Adolescent Psychiatry - Volume 3, Issue 4, 2013

Background: The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the DSM- 5, was approved by the Board of Trustees of the American Psychiatric Association (APA) on December 1, 2012, and released on May 18, 2013. The DSM-5 is the first major edition of the manual in nearly twenty years. Although designed for use in the United States, the DSM diagnostic system is widely used around the world. Objectives: To summarize the changes to the overall structure and conceptualization of the DSM-5. Methods: The author reports on information disseminated at training sessions for psychiatrists representing their District Branches held at the APA’s 2013 Annual Meeting. This is the first in a series of articles that will describe and explain the changes introduced into the DSM-5. This article focuses on the “metastructure” of the DSM-5. Conclusions: The DSM-5 differs in many fundamental ways from previous versions of the manual, and reflects an ongoing attempt to bring psychiatry into the mainstream of medicine as well as to adapt to anticipated continuing rapid changes within the field.

Background: Marijuana is the most commonly used illicit substance in the United States and worldwide. Marijuana use is a problem of increasing magnitude among adolescents. Use typically begins in adolescence and is associated with a variety of adverse outcomes. Method: This article will present an overview of trends in marijuana use, and will review the endocannabinoid system and marijuana. It will discuss recent policy developments in US and their implications, especially for adolescents. Existing treatments will be reviewed, including findings from a recent randomized double-blind trial of N-acetylcysteine, a compound that reverses the dysregulation of the glutamate system that occurs in substance dependence. Conclusions: The core treatment approaches include psychosocial interventions, sometimes in combination with each other. While a reduction in days of use is often achieved with most of these approaches, abstinence is a much more elusive goal. The evidence base for effective treatments remains inadequate especially with regard to adolescents, and there is an urgent need for more research in this area. Promising new treatments include N-acetylcysteine in conjunction with contingency management.

Background: Concussions (also known as mild traumatic brain injuries, MTBI) are common among adolescents, especially those who play sports. While often considered non-serious injuries, they can result in significant impairment in functioning. Neuropsychiatric symptoms, including cognitive impairment, behavioral dysfunction, and psychiatric disorders are among the most common sequelae. Method: This article presents an overview of what is known at this point and makes recommendations regarding assessment and management. Results: The knowledge base has expanded rapidly concerning risk factors, sequelae and neurobiology of MTBI. It is still underdeveloped regarding treatment, especially with regard to adolescents. Nonetheless, it is possible to extrapolate from the research on adults to develop a rational approach to management. Conclusions: Key aspects of management include education and support for patients and families, teaching coping skills, and making academic accommodations. There is a limited role for psychopharmacologic approaches in conjunction with a comprehensive multidisciplinary approach. Most patients will recover but treatment must be individualized to address the patient’s specific problems and concerns.

Background: Although United States still has the highest rate of juvenile incarceration in the world, the population of incarcerated juvenile offenders has been falling as there has been a recognition and implementation of “best practices” that involve alternatives to incarceration and reduce recidivism. Many of these practices are adaptations from those that have proven effective with adult offenders. Methods: This article will explain juvenile justice system terminology and identify common ground between the adult and juvenile offender populations. It will discuss the concept of criminogenic risks and needs, and identify interventions that “work” in terms of reduced recidivism and present the Risk/Need/Responsivity model currently being used in both adult and juvenile justice systems. Conclusions: Although there is a high rate of mental illness among juvenile offenders, factors responsible for criminal behavior are specific to cognitive and behavioral characteristics that are shared among offenders regardless of psychiatric status. Attention to these factors is essential for successful rehabilitation of juvenile offenders. Effective evidence-based approaches exist for juvenile offenders. These involve a range of interventions that modify criminogenic factors and behaviors. Targeting antisocial thinking is essential.

Background: Becoming a mother when one is still an adolescent interrupts the process of adolescent development. These difficulties are made more serious by the traumatic effects of the previous experiences of mistreatment and/or abuse. The child’s development is threatened by the fact that, in addition to being a possible target for the re-enactment of the mistreatment, she also serves as a container for the needs and projections of her mother, and is not able to mentalize. Method: This article examines the psychodynamic aspects of maternity in these adolescents, the interrelation between mother and child and their effects on the emotional development of the child. It describes and illustrates with case examples a therapeutic approach that focusses on the mother–child dyad. The treatment method is designed for children aged 0 to 2.5 and their adolescent mothers. It takes into account the difficulty of reaching adolescent mothers with traditional psychotherapy and integrates the acquisitions of the attachment theory and the studies of the early infant development. The therapeutic interventions (once a week for 60 minutes over two years) take place at the mother’s home. The therapists’ interventions are designed to help the mother recognize the child’s needs and signals, correct the distortions in the perceptions of the child, diminish splitting, promote the emergence of conflict in the relationship and elaborate instead of acting out them, getting in touch with one’s split off traumatic experiences and give voice to the baby. Results: The presentation of some case material will demonstrate the methodological approach, show the improvement in the relationship between mother and child, its transformations and the mother’s new capacity of mentalization. Conclusion: The treatment encourages the mothers to take back the projections they had been subjecting their children to, reprocess their own traumatic experiences and, consequently, resume their adolescent development, as well as providing support for the children, thereby breaking the chain of abuse.

Objective: There are estimated to be between 6 and 14 million homosexual parents in the U.S. It is likely that therapists will encounter families with same sex parents in their work. The question of whether the parents’ sexual orientation has any effect on their children is an important one for society and is often an issue in custody determinations. Methods: This article reviews the relevant research and gives recommendations for therapists working with same sex parents and their adolescent children. Conclusions: The current scientific literature supports a lack of detrimental effect of parents’ sexual orientation on their adolescent children. However, there are multiple limitations to this literature. Most data is taken from three longitudinal studies and focusses on families with lesbian mothers. More research is needed on families with gay fathers, and more emphasis should be placed on the direct assessment of adolescents.

Background: Most of the interventions developed for adolescents with learning disorders (LDs) focus on enhancing cognitive and learning skills. However, these adolescents have been usually found to score high on measures of insecure attachment orientations. Objectives: The purpose of the current analysis was to examine changes in attachment orientations towards parents, attachment- related representations of teachers, and feelings of loneliness among adolescents with LD during an open trial of a psychological intervention for adolescents diagnosed with learning disorders (the “I Can Succeed” program, or ICS). ICS aims to target both academic and emotional functioning. Methods: Participants included 40 adolescents with LD and their parents. Measures included Attachment to parents (Kerns); Attachment representations of teachers (Children’s Appraisal of Teacher as a Secure Base (CATSB); and Loneliness (Peer-Network Loneliness and Peer-Dyadic Loneliness Scale (PNDLS). Adolescents completed questionnaires before the ICS Intervention (baseline), at the end of the acute phase (end of treatment) and at a six months follow-up meeting (follow-up). Results: The main results of the current study indicate that 6 months after the “I Can Succeed” intervention, there was improvement in LD students’ attachment security to mothers, appraisals of homeroom teacher as a security-enhancing figures (more acceptance and less rejection), and satisfaction with relationships with peers and friends (lower dyadic loneliness scores). One practical implication concerns the use of attachment theory as a foundation upon which to develop interventions among adolescents with LD.

Background: Substance using juvenile offenders have some of the highest rates for engaging in risky sexual behaviors compared to other adolescent subgroups. Methods: An overview of the literature on sexual risk behaviors among these youth is provided, including the empirical support for including caregivers/parents as critical partners in sexual risk reduction efforts with this population. In particular, there is (a) evidence that family factors contribute to adolescent sexual risk, (b) emerging support for caregiver focused interventions that target adolescent sexual risk, and (c) established support for caregiver focused interventions that target other complex adolescent behavior problems. In addition, this paper presents preliminary results from a randomized controlled trial evaluating a family-based intervention for substance using juvenile delinquents that combines contingency management (CM) for adolescent substance use with a novel sexual risk reduction (SRR) protocol. Results through six months post-baseline (corresponding with the end of treatment) are presented for intervention fidelity and outcomes including number of intercourse acts (Sex Acts), use of condoms or abstinence (Safe Sex), and obtaining HIV testing (Testing). Conclusions: In comparison to youth focused group substance abuse treatment, the CM-SRR intervention was associated with significantly greater therapist use of SRR techniques and greater caregiver involvement in treatment sessions (supporting treatment fidelity) and significantly lower increases in Sex Acts (supporting treatment efficacy). There were also higher odds for Safe Sex and for Testing, although these results failed to reach statistical significance. Findings add to the growing literature supporting the feasibility and efficacy of caregiver focused interventions targeting sexual risk behaviors among high-risk adolescent populations.