Adolescent Psychiatry - Volume 9, Issue 3, 2019

Background: While practice parameters recommend assessment of conscience and values, few resources are available to guide clinicians. Objective: To improve making moral inquiry in youth aged 15 to 24. Methods: After documenting available resources for behavioral health clinicians who are inquiring about their patient’s moral life, we consider our studies of conscience development and functioning in youth. We align descriptions of domains of conscience with neurobiology. We compare youth reared in relative advantage, who have fairly smooth functional progressions across domains, with youth reared in adverse circumstances. We offer the heuristic conscience developmental quotient to help mind the gap between conscience in adversity and conscience in advantage. Next, we consider severity of psychopathological interference as distinct from delay. A case illustration is provided to support the distinction between conscience relevant and conscience sensitive approaches to psychiatric assessments. Results: Our findings support the hypotheses that youth who experience adverse childhood experiences show evidence of fragmentation, unevenness and delay in their conscience stage-attainment. We demonstrate proof of concept for conscience sensitive psychiatric assessment in the youth-span. Conscience sensitive inquiries improve upon merely conscience relevant interpretations by affording better appreciation of moral wounding, in turn setting the stage for moral-imaginative efforts that elicit and make the latent values of the youth more explicit. Conclusions: A conscience sensitive approach should be part of both psychiatric and general medical education, supported explicitly by clinical guidelines recommending conscience sensitive interview techniques that aim to acquire information aligned with current neurobiological terminology.

Background: Much of the literature on adolescent refugees has focused on their experiences of trauma, and trauma-focused psychotherapy has been emphasized. In addition to having experienced trauma, adolescents with refugee or migration backgrounds are confronted with distinct challenges in the process of identity formation. These problems result from the normal processes of identity formation and restructuring during adolescence (the socalled second individuation phase) complicated by their transition from their culture of origin to the new culture. This process has been called a third individuation phase. These teenagers live on the border between two worlds and are called borderland adolescents. Methods: This paper describes the developmental processes of young migrants, using case examples to illustrate how the migrant experience affects development, particularly identity development. Discussion: Splitting, which is part of normal adolescent development, also occurs during the process of adaptation to a new culture. Although the process of splitting can support the integration into the new culture, it can also lead to dangerous polarization with borderline features. It is important to take this into account in psychotherapeutic work with borderland adolescents.

Background: The need to develop clinical and empirically-based tools for assessing personality development in adolescence led to the proposal of the IPOP-A (Ammaniti, Fontana, Kernberg, Clarkin, & Clarkin, 2011), a semi-structured interview for adolescents that aims to differentiate personality organization processes from characteristics that may reflect a personality disorder. Objective and Methods: This research aimed to evaluate the adaptation of the IPOP-A to the Portuguese population, attending to its diagnostic properties and its discriminant validity by comparing a clinical group with a nonclinical one. A total sample of 44 adolescents from 13 to 18 years old has taken part in this study, 22 of whom had a previous personality disorder diagnosis. The content of the interviews was transcribed and codified according to the coding manual. Results: Acceptable internal consistency values across the dimensions of the IPOP-A are found and statistically significant differences are revealed between the clinical group and nonclinical group, with the clinical group revealing values that suggest higher impairment in the dimensions of the personality functioning in comparison with the nonclinical one. Conclusion: Our study supports that the Portuguese version of the IPOP-A can be considered a valid instrument to identify adolescents with a personality disorder.

Background: Young people carry mental health problems disproportionate to the size of their population, and rates of help-seeking are low. School mental health programs have been developed to address these issues, founded on an educational approach to target mental health literacy, and indirectly improve help-seeking. However, it has been suggested that knowledge does not necessarily predict health behaviour in young people. Objective/Methods: A cross-sectional study was conducted to explore whether knowledge about mental illness was related to attitudes towards mental illness and intentions to seek help in a sample of adolescent girls (N=327). Results: Results indicated a weak negative relationship between knowledge about mental health and stigmatising attitudes about mental illness, but no relationship between knowledge about mental health and intentions to seek help for mental health problems. When mental health was categorised (e.g., optimal vs. poorer mental health), a negative relationship between knowledge about and stigmatising attitudes toward mental health was shown in those with poor mental health, but not for adolescents categorised as having moderate or optimal mental health. Conclusion: Findings suggest that while the traditional adage - more information on mental health equals better attitude to mental health - may be true for those with ‘poorer’ levels of mental health (e.g., high levels of psychological distress), it may not reduce stigma associated with mental illness or motivate positive health behaviour in adolescent girls with ‘optimal’ mental health (e.g., low or no levels of psychological distress).

Background: Prevalent adolescent digital media use has brought clinical attention to its potential associated risks. While excessive digital media use has been connected to adolescent difficulties with mood and impulsivity, no study has examined digital media’s role in precipitating adolescent psychiatric admissions. Objective: Our study aims were to identify and characterize digital media-related admissions in a sample of psychiatrically hospitalized adolescents, and to recognize unique patterns of digital media use within this sample. We hypothesized that adolescents with digital mediarelated admissions would endorse higher amounts of digital media use and problematic online behaviors. Methods: We administered a cross-sectional survey of psychiatrically hospitalized adolescents between 2012 and 2016. Admissions were considered related to digital media use either by adolescent report or documentation in the medical record. Unadjusted comparisons were used to examine relationships between digital media-related psychiatric admissions, online behaviors and suicide-related risk factors. Results: 68 of 218 participants (31.2%) had digital media-related admissions. The most frequent cause of digital media-related admission was cyberbullying (31.9%). Teens with digital- media related admissions were significantly more likely to sext, use social media, and be cyberbullied; these adolescents were also at increased risk of suicide planning and hopelessness. Conclusion: Efforts should be made by mental health clinicians to identify and address online relational conflict, as well as to screen for cyberbullying and sexting. Clinicians should consider that adolescents with digital media-related presentations may be at elevated risk of self-harm, with higher rates of suicide planning and hopelessness compared to hospitalized peers with admissions unrelated to digital media.

Background: Few studies on gender-based diagnostic characteristics of adolescent suicide attempters in emergency departments (EDs) have included individuals with autism spectrum disorder (ASD). Objective: This study aimed to examine the clinical features of adolescent suicide attempts in EDs, focusing on gender differences and considering individuals with ASD. Methods: Ninety-four adolescent patients, aged less than 20 years, who had attempted suicide and had been hospitalized in an emergency department, participated in this study. Psychiatric diagnoses according to DSM-IV criteria and clinical features were compared between male and female patients. Results: The number (%) of males was 15 (16.0), and that of females was 79 (84.0). The mean age (SD) of males was 17.1 (1.5), and that of females was 16.9 (1.6). The attempt methods were more serious, length of stay in the emergency room longer, and rate of outpatient treatment lower in males. In addition, suicide attempters with ASD were significantly more frequent in male. Adjusting for age and gender, adjustment disorder was significantly associated with the presence of suicide attempters with ASD using a multivariable logistic regression. Conclusion: Males were less likely to visit psychiatric service previous to attempting suicides, and may be likely to complete suicides. In addition, suicide attempters with ASD are characteristic in male, and likely to have comorbid adjustment disorder. ED visits offer a window of opportunity to provide suicide prevention interventions for adolescents, and therefore, psychiatrists in EDs have a crucial role as gatekeepers of preventing suicide reattempts, especially in adolescent males including individuals with ASD having adjustment disorder.

Background: Hashimoto’s encephalopathy (HE) is a debilitating manifestation of an autoimmune reaction against the thyroid that rarely can present with prominent psychiatric symptoms. It is often under-diagnosed primarily due to its variety of symptoms as well as a lack of definitive diagnostic criteria. Methods: We report the case of a 13-year-old girl who was diagnosed with HE after presenting with recurrent and severe psychosis with fever and a thyroidopathy. The patient had prominent visual hallucinations and paranoid delusions. Between episodes, the patient did not show evidence of psychiatric symptoms. This patient struggled with several incorrect diagnoses and treatments for two years before the correct diagnosis of HE was made and displayed marked improvement upon corticosteroid administration. Discussion: This case illustrates the importance of increasing awareness of HE as well as including HE in a differential diagnosis when paediatric patients present with psychosis and concurrent thyroidopathy.