Adolescent Psychiatry - Volume 1, Issue 4, 2011

This issue of Adolescent Psychiatry spans the spectrum between evidence-based practice and practice-based evidence. A special section on eating disorders in this issue summarizes current knowledge about these challenging, all-too-prevalent, disorders and their treatment. Included in this section is an article on eating disorders in males, which are often overlooked. In this article, Stewart points out that this is because of the popular assumption that eating disorders only affect females, and the feminization of current diagnostic criteria. Anorexia nervosa, while among the most serious illnesses affecting adolescents, with a high rate of fatality, is treatable. However, the treatment must aggressively challenge the adolescent’s extreme level of control over the family. Two reviews deal with bipolar disorder and marijuana dependence. In the first review, Bernstein has provided an update on current knowledge and best practices for treatment of bipolar disorder. She emphasizes a rational treatment approach that may include alternative and complementary medications. Jaffe summarizes his long experience with treating adolescents who use marijuana, pointing out the many myths that such teenagers use to justify their use, and giving suggestions for how to counter these beliefs. He believes that marijuana use is particularly pernicious for adolescents as they do not recognize the impairment that their use is associated with. He underscores his points with neurobiological evidence, showing the significant and longlasting effects that marijuana has on the brain. The perspectives section contains three thought-provoking articles. Aggarwal and Pumariega discuss the many issues related to minors who were held at the U. S. naval base in Guantanamo in the aftermath of the terrorist attacks on the U. S. on September 11, 2011. As has been pointed out many times, detainees at Guantanamo lacked many of the legal protections available to prisoners on U. S. soil and this was no less true for adolescents than adults. It is clear that the base was not well equipped to provide adequately for their needs, with adverse consequences. Also in this section is a paper by Michael Kalogerakis, which summarizes his thinking about what needs to be done to promote mental health in children and adolescents, focusing on the role of families. The World Health Organization defines mental health as … a state of well-being in which an individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and is able to make a contribution to his or her community. In this positive sense, mental health is the foundation for individual well-being and the effective functioning of a community. (http://www.who.int/mediacentre/factsheets/fs220/en/). Two articles focus on the psychiatric inpatient treatment of adolescents. The authors-one group from Greece and another from the U. S.-describe how they have dealt with the challenges of limited resources in the face of unmet needs. Zilikis and colleagues describe the development of an adolescent inpatient program in which adolescents were hospitalized with adults and points out that there are some advantages to this arrangement. Shen, Dhillon, and McCarthy use the case of an adolescent with non-suicidal self-injury to discuss the role of the hospital as part of a continuum of care. Duric and Elgen present findings from their research on Norwegian children and adolescents with ADHD who presented for treatment in a clinic after having been referred from community sources. Their findings confirm that these youngsters have high rates of comorbid psychiatric conditions and often suffer from cognitive impairment, mandating careful evaluation of all aspects of their functioning. They add to the world-wide perspective on this common disorder. We are indebted to Glen Pearson who was able to obtain and edit “Embracing Spitfires,” a presentation given by James L. Cox at an ASAP meeting several years ago on his approach to adolescents who are difficult to engage in psychotherapy. Like others who have devoted their lives to psychotherapy with adolescents, Cox reminds us that this work is not for the faint of heart. Finally, a new section, Letters to the Editor, appears in this issue, with two letters on Dwyer and Jarrel's article, the “Use of Mental Health Services By Youths Who Have Sexually Offended,” which appeared in the last issue (2011, pp. 240-250). I hope that this is the start of an ongoing dialogue between Adolescent Psychiatry and its readers.

The idea for a special section on eating disorders in adolescents emerged from the collaborative conversations and enthusiasm for learning that characterized the March 2011 ASAP meeting in New York City: 9-11 to 2011, A 10-year update on Adolescent Psychiatry. The focus of the conference and this special section is on the bridge from research to clinical practice. We stand at a unique moment in time with the treatment of eating pathology. For the first time since the codification of these illnesses in the medical literature (Gull, 1874), the treatment literature has made strides to provide clinicians with a clearer path on the ways to manage these disorders. Nowhere has this advancement been as great as in the treatment of children and adolescents. Fortunately, we stand in a position today to assist our youngest patients make strides toward recovery, even cure. Despite advances in treatment, the dissemination of these strategies to front-line clinicians and care workers continues to lag behind. Clinicians must flexibly attend to the needs of individual patients and families in a multitude of settings, while a plethora of available treatment options compete for attention. Effective clinical practice rests on the clinician%apos;s desire and ability to seek out support for nascent skills and new learning opportunities. Studies of dissemination and implementation, such as the work of Beidas and Kendall, 2010, outline important questions about how to bring information from research centers to clinicians and about how the training experience and organizational factors impact the implementation of interventions. While the gold standard for evidence- based practice in psychotherapy remains a scientifically evaluated protocol with a treatment manual, training workshop and supervision, it is clear that active learning is essential for clinicians to be able to deliver key interventions and develop the level of competence and skill required to improve outcomes for patients. Adolescent psychiatrists are uniquely positioned to take a leadership role in implementing effective treatments for patients with eating disorders. Clinical expertise in working with teens and families with comorbid disorders including anxiety, depression, and substance use disorders, combined with a flexible, positive attitude toward taking on challenges in treatment is a natural fit for training in eating disorder treatment protocols. Many clinicians are already familiar with training formats available for cognitive behavior therapy through places such as the Beck Institute, where Dr. Judith Beck uses role-plays and other techniques to promote active learning, and Dr. Aaron Beck demonstrates goal setting and other interventions during a clinical interview, followed by an open format for questions from workshop participants. Treatment manuals, intensive training and regular consultation are elements of an adherent protocol in dialectical behavior therapy. In the treatment of eating disorders, clinicians now have ready access to treatment manuals, workshops and supervision for two main empirically supported treatments: Lock and LeGrange's Family Based Treatment (FBT or “Maudsley” at http://www.Train2Treat4ED.com) and Fairburn's Cognitive Behavior Therapy-Enhanced: (http://www.psychiatry.ox.ac.uk/research/researchunits/credo/ forthcoming-training-workshops). Learning from mentors and gaining new skills informs not only specific areas of expertise but provides skills that may be generalized and applied across a wide range of disorders and practice settings. Perhaps training is best thought of as a parallel process to the treatment alliance, with bonding (maintaining an atmosphere of mutual positive regard), goals, and steps to achieving goals. Representing one such alliance, we (Drs. Kara Fitzpatrick and Julie Lesser), the two guest editors of this special section on eating disorders, worked together first as supervisor and supervisee in the training program for Family Based therapy for eating disorders. In putting together this special section on eating disorders in adolescents, the ingredients were in place for a synthesis and collaboration that spans disciplines, institutions, health care settings and generations. The aim was to bring together articles that inform the treatment of eating disorders from various perspectives, building upon current knowledge and interpreting well-known techniques in the treatment of eating disorder symptoms. The broad clinical utility of these skills are presented with a goal of encouraging clinicians to consider the significant rewards of working with eating disorder patients and their families. Fitzpatrick leads the section with an overview of FBT for children and adolescents with eating disorders. She gives an update on the clinical outcomes and research findings with this approach. In the paper, she outlines the forms of family based treatment and key interventions. Strategies to help empower families in refeeding while learning to separate the eating disorder thinking and illness from the child are described. Family based treatment has been successfully implemented in younger patients and in eating disorders with comorbid conditions. Despite the empirical support for the approach, there is still a shortage of trained clinicians. In the second paper, Dr. Beth Brandenburg and colleagues discuss the approach to psychopharmacological interventions in adolescents with eating disorders, an area where the research findings are sparse. The adolescent psychiatrist must draw upon clinical expertise in treatments for adults and adolescents with comorbid disorders. Special attention is directed to coordinating care with a primary medical physician, and other members of a multidisciplinary team. The paper presents guidelines for monitoring medications, the medical and safety status, and nutritional needs of the patient. The authors discuss the treatment targets, and potential side effects, risks and benefits of psychotropic medications in this population. Medication use is integrated with the primary psychotherapy treatment, with a careful eye on maintaining the treatment alliance, and knowing when to recommend a higher level of care.....

Family-based therapy or “Maudsley” has increasing evidence for its efficacy in the treatment of child and adolescent eating disorders. Available in manualized form, widely available, and supported by an ever-increasing research literature, the application of this outpatient treatment continues to be challenging for many front-line clinicians and is a fairly significant departure from previous treatment methods. The current article explores the research supporting this methodology and the iterations of this treatment, such as the use of multi-family groups, parent support groups or with non-psychiatric comorbidities. Further clinical guidance is provided to assist the clinician in identifying tips, strategies and techniques for success in implementation of these skills with families.

The purpose of this article is to review evidence-based pharmacological treatments for eating disorders with a special focus on the adolescent population. Eating disorders commonly present in adolescence, yet little published data are available to guide the adolescent psychiatrist. The use of medications in the context of evidence-based psychotherapeutic interventions and co-morbid psychiatric conditions will be discussed. Defined will be the unique role of the adolescent psychiatrist in orchestrating treatment by a multidisciplinary team, determining the appropriate level of care, monitoring safety, and evaluating treatment response. Risks and benefits of the use of pharmacological interventions in individuals who are malnourished or engaging in eating disordered behaviors, such as purging or laxative abuse, will be delineated along with proposed monitoring. Each potentially affected organ system will be addressed. Sequentially described is the existing evidence for use of medications for anorexia nervosa, bulimia nervosa, and binge eating disorder in adults and, where available, adolescents. Atypical antipsychotics, particularly olanzapine, have shown promise for adults with anorexia nervosa. However, in a recent trial of adolescents, no benefit for olanzapine over placebo was found. Several antidepressants have been shown to be effective treatments for bulimia nervosa, and fluoxetine has the FDA approval for treatment of this disorder in adults. Although fluoxetine has been deemed safe and effective in an open trial of adolescent patients, controlled studies in this population are lacking. Special considerations for the use of these medications in adolescents are discussed.

This article aims to provide background and theory supporting the use of a problem-solving, emotion regulation, and self-esteem module for children and adolescents with eating disorders. Eating disorders typically present in adolescence, and low self-esteem and perfectionism are hallmark features of eating disorder pathology. We will examine how low self-esteem and perfectionism interact and serve as risk factors as well as maintaining factors in eating disorders. Both features have distinctly been show to predict poor treatment response in eating disorders, as well as in depression and in certain anxiety disorders. We will review the limited existing models for treating low self-esteem and perfectionism in adults with eating disorders and potential problems of using these models with younger patients. Finally, we present a pilot intervention designed to be integrated into primary eating disorder treatments for patients where low self-esteem, mood intolerance, and problem-solving deficits may present difficulties with eating disorder treatment implementation or risk for relapse. This intervention is based on principles from established treatments, including Christopher Fairburn's cognitive behavioral therapy enhanced for eating disorders, Marsha Linehan's dialectic behavior therapy, Melanie Fennell's and Leslie Sokol's guides to overcoming low self-esteem, Aaron and Judith Beck's cognitive behavioral therapy, and anxiety and phobia treatments for children. We have used this 4 to 6 session interactive module in multi-family groups, family and individual sessions. We believe this will be an important intervention in the treatment of adolescents with eating disorders, and that it merits further study

Eating disorders (EDs) are serious illnesses whose treatment, particularly with children and adolescents, requires sophisticated integration of skills and techniques from the armamentarium of evidence-based treatments targeting EDs and associated symptoms. Especially difficult to treat are cognitive impairments, because they are both disease specific (e.g., cognitive distortions related to the body itself) and more general (e.g., difficulties with uncertainty). This paper discusses cognitive impairments in EDs that involve difficulty coping with uncertainty and the associated implications on emotional and behavioral functioning. A set of skills to assess and increase adaptive coping with uncertainty is discussed in depth. Clinicians are strongly encouraged to target cognitive difficulties such as intolerance of uncertainty in ED treatment, as they can otherwise significantly interfere with one of the strongest predictors of successful outcomes - behavior change.

Males have not received much attention in the eating disorders (ED) literature, and adolescent males have received even less. As a result, we have inappropriately extrapolated from the adult literature, and many commonly held assumptions have gone unchallenged. This paper discusses some of the most common assumptions made about EDs in adolescent males, and reviews the evidence for those assumptions. Specifically, the assumptions that (1) males account for 10% of ED cases; (2) ED behaviours are rare among adolescent males; (3) EDs are similar in males and females; (4) males are not subjected to media programming depicting physical ideals in the same way that females are; and (5) EDs are exclusively associated with female gender, are discussed. It now seems clear that while there are many more adolescent males in the community with EDs than estimates from clinical samples would suggest, there are insufficient data to allow us to draw conclusions about the similarity between male and female EDs. Males are subjected to media programming that prescribe an equally unattainable physique as for females, however, it may affect them indirectly. Finally, contrary to being feminine issues, EDs in males are sometimes related to factors usually associated with extreme masculinity, such as muscle mass and athleticism. While these opposing views are offered, in general, there are very little data from which to conclude and further research is encouraged.

Bipolar disorder (BD) is an uncommon, but not rare, psychiatric disorder, that often has its onset during adolescence. This disorder is associated with a significant burden of illness both during adolescence and in subsequent adult life. Although a serious and persistent mental illness, it can be treated effectively so that functional impairment is minimized. Early diagnosis and prompt and effective treatment is important. This article provides a brief overview of the diagnosis and treatment of this disorder. In addition to the various medications (mood stabilizing, antipsychotic), and psychosocial interventions that have demonstrated efficacy, the use of alternative forms of treatment, such as herbal supplements, may have a role as adjuncts in helping with mood and with sleep architecture.

Although marijuana dependency is probably the least severe of the drug dependencies in terms of acuity and severity of negative consequences, it is one of the most difficult to treat. In this paper I propose that some of the difficulty in treating marijuana dependency in adolescence is due to the adolescent's impairment in recognizing the negative effects of regular use. This impairment in recognizing impairment is the result of the combination of both the executive function cognitive deficits and that everything is experienced in a mild high state. Adolescents then begin to lose the capacity to make meaningful logical connections between their drug usage and its effects on their life. Understanding this process helps the therapist to tolerate the frustrations in treating these adolescents. Suggested treatment interventions are to first establish an initial period of abstinence for 3-4 weeks. This can be done by utilizing one or more of the following: parental limit setting with random urine drug screens, contingency management techniques, direct suggestions to try abstinence for a limited time, and/or positive program peer pressure that abstinence is necessary to be part of the group. After a period of abstinence, the usual therapy approaches of motivational enhancement therapy, cognitive behavioral therapy, family therapy, community reinforcement approach, 12-Step mutual help programs and pharmacotherapy of co-morbid disorders may become more meaningful. Other practical clinical interventions with case examples are described.

This article addresses the bioethical implications of child and adolescent mental health services for Guantanamo minor detainees, hitherto unexplored since the American War on Terror. First, the literature on child soldiers is reviewed as a standard to measure treatment of minor detainees. Next, frameworks for mental evaluations with children and adolescents are surveyed given the complexity of issues involved. Afterwards, the cases of Mohammed Jawad and Omar Khadr are analyzed through interviews with key informants. The article concludes that the American government can improve future treatment of child soldiers by tailoring medical services for children and adolescents, providing regular access to caregivers and systematically obtaining informed consent, enforcing least restrictive environments, and emphasizing rehabilitation to punishment.

Increasing awareness of the prevalence of mental illness in children and adolescents has been followed by an awareness of the global burden—economic and social, in addition to the suffering of individuals and their families. The Institute of Medicine recently acknowledged that insufficient attention has been paid to attempting to reduce the global burden of mental illness. In light of what we know about development and the important role of the family in promoting healthy development in children, it is crucial to support the role of the family. The author draws on his long career as a therapist, an administrator of clinical services, and a leader in mental health service agencies, as well as his personal experience as a father and grandfather, to present a comprehensive overview of what we know and what we need to do to promote mental health in our children and adolescents.

More than half a century since the creation of the first specialized units in the USA and the U.K., inpatient treatment of adolescents remains an illustrative example of the difficulties in integrating adolescent services in mental health care systems. Through a literature review, the various parameters of adolescent hospitalization in psychiatry are examined. Among the different “solutions”, admission to general (adult) psychiatry remains a realistic option, as long as the gap between child and adult psychiatry perpetuates the difficulties of older and post-adolescents in having access to inpatient treatment facilities. The report of an experience from Northern Greece of 253 admissions in a general psychiatric ward at a university general hospital gives the authors of this paper the opportunity for a discussion on this particular practice, and for reconsidering the main questions on adolescent hospitalization in general.

Objective: To retrospectively evaluate comorbid conditions including cognitive and social performance in a cohort of ADHD referred children and adolescents. Method: A population of 187 children and adolescents was referred to an outpatient clinic for Child and Adolescent Mental Health in Norway regarding attention deficit hyperactivity disorder (ADHD). Examinations of the population were done using interviews and questionnaires with parents, teachers, children and adolescents regarding ADHD. After a review of all the assessments, the children and adolescents were classified as ADHD (96) and non-ADHD (91). In addition, when available, cognitive performance was registered. Results: Seventy-one (74%) children and adolescents met the criteria for combined type ADHD (ADHD-C, both inattention and hyperactivity-impulsivity symptoms) and 21 (22%) predominantly hyperactive-impulsive type ADHD (ADHD-HI, hyperactivity-impulsivity). Referral age was from 6 to 18 years; 82% were boys. Nearly all of the ADHD group (93%) had comorbid conditions compared to half of the non-ADHD group (OR: 14; 95% CI 5.6 to 36, p=0.001). Disruptive behavior disorder, anxiety/stress related disorder and encopresis/enuresis were the main disorders. One out of three ADHD children had a low IQ, almost double as many as in the non-ADHD group (OR: 1, 5; 95% CI 0.5 to 3.9, p=0.5). Social dysfunctions were found in four out of five ADHD children. In an explorative binary logistic regression analysis with social dysfunction as the dependent variable and IQ, gender and ADHD/non-ADHD group as independent variables, a low IQ was the only predictable factor contributing to social dysfunction. Conclusions: The study provides evidence for ADHD children and adolescents with combined ADHD type (predominantly hyperactivity and impulsivity) associated with comorbid conditions being relevant to low cognitive performance and low social skills. Trial registration: Current Controlled Trials NCT01252446.

The recurrent nature of non-suicidal self-injury (NSSI) and its frequent association with multiple psychopathological conditions makes it a challenge for assessment and treatment. While the behavior can often be effectively addressed in a hospital setting, the short term stays that are typical in the current environment make it unlikely that therapeutic gains will be maintained following discharge. The result is often therapeutic nihilism, and a revolving door phenomenon, which can become a pathway to chronic psychiatric disability. However, if the hospital can be viewed as part of a continuum of community-based care, rather than a retreat from the community, it can play a valuable role in stabilization and improvement in adaptive functioning. The authors describe a hypothetical yet typical case of an adolescent admitted to the hospital for NSSI and review the clinical decision-making process that led to the development and implementation of an appropriate treatment plan.

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