorders (Kleber et al., 2007) and: Alcohol and other psychoactive substance use, abuse, and dependence in children and adolescents continue to present a serious public health problem in the United States. Alcohol and other substance use are among the leading causes of morbidity and mortality from motor vehicle accidents, suicidal behavior, violence, drowning, and unprotected sexual activity in this population. The Substance Abuse and Mental Health Services Administration (SAMHSA), has called substance abuse treatment for teenagers and#x201C;A major unmet needand#x201D; (2002). Among youths in the U.S. aged 12 to 17, there were 1.1 million (4.5 percent) who needed treatment for an illicit drug use problem in 2009. Of this group, only 115,000 received treatment at a specialty facility (10.5 percent of youths aged 12 to 17 who needed treatment), leaving 983,000 youths who needed treatment but did not receive it at a specialty facility. In 2009, there were 1.2 million youths (4.8 percent) aged 12 to 17 who needed treatment for an alcohol use problem. Of this group, only 96,000 received treatment at a specialty facility (0.4 percent of all youths and 8.2 percent of youths who needed treatment), leaving almost 1.1 million youths who needed but did not receive treatment (Substance Abuse and Mental Health Services Administration, 2010). Traditionally, many psychiatrists who treated adolescents were not knowledgeable about or comfortable treating substance abuse problems, and those psychiatrists who provided treatment for substance abuse were not comfortable treating adolescents. I had no formal training in addiction psychiatry during my residencies in general and child and adolescent psychiatry in the 1970s. I learned what I did through a moonlighting job at a substance abuse treatment program in a local community hospital. Although today, formal training in the treatment of substance use disorders is a required part of general psychiatry residency training in the US, only one month is required. There is no stipulation of how much time in child and adolescent psychiatry training programs must be devoted to substance use disorders.1 If one looks at the manpower numbers they are not encouraging. The American Academy of Addiction Psychiatry's website (www.aaap.org) indicates that there are 1,000 AAAP members (membership is open to any psychiatrist who has an interest in addiction medicine, so not all members have had fellowships). Following the completion of general psychiatry training, residents may take advanced training in the form of fellowships. To be formally trained in child and adolescent psychiatry and in addiction psychiatry requires two fellowships, adding a minimum of 3 years of training to general psychiatry training. While undoubtedly there are many psychiatrists without formal training in addiction who are qualified to treat adolescents with substance use problems, it is clear that even if the total number were 5,000 there would not be enough to treat the million plus adolescents who need treatment. Leaving aside the issue of manpower, most substance abuse treatment programs are not tailored for adolescents. Such approaches as Twelve Steps, therapeutic communities, and relapse prevention were all originally developed for adults. Children and adolescents are generally more likely to have abuse rather than dependence disorders and are less likely to appreciate the need for entering and remaining in treatment (Kleber et al., 2007). Adolescents who abuse substances are likely to abuse more than one substance, and are also likely to have other psychiatric disorders, such as conduct disorders, mood disorders, and attention-deficit hyperactivity disorder (Langenbach et al., 2010; Grilo, Becker, Fehon, Edell, and McGlashan, 1996). This level of complexity requires a sophisticated level of knowledge and skill in planning and delivering treatment. A particular challenge is the youngster with ADHD and addiction. Dominic Ferro addresses this problem and summarizes data presented at the 2010 ASAP Annual Meeting. While still a relatively underdeveloped field, substance abuse treatment for adolescents has evolved to the point that there now are specialized treatment programs and psychiatrists trained in addiction medicine and adolescent psychiatry. Richard Rosner, one of these psychiatrists, writes about relapse prevention, which does have a strong evidence base, and about his observations of self-help groups. He is critical of the emphasis on a and#x201C;higher Powerand#x201D; in AA and NA and sees it as antithetical to the need to develop a greater sense of self-efficacy, which is part of the relapse prevention approach. Interesting, the APA Practice Guidelines cite a study of AA that indicates participants do gain an increased sense of efficacy, at least in terms of their perception of control over their addiction. It may be that each of these approaches (relapse prevention and AA/NA) is effective for a different subset of patients. Kelly and colleagues found that more severely addicted adolescents tended to participate more fully in AA and NA (attending meetings, completing steps, having sponsors) than those who were less impaired, and suggested that relapse prevention may be more appropriate for less severely addicted adolescents, while the AA/NA approach is more suitable for those with more severe problems (Kelly, Myers, and Brown, 2002). The notion that different approaches are appropriate for different individuals should certainly not come as a surprise, and it is an indication of how far the field of adolescent substance abuse treatment still has to go to catch up with treatment for other disorders. Charles Goldberg describes an inpatient treatment program for teenagers with drug and alcohol problems and links the Twelve Steps to various principles utilized in psychodynamic psychotherapy with youngsters in the program. Historically, outcome data to guide treatment decisions have been lacking. This is starting to change. Relapse prevention has a reasonably sound evidence base, which includes controlled studies (Irvin, Bowers, Dunn, and Wang, 1999). AA/NA, where all studies are essentially naturalistic, remains controversial, with reviews of the literature coming to different conclusions about its efficacy (Kaskutas, 2009; Ferri, Amato, and Davoli, 2009). Bunt reviews the literature on the efficacy of the therapeutic community for the adolescent substance abuser, and finds that there is reasonably good support for it. As with AA/NA, studies are naturalistic. One cannot simply assign patients to no treatment or sham treatment, so this situation is not likely to change. What has changed, and will continue to change, is the level of sophistication in measuring change and analyzing results.....

Love's Labor's Lost: A Study in Puberty by Joseph D. Noshpitz (97-119).
Love's Labor's Lost is a whimsical and fashionable play of lords, ladies, love, and badinage. The humor is sparkling, the situations farcical, the language for the most part in rhyme and the ending lighthearted. Viewed from a dynamic standpoint, however, some elements creep in, which suggest that in this work, Shakespeare was telling the story of his early puberty, and reliving through the means of comedy some of the bittersweet memories of a talented youngster coming into the first flush of early adolescence. This essay will attempt to analyze the play in the light of what we know about puberty, with special emphasis on male puberty.

Full text available.

The Therapeutic Community for the Adolescent Substance Abuser by Gregory C. Bunt, Britta Muehlbach (122-130).
Therapeutic communities have a long history, dating back to the Middle Ages. Beginning in the mid 20th century, the therapeutic community was revived in the form of such programs as Synanon, led by former substance abusers. Subsequent TCs have built upon the early principles of Synanon but adapted to meet the changing needs of clients and incorporated what has been learned from the expansion of the knowledge base of substance abuse treatment. Most notably, psychiatrists have come to play an important role as medical directors of TCs. This paper describes the adolescent treatment program at Daytop Village in terms of its functioning and patient population, and the role of the psychiatrist-medical director. Necessary adaptations to the TC model for adolescents are explained. The literature on outcome of this type of treatment with respect to adolescents is reviewed. The evidence suggests that therapeutic communities are an effective form of treatment for adolescent substance abusers.

Relapse Prevention by Richard Rosner (131-135).
Interventions to reduce the likelihood of relapse, or a return to substance abuse after a period of abstinence, are important components of substance abuse treatment. Treatment interventions for adolescence with substance use disorders should incorporate principles of relapse prevention. The relapse prevention model advanced by Marlatt and Gordon and others in the addiction field is a self-control model, based on a cognitive-behavioral approach. This model stands in contrast to a disease model, which many in the medical field have adhered to. This paper presents a summary of the key features of Marlatt and Gordon's cognitive-behavioral approach to relapse prevention.

Commentary: ADHD and Substance Abuse by Dominic Ferro (136-137).
Full text available.

Historically there has been a lamentably wide gap between Alcoholics Anonymous (AA) and psychodynamic psychotherapy. Although each has a distinct language, they actually utilize parallel principles. This paper is an attempt to integrate the two fields, using clinical examples from an inpatient unit for chemically dependent adolescents. Each of the Twelve Steps is equated with a psychodynamic mechanism. For example, the First Step, admitting powerlessness, is equated with the defense mechanism of denial.

Boys greatly outnumber girls in mental health treatment settings prior to adolescence, but this ratio begins to change dramatically in early adolescence. While adolescent girls are less likely to commit violent crimes, suicide, be victims of homicide, use drugs and alcohol, or smoke, than adolescent boys, they are more prone to psychological distress, and subject to increased risks of depressive illnesses, eating disorders, and post-traumatic stress syndromes, often leading to patterns of chronic morbidity. In fact, while boys' risks for mental health problems such as violence and suicide are decreasing, girls' risks are going up. This selective review will explore the interaction between female adolescent development and psychopathology focusing on disorders for which teenage girls are at high risk.

This study investigated Israeli adolescent coping with terror during a three year period. Ten and 11th graders (n=147) from two major cities in Israel, one exposed to frequent terror attacks and the other relatively free from terrorism participated in the study. A self-report questionnaire measured terror-related stress responses (TRSR), perceived vulnerability and controllability, and measures of indirect exposure to terrorism - living area, exposure to media and knowing a victim of terror. Adolescents from the high risk area scored significantly higher on most TRSR items compared to those from the low risk area, felt more vulnerable about being directly involved in a terror event, and perceived themselves as being more cautious. These effects were more pronounced among news consumers and among girls. Indirect exposure to terrorism significantly intensified adolescents' stress symptoms and changed their daily routines, possibly with long term effects on their development.

Effectiveness of Wet Sheet Packs in Children and Adolescents with Severe Auto/Hetero Aggressive Behaviors: An Exploratory Approach by Arnaud Lobry, Claire Jutard, Nicolas Bodeau, Anja Kloeckner, Angele Consoli, David Cohen (163-168).
Objective: To explore the effectiveness of wet sheet packs on auto/hetero aggressive behaviors in children and adolescents hospitalized in a psychiatric setting. Method: We reviewed the charts of all patients (N=8) who received packing therapy in the context of resistance to behavioral interventions, milieu therapy and medications from 2005-2009. We scored the level of auto/hetero aggressive behaviors per patient for each day they were hospitalized. Inter-rater reliability was good (Intraclass correlations=0.91). We used a mixed generalized linear model to assess whether the following explanatory variables (time, typical and atypical antipsychotics, mood stabilizer, sedative drug, stimulant and wet sheet pack) influenced the course of aggression over time, the dependant variable. Results: Using univariate analysis, the only variables that were found to be associated with a significant decrease in auto/hetero aggressive score were time (p=8 10-3), atypical antipsychotics (p=.027) and packing therapy (p=10-9). Effect of packing therapy remained significant after adjustment for atypical antipsychotics (p=1.8 10-9) and for time (p=.0017). Conclusion: In addition to atypical antipsychotics and milieu therapy, the results of this exploratory study suggest that wet sheet packs may be effective in relieving auto/hetero aggressive behaviors.

This paper presents a follow-up of the psychoanalytic psychotherapy of eight male adolescents treated by one of the authors (IHB). A questionnaire was offered to them 15-30 years after their initial psychotherapeutic contact in an effort to assess the effects of the psychotherapy and their current status. Good outcome was defined in terms of their sense of fulfillment and satisfaction with their lives, success in their work, marriage, having children, and being integral parts of their community. The findings were that all of the men had completed the developmental tasks of adolescence, but they separated into two groups due to differences in their adult outcomes. Those who did well had had good therapeutic alliances in psychotherapy as adolescents. Several improved despite significant substance abuse during adolescence and had fulfilling adulthoods. Those who did less well had more severe psychopathology and physical illness during adolescence, were less introspective, and had weaker relationships with the therapist. It is proposed that the psychotherapy in adolescence was beneficial for all of these patients, but different in its efficacy in accordance with patient characteristics.

Exhibitionism has been diagnosed in patients during adolescence into late adulthood. Although there are multiple etiologic theories for exhibitionism, there is very little consistent empirical evidence for these theories. Multiple theories are discussed with a focus on a pattern of humiliation supporting the theory of exhibitionism as countershame, as well as components of courtship theory. This case example provides a concise report of one patient's childhood relating to exhibitionism. This example was based on an outpatient clinic chart review, an interview with the patient, and phone interviews with the patient's parents and siblings.