Adolescent Psychiatry (v.2, #4)

The opera Lost Childhood is based on a fictional encounter between the son of a Holocaust survivor and the son of a German Nazi sympathizer. The account of the Holocaust survivor is based on the book The Lost Childhood by Yehuda Nir, a child and adolescent psychiatrist living in New York, who spent the war with members of his family in hiding pretending to be Polish Catholics. The son of the Nazi sympathizer is fictitious, but the dialogue between the two characters is based on the friendship between Nir and the author of this article, a music historian and great grandson of the composer Richard Wagner. The author describes his involvement with the author of the opera, what the opera attempts to convey, and his own life's work to confront the Wagner clan's anti-Semitism, and its close friendship with Hitler between 1923 to 1945 and support of the Nazi regime, and to create his own moral standards. Finally, he describes his own son's thoughts and feelings as he, as a Wagner and German, born after Hitler, learns about the genocide of European Jews between 1933 and 1945 and reacts with his humanitarian commitments.

Operationalized Psychodynamic Diagnosis by Teresa Sau-fan Chan (283-384).

Editorial by Lois T. Flaherty (287-288).

Self Destructive and Self Harm Behavior in Adolescence — An Integration of Dynamic and Empirical Psychological Models by Shira Barzilay-Levkovitz, Dana Feldman, Avigal Snir, Alan Apter (289-295).
Background: Psychologists have long been fascinated by the propensity of young people to engage in self harming and self defeating behavior. One of the first attempts to address this issue was Freud in his seminal article "Beyond the Pleasure Principle" The ideas were further developed by Klein and Menninger and more recently by Noshpitz. Recent empirical models of self harm—which take a descriptive approach—have been proposed by Baumeister, Williams, Brent and Mann and Nock. The theories of Jessor and Joiner have also attracted considerable attention. However, both approaches have their limitations and the factors that underlie self-destructive behavior have not been fully elucidated. This limits our ability to predict suicide risk, and hence, reduces the effectiveness of our efforts at prevention. Goals: To review both theoretical and empirical models of self-destructive behavior, including various kinds of self-harm and suicide, and discuss a new, integrative, model that can help describe how the transition from suicidal ideation to suicidal behavior occurs. Methods: In this review article we briefly describe these theories and postulate an integrative model which we think is testable. Conclusions: Our model takes into account the adolescent’s emotional and interpersonal distress, the degree to which a major psychiatric disorder is present, the trajectory of suicidal ideation, and the capability to engage in self injury. Research testing such a model could lead to better ways of identifying and intervening to prevent adolescent suicide.

Depression in Adolescence: From Qualitative Research to Measurement by Jonathan Lachal, Mario Speranza, Anne Schmitt, Michel Spodenkiewicz, Bruno Falissard, Marie-Rose Moro, Anne Revah-Levy (296-308).
Introduction: Depressive disorders among adolescents are public health challenges whether in terms of both morbidity and mortality. Because of the paucity of specific instruments to measure depression in adolescents, we undertook to design and develop a new tool, the ADRS (Adolescent Depression Rating Scale) using a qualitative and quantitative procedure. The psychometric properties of the ADRS have been already published in a previous paper (Revah-Levy, Birmaher, Gasquet, and Falissard, 2007). Goals: The aim of the present paper is to describe the results of the qualitative method we employed to build the scale which used in-depth interviews with 5 patients and 11 clinicians followed by a thematic analysis based on the principles of the Grounded Theory. Results: These research interviews yielded three aspects of the depressive experience: 1) Emotional state: irritability, the overwhelming nature of the depressive experience, negative perceptions of self and ideas of death; 2) non-emotional manifestations: mental slowing, sleep disturbances; 3) manifestations in social interactions: at work, in leisure activities, and in relationships. Using with three aspects of the depressive experience, a clinician version and a patient version of the scale were elaborated and submitted to a classical validation procedure leading to a final selection of 10 items for each (self and clinician) version of the instrument. Conclusions: This work supports the interest of using qualitative methods in psychiatric research to investigate the subjective experience of patients, which is a central dimension in clinical care.

Traumatic experience and posttraumatic stress disorder (PTSD) is highly prevalent among adolescents hospitalized in psychiatric facilities and also among those who are incarcerated. However, it is often not detected in the course of routine evaluations, even those done by mental health professionals. Lack of recognition of trauma exposure and PTSD in hospitalized or incarcerated adolescents has serious implications. The severe behavior problems that result in hospitalizations or incarceration may actually be the result of emotional dysregulation, which is one of the core PTSD problems. This article describes strategies for integrating and evaluating systematic screening, assessment and developmentally appropriate interventions in a public hospital and juvenile justice settings. While research on these interventions is ongoing, preliminary findings have been positive. It is essential that the important role that trauma plays in severe psychopathology be recognized and effectively addressed if we are to help these young people change their trajectory from one of continued victimization to one of effective self-regulation.

Treating Traumatic Stress in Children and Adolescents by Glenn Saxe, Adam Brown (313-322).
Introduction: Trauma Systems Therapy (TST) intervention arose out of the recognition that the patient population we served, many of whom were suffering from the aftermath of traumatic stress, were not improving from the traditional approaches we were using. Method: This article summarizes the experience of developing an approach to assessment and treatment called trauma systems therapy (TST), that my colleagues and I have been evaluating and developing over the past 10 years. Results: TST is classified by the National Child Traumatic Stress Network an effective and promising intervention .This work resulted in the writing of the book, Collaborative treatment of traumatized children and teens: The trauma systems therapy approach (Saxe, Ellis, and Kaplow 2006), which is the manual for TST. This book gives details about how and why we developed trauma systems therapy, and is the guide for assessment, treatment and systems implementation using this model. Conclusions: TST makes sense in light of what we know about the neurobiological underpinnings of traumatic stress disorders as well as our understanding of difficulty with emotional regulation. TST is both an effective clinical model for treatment of traumatized children and adolescents, and also an organizational model for the integration of services among agencies that provide treatment to these children.

Augmenting Anger Control Therapy with a Videogame Requiring Emotional Control: A Pilot Study on an Inpatient Psychiatric Unit by Peter Ducharme, Elizabeth Wharff, Jason Kahn, Eliza Hutchinson, Grace Logan (323-332).
Emotional dysregulation in childhood, which has been linked to significant social problems in older adolescence, is one of the most common reasons for pediatric mental health treatment and psychiatric hospitalizations. Behavioral approaches to treatment for these disorders are limited, however, resulting in increasing use of restraints and psychotropic drugs. A pilot study was implemented on an inpatient psychiatric unit to evaluate feasibility and provide proof of concept for a novel behavioral intervention comprised of anger control therapy (ACT), a cognitive-behavioraltherapy intervention, augmented by RAGE-Control, a videogame that trains players to regulate physiological arousal in a challenging but controlled situation. Patients (N=18, 9-17 years old) with high levels of anger documented by the State Trait Anger Expression Inventory-Child and Adolescent (STAXI-CA) were enrolled in a 5-session intervention (Experimental group). Changes in STAXI-CA State-Anger and Trait-Anger scores from baseline to Day 5 were compared to those of a demographically comparable treatment as usual (TAU) historic control group (N=19). The Experimental group showed large reductions in STAXI-CA scores, compared to the TAU group. Compliance and satisfaction were high. These findings support the feasibility of the ACT with RAGE-Control intervention. Randomized controlled trials augmenting ACT with the RAGE-Control game are needed to establish efficacy.

Eating Disorder Subtypes in a Young Female Sample Using the Operationalized Psychodynamic Diagnosis System: Preliminary Results by Maria Laura Zuccarino, Pablo Zuglian, Margherita Magni, Aurora Rossetti, Giulia Manna, Maria Gabriella Gentile, Michele Nichelatti, Emilio Domenico Fava, OPD Eating Disorders Milan group (Pietro Bondi, Dario Ferrario, Marianna Greco, Giovanni Mentasti, Tiziano Monea, Angela Testa, Francesca Cadeo, Pasqua Cafagna, Valeria Piemontese, Marco Tettamanti) (333-344).
Background: We believe that the frequent treatment failure with patients with eating disorders is in part due to the heterogeneity of patients with this diagnosis and to an incomplete understanding of psychopathological factors relevant to prognosis and treatment planning for subgroups of patients. Goals: This ongoing study aimed to investigate the existence of psychopathologically significant dimensions in a sample of patients with Eating Disorders (EDs), using the Operationalized Psychodynamic Diagnosis (OPD-2) system (OPD Task Force, 2006). Methods: The sample included 50 consecutive non-selected young women (mean age 19, [SD = 2,6] years old) attending a Nutrition Day Hospital at the Eating Disorder Unit of the Niguarda Hospital, Milan, who were evaluated by an OPD-2 trained interviewer. We performed two different factor analyses with the Oblimin rotation: the first one using OPD Axis I (Experience of Illness) variables, and the second using factors taken from Axis I and Axis III (Conflicts) and Axis IV (Structure) variables. Conclusions: In the first analysis, we obtained four different psychodynamic dimensions, that we called Explicit Illness Configurations (EICs), that represent the patient's psychological, somatic and social theory of illness and a symptomatic dimension. In the second analysis, we discovered three recurrent psychodynamic dimensions, which we called Implicit Functioning Profile (IFPs), representing more stable organizations of illness that may contribute to the high outcome variability in this disorder. These results suggest the existence of different subgroups of patients with EDs differing from each other with respect to psychodynamic features. These data suggest that tailoring therapeutic approaches to the patients' individual profiles could improve outcomes.

Adolescent Parenthood and Offspring Suicide Attempts in Adolescence by Nikos Zilikis, Tatiana Tairi, Grigoris Abatzoglou, Apostolos Iacovides (345-349).
Background: Adolescent motherhood has been found to be associated with offspring suicidal behaviour in adolescence in a few cohort and general population studies. Aims: To examine this association in a clinical adolescent population. Method: As part of a continuing study on attempted suicide among adolescents in Northern Greece, 160 cases were examined and compared to a same size general clinical population (all diagnoses except attempted suicide). Comparisons were also made with general population data. Results: The suicidal adolescents were statistically more likely to have been born to a teen mother or to a mother who gave birth to her first child before the age of twenty. We found that 16.3percent of the suicidal adolescents' mothers were aged ≤19 at their suicidal offspring's birth, while 34.4 percent were ≤19 at first childbirth. Corresponding rates in the general clinical population were 5.6% and 17.5% respectively. Rates of teen childbirth appear dramatically higher in the mothers of suicidal adolescents compared to those in the general population in Greece. Conclusions: Our findings suggest that teenage motherhood should be studied more systematically in its association to offspring suicidal behaviour in adolescence.

This article is an introduction to articles by Peter Pogany-Wnendt and Gottfried Wagner in this issue. In this article the author describes his own experience in coming to terms with his German-American heritage and the role that Germans of his parents' generation in Germany played in the Holocaust. His goal has been to understand how reconciliation can occur between children of Holocaust survivors and children of Nazi sympathizers.

Over 70 years have passed since the Holocaust began in Germany. Both victims and perpetrators were for the most part unable to discuss their painful past with their children. On their part children were afraid to ask about their parents' experiences, and engaged in a process of trying to protect their parents. As time has gone on, perpetrators, accomplices, fellow-travelers, and also the victims have died. Their children, who grew up with their parents' silence, have now come to an age in which the emotional processing is possible. The opera Lost Childhood deals with a fictious dialogue between a Jewish Holocaust survivor and the son of a Nazi sympathizer, as they struggle to understand each other. Each carries a heavy burden from the past. Ultimately they understand that while forgiveness is not possible, understanding is. This article traces the opera and contains the author's reflections on his experiences as a child survivor and the impact on his daughter. The children of the perpetrators and survivors bear a special responsibility. Even though, they did not participate in the Holocaust, they have to address the burden that was handed to them. Otherwise, their children will inherit the burden and its inherent destructiveness.

The various man-made disasters of the twentieth Century, most notably the Holocaust, continue to challenge our attempts to understand how such enormities can occur, and to confront the horror and suffering of victims and witnesses. Social discourse has been concerned with historical truth for both the individual concerned and society in connection with these disasters. At the same time reluctance to know often sets in here that stems from the desire to avoid confronting the crimes, the horror and the victims' suffering. The author argues that a psychoanalytic understanding can help not only in the understanding of the effects of traumatic stress on individuals, but in grasping the interactive, reciprocal effects of man-made disasters on individuals and society as a whole. After a review of the effects of traumatic stress on the developing child, he discusses the role of memory and remembrance in coming to terms with the past. It is beyond the individual’s capacities to integrate such traumatic experiences in a purely personal narrative context. The historical truth of the traumatic events, as well as their denial and defensive repudiation, must be acknowledged and included in social discourse. The prevalence of denial or silence has meant that traumatized survivors are left alone with their experiences. The author describes both the dynamics of these difficulties and their transgenerational effects on post-war German society, ending with the observation that the second generation has finally begun to talk about their expereinces and engage in public discourse, which offers a hopeful path for future generations.

Introduction: Germans who were children during World War II tended not to discuss their experiences, which were often quite traumatic. As they reached their sixties these “war children” began to show signs of posttraumatic reactions and other psychiatric problems. Goals: To describe the characteristics of the German war children—those who were children in Germany during World War II and the Nazi government—and discuss the reasons why these children never brought into language their traumatic wartime and post-war experiences for many decades after the war. Methods: The author reviews the research on this topic as well as his own findings based on interviews with these war children, and offers hypotheses as to why they did not discuss their wartime experiences. Results: This generation was afflicted by traumatic experiences, an inability to mourn, and guilt over their inability to do anything about their parents' privations and sufferings. In addition, the ethos of the strength of German children, and the parents' guilt over the Nazi atrocities, rendered them unable to recognize their children's distress. German war children were indeed victims of war, and although not comparable to the victims of Nazi terror, they have suffered lasting consequences that are only now being recognized, as their collective silence comes to an end.

War is a major cause of traumatic stress for children and adolescents. German children who were born just before WWII experienced multiple stresses during and after the war. In addition to the losses and deprivations associated with the war, they had to face the shame of their country's defeat and responsibility for the war, and many lived with the knowledge of their families' complicity in the Nazi atrocities—something that was largely unacknowledged and never discussed. While in some cases, war trauma results in an ever-repeating cycle of violence, in others, the children who experience war are remarkably open to reconciliation and peace. While genocidal violence has recurred—in Cambodia, in Bosnia, in Rwanda, for example, there is hope that the children who live through these experiences can help to bring an end to these horrific events. The author offers his views on how the unique perspectives of these children can inform us. He describes his experiences and his observations of his contemporaries and peers who were children in Germany during World War II, and adolescents in the post-war era. Some of these children have led the way in the ultimate acknowledgement of individual and collective responsibility and in taking steps to ensure that the horrors of the genocide would not be repeated.