Adolescent Psychiatry (v.1, #3)

Editorial by Lois T. Flaherty (184-186).
The Annual Meeting of the American Society for Adolescent Psychiatry (ASAP) took place in New York, March 26-27.2011. This issue contains three articles based on presentations at the meeting. The theme of the meeting was “From 9/11 to2011”a Ten Year Update on Adolescent Psychiatry.“ Two of the presenters”Craig Katz and Cynthia Pfeffer bothpsychiatrists were in New York City at the time of the terrorist attacks on the World Trade Centers on September 11, 2001,and afterwards worked to organize and deliver mental health care to people affected by the disaster. As Dr. Pfeffer points out inher paper on children and adolescents who experience disasters (see page 197), 9/11 was a turning point in American history inmany ways. Much was learned afterwards about the needs of populations exposed to disasters. The extensive media coverage ofthe 9/11 disaster meant that many children far from the site of the attacks even those as far away as Seattle experiencedsymptoms of traumatic stress. Dr. Katz describes the efforts that were made to set up emergency psychiatric services in variouslocations in New York City using volunteer psychiatrists and other mental health professionals to staff them. In his article ondisaster psychiatry (see page 187) he discusses elements of an effective mental health system for disaster work and concludesthat an optimal system would attend to a population’s mental health needs pre-disaster in addition to providing much neededservices post- disaster. The challenges are enormous and the resources inadequate. Ten years after 9/11, a residual group,including many who were first responders, still suffer with aftereffects of the disaster, both in terms of posttraumatic stressdisorder and impaired functioning. Subsequent disasters, such as Hurricane Katrina, proved to be just as devastating in terms ofboth immediate and long term effects. The oil spill in the Gulf of Mexico, in which loss of life and injuries were confined to theoil rig that exploded, has had a major impact on the mental health of residents of the coastal areas affected by the spill, by itsconsequent economic disruption and the destructive effects on the environment that these people call home.Alan Ravitz, a child and adolescent psychiatrist who has done over 500 custody evaluations, also presented at the ASAPmeeting. Here he draws on his extensive knowledge of the research literature on the effects of divorce and distills his vastclinical experience in working with families and children in the context who are involved in high conflict divorces (see page204). While high levels of parental conflict are common at the time of separation, litigation, and the issuance of the finaldivorce decree, only in 20 to 30% of divorces does a high level of conflict continue and become chronic. The effects can bedevastating for children and adolescents. Based on his experience both as a forensic evaluator in over 500 cases of contestedcustody, and as a therapist for divorcing families and their children, Dr. Ravitz offers suggestions for working with adolescentswhose parents are involved in high conflict divorce.Writing on the gap between research findings and clinical practice, Elizabeth Sburlati and colleagues from Australia assertthat evidence is growing that insufficient training is offered to therapists in clinical practice to equip them to effectivelyimplement evidence based treatments (EBTs) for youth psychiatric disorders (see page 210). This is a serious charge but in myexperience has certainly been validated when I’ve tried, for example, to find a therapist to do cognitive behavior therapy with ayoungster with obsessive-compulsive disorder. Training programs in psychiatry are now mandated to teach a variety of EBTs(although how uniformly this requirement is being implemented is unclear), but what about practitioners who completed theirtraining before these mandates went into effect? Furthermore, there is no requirement that therapist competency in deliveringEBTs be assessed. In a recent review Weerasekera and colleagues stated (2010, p. 10):“Although competence and proficiency are emphasized as outcomes of training, and despite the availability ofobjective, evidence-based methods to assess competence, use of these methods has not been required”.Historically, training residents in psychotherapy has depended largely on process notes, with residents graduatingwithout ever having been observed conducting psychotherapy. One wonders how comfortable we would beundergoing a surgical procedure with a surgeon trained in a similar manner!The practice of evidence based psychiatry does not mean that the therapeutic relationship can be ignored there can be nopsychotherapy without a therapeutic relationship. An American Psychological Association Task Force recently made thefollowing points (2011): The therapy relationship makes substantial and consistent contributions to psychotherapy outcome independentof the specific type of treatment. The therapy relationship accounts for why clients improve (or fail to improve) at least as much as the particulartreatment method. Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote afacilitative therapy relationship. Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship areseriously incomplete and potentially misleading. Adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis)enhances the effectiveness of treatment. The therapy relationship acts in concert with treatment methods, patient characteristics, and practitionerqualities in determining effectiveness; a comprehensive understanding of effective (and ineffective)psychotherapy will consider all of these determinants and their optimal combinations.Three articles by practitioners who reflect on their work address the issue of the therapist-patient relationship. All threedescribe how to get through to adolescents who are challenging at best. The authors of all three articles have definitely earnedtheir stripes and know what they are talking about. Perry Bach has spent his career in the public sector and worked in mentalhealth systems in California and Colorado. He describes his approach to the initial interview with adolescents who often havebeen through the system for years and have no interest in seeing yet another psychiatrist whom they assume will ask them moremeaningless questions. By understanding the adolescent’s point of view, and imagining what he or she is probably thinkingduring the interview, the interviewer is able to convey a genuine appreciation for the young person’s need for autonomy and iscareful to respect the adolescents point of view (see page 214). Glen Pearson, who worked in a state hospital, a private hospital,and is now in outpatient psychotherapy practice, all in Texas, draws on his experience to describe how active involvement onthe part of the therapist in the adolescent patient’s life is necessary to promote therapeutic change (see page 218). Finally,Thomas Bratter, the head of a residential school in Massachusetts for gifted but dysfunctional adolescents, explains hiscompassionate confrontation approach to convincing students at the school to turn their lives around (see page 227). All ofthese therapists are following in a long tradition in adolescent psychiatry, which early on recognized that a more activeapproach than that usually taken with adults was necessary to engage adolescents in the treatment process.....

Disaster psychiatry has existed for many decades as a field but has received heightened attention since 9/11. Inthe last ten years, a good deal has been written about the field, but efforts to establish its evidence base or to fundappropriate services have been more variable. This article will review the current state of the science in disasterpsychiatry, with particular emphasis on acute psychopharmacologic and psychotherapeutic interventions. Additionally, itwill examine the systems issues that remain a challenge to establishing an effective and meaningful psychiatric responsesystem for disasters. Particular attention will be paid to the developing literature on adolescents’ reactions to disaster andhow these may shape psychiatric services for this population.

Since the terrorist attacks on September 11, 2001 the immediate and longer term effects of disasters ondevelopment and well-being of children and adolescents who survive them have been significant public and mental healthissues. Young people exposed to a traumatic event are at higher risk for developing mental disorders, but not all areaffected equally. The impact of a disaster is affected by many individual, family and community variables. Knowledge ofmoderating effects has increased with the many studies that have been done on the effects of disasters, before and sinceSeptember 11, 2001. Effective interventions exist to help mitigate the effects and promote resilience in individuals,families and communities. This article reviews the literature on effects of disasters, including the author’s own researchthat showed sustained alterations in cortisol levels in children and adolescents whose parents were killed in the attacks onthe World Trade Center buildings in New York City. Recommendations are given about future research needs andpreventive interventions.

With approximately 50% of marriages ending in divorce in the U. S., children have a high probability ofexperiencing their parents’ divorce. High levels of parental conflict are common at the time of separation, litigation, andthe issuance of final divorce decree. In 20 to 30% of divorces conflict continues and becomes chronic. While divorce isalways stressful for children, high conflict divorces are the most stressful, with children suffering not only the harmfuleffects of familial dissolution, but also those related to their exposure to chronic, often violent discord. The author offerssuggestions for working with adolescents whose parents are involved in high conflict divorces based on his experienceboth as a forensic evaluator in over 500 cases of contested custody and as a therapist for divorcing families and their children.

While policy makers demand that mental health care professionals implement empirically supported treatments(ESTs) for youth psychiatric disorders, research indicates that mental health care professionals do not possess the requiredcompetence for the implementation of these ESTs, due to less than optimal EST training. This paper discusses the needfor: 1) the clear articulation of therapist competencies required for the effective treatment of youth psychiatric disorders,2) the development of effective training aimed at instilling these competencies in mental health care professionals, and 3)accurate, reliable, and cost efficient assessment of therapist competencies. Current initiatives and future directions relatedto the definition, training and assessment of therapist competencies for the treatment of clinical disorders in youth arediscussed in this paper.

Setting The Stage For Work with Adolescents by Perry B. Bach (214-217).
What happens in the first encounter has long been recognized as crucial to psychotherapeutic work. This isespecially true when working with adolescents, whose preconceived ideas about psychiatric treatment and therapist areoften less than positive. Adolescents seen in public mental health settings present particular challenges, as theseyoungsters have often had negative experiences with therapy. The author presents his own strategies for creating anatmosphere in which some of the adolescent patient's negative expectations can be countered and a sense of hope createdthat the encounter with the therapist can lead to an alliance that will eventually have a positive outcome.

Long term inpatient treatment is no longer generally available for adolescents, and young patients whosebehavior would have resulted in hospitalization in the past are now by default treated in outpatient settings. In order foroutpatient treatment to be successful, some key ingredients are necessary. These include genuine interest and commitmenton part of the therapist and the ability to communicate these to the adolescent. In addition, some of what was available inthe inpatient milieu needs to be recreated in the context of the therapy, the family, the school and the community. Theauthor draws upon the principles of systems of care, multi-systemic therapy, and his own long experience treatingadolescent patients in a variety of settings to illustrate the process of effective psychotherapy of adolescents with severepsychopathology.

Until bright, creative, and alienated adolescents learn to make reasonable decisions, they will not engage inproactive, constructive, and creative change. Grounded in principles of reality therapy and choice theory, compassionateconfrontation psychotherapy (CCP) stresses the concepts of conscious choice and acceptance of responsibility for one'sactions. CCP provides a unique therapeutic experience to induce change. Viewed from this pragmatic and humanisticperspective, the overuse of psychiatric diagnoses and psychopharmacologic treatments inadvertently relieve giftedadolescents from accepting accountability for their choices. Evidence of the success of CCP can be found in the highpercentage of alumni of the John Dewey Academy who are admitted to and complete their educations at leading collegesand graduate schools. Further evidence is provided by their academic performances at those institutions of higherlearning.

The Use of a Geographic Information System (GIS) to Study Spatial Distribution and Factors Associated with Stress Among Thai Adolescents by Suporn Apinuntavech, Tuanjai Nuchtean, Sukontha Siri, Kittipong Hancharoen (235-244).
This research aims to describe the spatial distribution of factors associated with stress among adolescents in theBanpaew District, Samutsakhorn Province of Thailand, by using a Geographic Information System (GIS). A crosssectionalstudy was conducted to analyze the level of stress in a sample of 321 students, aged 12 - 18, during the year2008 at three schools in the Banpaew District. The data was collected by using questionnaires which collected informationfrom the students about demographic characteristics, stress level, and environmental, personal, and social factors. Theinformation was then used to plot the spatial distribution of stress among adolescents.The results revealed that the majority of students had a moderate stress level (stress score: 27.37 - 37.59, 68.5%), followedby a smaller group who had a low stress level (stress score: < 27.37, 16.8%). Only 14.6% had a high stress level (stressscore: > 37.59). It was found that the level of stress was strongly associated with problems with friends (adjusted OR =3.32, 95% CI = 1.55 - 7.09, p = 0.002). Having family size of more than 3 served as a protective factor (adjusted OR =0.38, 95% CI = 0.16 - 0.91, p = 0.029). From the distribution map of stress in the Banpeaw District, the subdistrictLaksam had a higher frequency of stress amongst students than in other areas. There was no statistically significantclustering pattern of stress detected. The stress of adolescents in the Banpeaw district did not depend upon the geographicvariables we mapped (location of factory and nightclub) but rather involved issues of family and peer relationships. Thesefindings indicate that relationships with family and peers rather than specific geographic factors are correlated with stress.Intervention to improve the level of family support and enhance peer relationships would appear to be very important forreducing adolescents' stress.

Use of Mental Health Services By Youths Who Have Sexually Offended by R. Gregg Dwyer, Jeanette M. Jerrell (245-250).
Objectives: To examine differences in personal characteristics, types of services, and outcomes of care in astate mental health system among youths identified as having committed sex offenses.Methods: A cohort of 188 youths identified with sexual offending behaviors served during one fiscal year was compiledand their existing personal, service, and functioning data from medical and computer files were used in retrospectivecomparisons employing analysis of variance, logistic regression, and random effects regression modeling.Results: A diagnosis of conduct disorder or oppositional defiant disorder significantly distinguished between males andfemales in the cohort. The primary form of intervention was 24-hour residential or inpatient treatment, with males havinglonger lengths of stay than females. In community-based outpatient care, males received significantly more crisis services,group therapy, and medication monitoring. Child Global Assessment of Functioning (CGAF) ratings improved over time,but not to a statistically significant extent.Conclusions: Given the potential for untreated adolescents with sexual offense histories becoming adult clients in mentalhealth systems, evidence-based interventions should be employed as early as possible. This requires a matching of needswith interventions of proven efficacy, thus necessitating periodic reviews and monitoring of the demographics of theadolescents (and children) identified as having engaged in sexual offending behaviors and their outcomes (functionalimprovement) over time.

The therapeutic milieu plays a critical role in the management of patient behavior and delivery of therapeuticcontent. Formal training in the techniques of milieu therapy and collaborative problem-solving (CPS) provides mentalhealth employees with a unique set of practical strategies that enhance pro-social behavior of children and adolescents.The empowering techniques of milieu therapy and CPS include skills to establish and maintain a healing milieu, addresstargeted behaviors, de-escalate potentially dangerous situations, and prevent individual or unit crises. We hypothesizedthat formalized training in and implementation of milieu therapy and collaborative problem-solving would allow forproper management of aggressive behavior, thus reducing or eliminating the need for restraints in a residential treatmentprogram. We sought to determine whether formalized, Web-based milieu therapy training for adult mental health staffwould be a successful intervention to manage and prevent disruptive behaviors in children. We implemented our programat Maple Shade Youth and Family Services, Inc., located in Mardela Springs, Maryland. All levels of staff participated ina training program for the prevention and management of disruptive behaviors in children and adolescents. Pre-initiativeand post-initiative totals were compared as an indicator for successful implementation of milieu therapy techniques. Therewas a substantial reduction in the post-initiative number of restraints required as a result of these trainings. There were205 restraints required in 2006, which was the year immediately following the beginning of the implementation of theprogram. The number of required restraints decreased in 2007, when only 97 incidents occurred. The full program wasimplemented in 2008, and there were only four instances requiring restraints that year and the year after.

The Aftermath of Childhood Sexual Abuse: A Case Report and Review of the Literature by Minniel Douglas, Dawnelle Schatte, R. Andrew Harper (255-259).
Objective: Childhood sexual abuse (CSA) can have many medical, social, and psychological sequelae. Theseuntoward effects include abdominal pain, gynecologic disorders, changes in peer and family interactions, depression,bipolar disorder, behavioral changes, as well as many other complications. The purpose of this paper is to present a casestudy that illustrates many of these sequelae and compare features of the case with what has been reported in the literatureon the effects of childhood sexual abuse. The case is that of a Hispanic American female adolescent who was sexuallyabused as a child.Methods: A review of the current admission to a psychiatric unit and a retrospective examination of charts from previousadmissions was conducted. Also, the results of a review of the literature on the medical, social, and psychological effectsof childhood sexual abuse are summarized.Results: The patient shows behaviors and psychopathology that are in many ways consistent with the effects of sexualabuse described in the medical and psychiatric literature.Conclusion: There are many effects of childhood sexual abuse, all of which can halt the growth and developmentalprogression of the victim, leaving the victim with the need for many years of treatment, both medically andpsychologically.

Based on diaries he kept between the ages of 13-16, musician and author Jim Carroll's book, The BasketballDiaries, describes his harrowing descent into drug use. The descriptions in the book are useful in helping those who workwith adolescent substance abusers understand their patients' experiences. Using Carroll's descriptions of his addiction, theauthor discusses various parameters that determine the appropriate treatment approach to the adolescent substance abuser.He discusses how Carroll's depictions of himself can be understood in light of research on motivation and readiness forchange, and concludes that the evidence at age 16 does not suggest a good prognosis. Nevertheless, Carroll did survive,overcame his addiction, and made an adaptation to the drug-free adult world.