Adolescent Psychiatry - Volume 10, Issue 3, 2020

Purpose: The field of psychiatry has conventionally employed a medical model in which mental health disorders are diagnosed and treated. However, the evidence is amassing that using a strengths-based approach that promotes wellness by engaging the patient’s assets and interests may work in synergy with the medical model to promote recovery. This harmonizes with the patient-centered care model that has been promoted by the Institute of Medicine. Methods: The article uses a clinical case to highlight the attributes of a strength-based model in the psychiatric treatment of adolescents. Results: Outcome metrics from a number of studies have demonstrated enhanced youth and parent satisfaction and decreased use of hospital level of care with the implementation of strengths-based therapeutic modalities. Implications: Incorporating strengths-based interventions into conventional psychiatric practice provides a multi-faceted treatment approach that promotes recovery in children and adolescents with psychiatric disorders.

Background: Studies have shown the practicality of diagnosing borderline personality disorder (BPD) in children from the age of 12 years (cf. ICD-11, DSM-5). Research in the psychodynamic therapy of adolescents with BPD has been rare to date, however, there do exist some studies on the efficacy and effectiveness of psychodynamic therapy in adults with borderline personality disorder. Methods: We adapted the psychoanalytic-interactional method (PiM), originally developed in the treatment of severely disturbed adults, to the conditions of adolescents diagnosed with borderline personality disorder or structural deficits. Randomized controlled trial in an inpatient setting (Salzer et al., 2013; Salzer et al., 2014) showed that PIM is efficacious for adolescents with BPD symptoms. We describe the approach to treatment in detail. Results: The results of the therapeutic study and the short case vignette show that PiM is a useful method in both inpatient and outpatient treatment and meets the specific requirements of adolescent treatment.

Background: Suicide is the second leading cause of adolescent death and suicide attempts outnumber deaths 50:1 for adolescents 15 to 19 years of age. This study examines differences in outcomes between adolescents and adults treated at an adult trauma center in an effort to guide recovery and prevention strategies following an adolescent suicide attempt. Methods: Retrospective review of patients aged ≥14 years treated at an urban, Level 1 trauma center for self-inflicted injuries between 2009 and 2018 was performed. The cohort was divided into adolescents (14-19 years) and adults (≥20 years) and into group A (economically distressed) and group B (non-distressed). Demographics, injury, outcomes, and geospatial analysis were compared. Results: Among 723 patients, 60 (8%) were adolescents of which 92% were male, 55% black, 47% blunt injuries, and 53% penetrating. In adults, 76% were male, 41% black, 28% blunt injuries, and 72% penetrating. Mortality estimates for adolescents and adults were 35% and 24%, respectively (p=0.09). Most adolescent deaths occurred within 3 days after admission, while adult deaths occurred further into hospitalization (p<0.01). Cox regression analysis found higher mortality with self-pay compared to private insurance (HR 2.6; p<0.001), and penetrating vs. blunt/other injuries (HR 2.4; p<0.001). Psychiatric care was administered in 64% of adolescents (n=39) and 84% of adults (p< 0.01). Conclusion: Inpatient psychiatric care for adolescents who attempted suicide was limited at an adult trauma center. The high incidence of suicide attempts and community-level distress in adolescents require immediate attention and resources.

Background: Family background, social support and psychological characteristics are known to be associated with depression in adolescence, but scientific data in complex, naturalistic settings are scarce. Objective: To investigate the characteristics of adolescent psychiatric inpatients with depressive disorders compared to peers without psychiatric disorders and to adolescent psychiatric inpatients without depression. Methods: The study population of 206 inpatients (13-17 years old) and 203 age and gendermatched non-referred adolescents was evaluated using the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version (K-SADS-PL) interview, and clinical interview and clinical records when available. Structured self-reports provided information on family background, defense styles, self-image and perceived social support. We compared firstly subjects with current depressive disorders (n=120) to subjects without any psychiatric disorder (n=159) and secondly within the inpatient population, those with depressive disorders (n=117) to those with any other psychiatric diagnoses (n=89). Results: Current depressive disorders were characterized by worse self-image, less mature defenses and less perceived social support particularly from the family. Adversities in the family were more prevalent in subjects with depression compared to subjects without any psychiatric diagnosis, while among inpatients, no significant differences were observed. Psychiatric comorbidity was common in all inpatients, whereas suicidality was more prevalent among inpatients with depression. Conclusion: Negative self-image, less mature defense style and low perceived social support particularly from the family were characteristics of depression in adolescents.

Background: Body dysmorphic disorder encompasses a range of cognitive and behavioural states stemming from distressing, negative evaluations of one’s appearance. Despite the seriousness of this condition, little is known about who is likely to receive a diagnosis and more importantly what the putative risk factors are. This is particularly so among adolescent samples, where the extant literature is considerably smaller. Objective: This study had two broad aims: to estimate the prevalence of body dysmorphic disorder within a young-adult population, and to examine the predictors of body image disturbance. Methods: Three-hundred and four adolescents (242 females; Mage = 17.68) completed the Body Image Disturbance Questionnaire and Body Dysmorphic Disorder Questionnaire, along with measures of clinical psychopathology, self-esteem, experiences of parenting, and bullying. Results: Body dysmorphic disorder was present in 3.9% of the sample, which is in line with previous estimates among adolescents. More interestingly, results indicated that instances of high stress, low self-esteem, and reported experiences of bullying were able to predict 48% of body image dissatisfaction. Conclusion: Psychological interventions should be directed towards adolescents with body image concerns, especially if they also report bullying, elevated stress, or diminished selfesteem. However, additional research is still warranted to gain an increasingly accurate understanding of the prevalence of body dysmorphic disorder and who is susceptible to developing this disorder and how we can best serve these individuals in the community.

Objective: This study explores the differences in the association between three different types of aggression (reactive aggression, power-related proactive aggression and affiliation- related proactive aggression) and emotional and conduct problems between early adolescents with immigrant and non-immigrant backgrounds in Norway. Methods: The sample comprised 1759 early adolescents in fifth to eighth grade (10- to 15- year-olds). The proportion of early adolescent immigrants with two foreign-born parents was 862, and 897 participants were adolescents with two Norwegian-born parents. The gender distribution was similar in the immigrant and non-immigrant samples, 48.2% boys and 49.5% girls. The mean age was 11.6 years (SD 1.25) for immigrant boys, 11.7 (SD 1.29) for non-immigrant boys, 11.6 (SD = 1.25) for immigrant girls, and 11.8 (SD = 1.27) for nonimmigrant girls. Data were collected via self-report assessments. Results: A multigroup structural equation model revealed that the effects of reactive and proactive aggression were different for conduct and emotional problems. Only reactive and power-related proactive aggression was significantly associated with conduct problems, and effect sizes were independent of immigrant status. The effects of reactive and power-related proactive aggression on emotional problems were stronger for non-immigrant early adolescents, while the effects of affiliation-related proactive aggression were stronger for immigrant- background early adolescents. Conclusion: A better understanding of the underlying mechanisms of the associations between aggression and emotional problems and the variation between immigrant and nonimmigrant early adolescents can shed light on the etiology of mental health and behavioral problems. The importance of such knowledge in designing interventions targeting aggression among early adolescents in multicultural contexts is discussed.

Background: Anti-NMDA receptor (NMDAR) encephalitis is an autoimmune syndrome characterized by a well-described constellation of neuropsychiatric symptoms. Its exact pathophysiology is poorly understood, but it is thought to be mediated by autoantibodies against NMDA (N-methyl-D-aspartate)-type glutamate receptors in the central nervous system. There is ongoing literature to suggest that patients with autism spectrum disorder (ASD) have evidence of neuroinflammation—or by definition, encephalitis. Objective: To investigate the link between autism spectrum disorder and autoimmune encephalitides. Methods: We present a case of anti-NMDA receptor encephalitis in a patient with autism spectrum disorder. “OP” is a 16-year-old male with a history of attention-deficit/ hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) who presented with a 3-day history of acute-onset altered mental status, electroencephalogram (EEG)-corroborated seizures, and slurred speech. Laboratory studies were significant for serum- and cerebrospinal fluid (CSF)-positive NMDA antibodies. The child psychiatry consult-liaison service was consulted for significant agitation and behavioral dyscontrol. We recommended 1:1 observation for safety, as well as antipsychotic agents titrated to clinical effect. The patient had a protracted hospital course, but was eventually discharged to an acute rehabilitation facility for continued stabilization and therapy. Conclusion: It remains to be seen if the relation between encephalitis and ASD is uni- or bidirectional, that is: whether children with ASD have a genetic diathesis to developing encephalitides (such as those mediated by the NMDAR), or conversely, if deranged or inflamed neuroreceptor processes are implicated in the development of ASD.