Adolescent Psychiatry - Volume 8, Issue 2, 2018

Background: Increasing numbers of adolescents and college students are presenting with complaints of symptoms suggestive of attention deficit hyperactivity disorder (ADHD; Harrison, Edwards & Parker, 2007). These individuals have often not been previously evaluated for ADHD during childhood, which can complicate assessment. This is further compounded by the lack of a consistent pattern on neuropsychological testing as well as the lack of rating scales with adequate diagnostic sensitivity and specificity to ADHD (Harrison et al., 2007). The differential for symptoms of inattention and hyperactivity is broad and includes ADHD, non-ADHD psychiatric disorders that mirror ADHD and malingering of ADHD symptoms for secondary gain. The purpose of this paper is to explore these diagnostic categories and discuss diagnostic challenges for ADHD in this age group. Methods: A review of the literature was conducted utilizing MEDLINE and PsycINFO searches. Keywords included ADHD, attention deficit hyperactivity, adolescent, college, university, assessment, diagnosis, diversion, malinger and feign. A total of 46 papers primarily targeting adolescents and college student populations are included in this review. Results: 46 articles were published in peer-reviewed journals describing ADHD symptoms in adolescents and college students. The articles were all published in or after 1991. All participants had either symptoms of ADHD or a diagnosis of ADHD with diagnostic assessments ranging from clinical interviews, neuropsychological assessment and use of rating scales. Discussion and Conclusions: Initial diagnosis of ADHD in adolescent and young adult populations is challenging. Childhood histories can be useful in identifying ADHD in older adolescents and college students, including history of executive functioning deficits, social skill deficits, increased emotional problems, early development concerns, behavioral problems, and family history of ADHD. It is important to evaluate carefully for comorbidities and other causes of ADHD symptoms, including depression, anxiety, bipolar disorder, disruptive mood dysregulation disorder, sleep disorders, medical disorders, and substance abuse etiologies. If non-ADHD psychiatric disorders are present, it may be worthwhile to treat these disorders first. Finally, there are increasing concerns for malingering of ADHD symptoms for secondary gain, particularly to obtain stimulant medications for academic and recreational purposes. Unfortunately, ADHD symptoms can be feigned on self-report instruments, clinical interviews, and objective testing. Clinicians should utilize a combination of strategies to ensure the accuracy of diagnosis, including clinical interviews that emphasize early childhood history and current academic performance, as well as objective and validity tests that are able to discriminate between ADHD and malingered symptoms. Prescribers should also establish routine clinic practices to reduce diversion such as requiring regular appointments, conducting periodic urine drug screens, using prescription monitoring services, and delaying initial stimulant prescriptions until an ADHD diagnosis is thoroughly established.

Background: Antidepressants are widely used to treat adolescent depression, despite ongoing debates regarding their efficacy for youth. In this back and forth, surprisingly little attention has been paid to measurement issues. Though seemingly basic, careful consideration of measure selection and related assessment decisions is critical to evaluating antidepressants as a treatment option for adolescents. Objectives: The objectives of the current review are to 1) highlight the psychometric quality of commonly used assessment measures in randomized controlled trials (RCTs) and 2) discuss pertinent assessment issues that may impact conclusions drawn regarding antidepressant efficacy. These issues include consistency of findings across measures, selection of an index of symptom change, choice of symptom reporter, and time to assessment follow-up. Methods: This review discusses the quality of widely used assessment measures and highlights how findings from RCTs differ based on assessment decisions. Conclusion: Measures and measurement decisions impact conclusions drawn when evaluating antidepressant effectiveness. Even some of the most commonly used measures in RCTs have limited evidence for reliability and validity, calling into question findings derived from those measures. Additionally, antidepressants are inconsistently found to outperform placebo, with only a quarter of comparisons finding antidepressants to be statistically superior. Results are even less promising when looking at youth- or parent-report and longterm follow-ups. The review concludes by providing suggestions for improving assessment of antidepressant effectiveness for youth.

Background: Research on factors contributing to a patient's length of stay on youth psychiatric inpatient units is relatively scarce and increasingly dated given changes in health care. Objective: Hence, the current exploratory study attempts to take a step at identifying variables that are associated with length of stay for youth on an inpatient psychiatric unit in order to generate hypotheses for future larger-scale multisite research. Method: A chart review was conducted on consecutive admissions to an academic medical center youth psychiatric inpatient service from September 2011 to June 2014. Analyses are for 1,201 consecutive admissions (M age = 13.37, SD = 2.79), who were predominantly African American (54.0%) and female (58.3%). Results: Significant variables were entered into a hierarchical linear regression organized by variable category (i.e., patient characteristics, diagnostic/disease related, treatment-related characteristics, clinical caregiver characteristics, and characteristics or properties of the healthcare system). The final model accounted of 23% of the variance. Significant variables included insurance status, psychotic disorder, adjustment disorder, receiving pro re nata (PRN) medication for agitation during admission, being on a standing antipsychotic, change in attending from intake to discharge, presence of certain attendings during admission, and discharge to day hospital program or residential treatment center. Conclusion: These variables provide provisional information suggesting that factors from multiple categories are related to length of stay including patient characteristics, diagnosis, treatment-related, clinical caregiver, and healthcare system. It is critical to take into account factors both internal and external to the child when developing an understanding of length of youth psychiatric hospitalization.

Background: Although adolescents at risk of developing psychosis may have access to many standard treatments, it is also important to investigate the efficacy and sustainability of new specific interventions working on self-image, identity and social skills. Objectives: The aim of this pilot study is to assess the possible efficacy and the sustainability of the a novel intervention, VideoTherapy (VDT), combined with a treatment of proven efficacy, metacognitive treatment (MT). Methods: In this pilot study we created a Video Therapy (VDT) treatment protocol to work on Identity and Self-image. Through the use of an iPad, individuals were asked to interact with their Image reflected in the screen. VDT was carried out in this work in combination with metacognitive group treatment to improve social competence, recognize and manage the automatic biases active in the interaction with the external world, and to reduce social withdrawal. The study involved 18 youths at risk, between 12 and 21 years of age. A preand post- treatment evaluation was conducted through the administration of tests and questionnaires. Results: The intervention was found to be sustainable and could be implemented in association with standard treatments. Active participation from patients was observed. They engaged well with the activity, giving positive feedback. Improvement in social skills as well as in anxiety, depression and aggressive behavior occurred. Conclusion: Results from this study are encouraging for the development and improvement of the VDT protocol. The main strengths of the intervention are that they are relatively inexpensive and easy for clinicians to apply. The use of new tools that are familiar to the adolescents, such as the iPad, made the novel treatment attractive and interesting for participants. The next recommended step would be to apply the study on a wider and more representative sample.

Background: While cyberbullying has been tied to mental health problems, there is a lack of research related to this phenomenon and associated psychopathology among the adolescent inpatient psychiatric hospital population. Objective: To examine the relationship between cyber aggression, cyber victimization, and depression among adolescents (N = 100) in an acute inpatient psychiatric setting. Method: We utilized the Cyber Peer Experiences Questionnaire and the Center for Epidemiological Studies- Depression Scale to obtain information related to cyberbullying and depression. Results: The findings indicate 95% prevalence rate of cyber victimization and 94% prevalence rate of cyber aggression among participants, during the previous two months. The findings also indicated there was a significant difference between the association of gender and cyber victimization (t = 4.12, df = 69, p = 0.01) and gender and cyber aggression (t = 2.36, df = 48, p ≤ 0.02). Ninety nine percent of females reported experiencing cyber victimization (M = 25.53) at least once in the previous two months, compared to 87% of males (M = 20.10). Additionally, 97% of females reported participating in cyber aggression (M = 20.31) at least once in the previous two months, compared to 87% of males (M = 17.73). The findings also indicated a significant association between cyber victimization and depression (r = 0.218, p ≤ 0.03) and adolescents who reported experiencing cyber victimization were significantly likely to engage in cyber aggression (r = .555, p ≤ 0.01). Conclusions: Inpatient psychiatric hospitals need to update assessment and treatment procedures to account for the impact cyberbullying has on the adolescent population.

Background and Goals: Cannabis is the most widely illicit substance around the world. Treatment success is predicted by different factors, among which, motivation for changing the behavior is one of these factors. Therefore, identifying the client's readiness to change is important. Working with clients that are in precontemplation stage of change constitutes a big challenge for therapists. Methods: In this paper, we present the case study of Joao, a young adult with cannabis use disorder, comorbid with social anxiety. The therapeutic intervention followed the principles of motivational interviewing, highly recommended with clients less ready to change. It also combined techniques from cognitive-behavioral therapy and narrative therapy, to help separate the client from the problem, thus helping him to construct a more fulfilling life. Throughout the article, the subjective viewpoints of the client will be highlighted, in the form of micronarratives written by the client, suggested as therapeutic tasks. Discussion/Results: Several challenges were faced while addressing resistance and ambivalence, early on and throughout treatment. Joao dropout in the 23rd session, after achieving some therapeutic gains. Changes in his self-talk, documented in the micronarratives, served as indicators that his relationship with cannabis started to change. The therapeutic tasks suggested were important in helping him to increase motivation for change and to write new paths for his life. Conclusion: It is crucial to adjust the therapeutic interventions to the client's readiness to change, and continuously reflecting about the therapeutic process, addressing moments of disengagement, early on, to increase the probability of behavior change.