Adolescent Problems

Developmental Issues and Treatment Approaches

prepared by Dr Elizabeth Cosgrave

2007

Some considerations before you make a start…

Engagement Nothing will work if you are not

engaged with the adolescent Engagement takes time Things that might help

Explain your role clearly What to expect from seeing you (be

specific & give examples)

Confidentiality Explain it at the beginning of the 1st

session, preferably with the parent also in the room

Be specific & give examples What you will & won’t tell parents

Establish ground rules What if your Mum rings me to ask how

you’re going? How do I contact you if you don’t turn up?

Language Explaining things

Needs to be simple, non-pejorative & not too jargonistic

Most adolescents won’t respond well to being asked to monitor their “dysfunctional cognitions”

Age-appropriate questioning (CBT) “what would you say to a friend who came to

you with this problem?” “If you surveyed 100 Year 9 students, would

they all have reacted in the same way you did?”

Homework Monitoring Sheets

Tailor them to the individual if at all possible, & involve the adolescent in this process

Completing Homework Non-completion is not necessarily a

poor prognostic indicator Adolescents will often complete

homework…of sorts

Dilemmas associated with working with adolescents Involvement of family

Who wants this & who is likely to benefit from this?

Making a diagnosis Diagnosing a personality disorder The use of medications Deciding when there is a problem

How to differentiate from normative adolescent development

Deciding when there is a problem - I

Is the adolescent distressed about the Sxs?

Is anyone else concerned? Who & why?

Is the problem having an impact on the adolescent’s functioning?

Do the Sx represent a change from the adolescent’s normal functioning?

Measure the frequency, intensity & duration of the problem/Sx

Deciding when there is a problem - II

What is the potential for the adolescent (or anyone else) to be seriously harmed by the problem?

Consider what is problem behaviour & what is developmentally normal experimentation Substance use Health risk behaviours View of selves as omnipotent

Depression in Adolescence-I Incidence of depression, attempted

suicide & completed suicide increases significantly in adolescence (cf. childhood)

Depressive symptoms experienced by 15-40% of adolescents

Evidence that early onset depression is a more serious form of the disorder

Depression in Adolescence-II Adolescent depression predictive

of a number of negative outcomes: Academic difficulties Delinquency Unemployment Substance use Forensic involvement

Adolescent Depression: the Myths “Adolescents don’t get depressed” “Depressed adolescents will just

get over it” “All adolescents will become

depressed at some stage because adolescence is a time of turmoil”

“(S)he’s just being lazy/grumpy/difficult to live with”

Risk Factors for Adolescent Depression-I

Previous MDE Being female Family Hx of psychopathology Stressful life events Low social support Subthreshold depressive Sx “out of sync” pubertal development

Risk Factors for Adolescent Depression-II

Other psychopathology (current or past)

Serious physical illness Previous suicide attempt “depressogenic” cognitive style

(pessimistic, internal, global, stable) Poor coping skills

Recognising depression in adolescents-I

Disturbance of mood: May be sad or gloomy, but also very

likely to be irritable May describe mood as “angry”,

“numb” or “nothing”

Recognising depression in adolescents-II Disturbance of thinking:

Self blame, self criticism Negative thoughts re future Difficulty making decisions

Time of important vocational choices Inability to think clearly

Time when organisational & cognitive demands increase

Memory & concentration problems Impact on schooling

Recognising depression in adolescents-III Disturbance of thinking (cont.):

Hypersensitive to feedback from others Perceived as criticism

Thoughts about being hurt, hurting oneself, dying or committing suicide

Useful to think of these along a continuum May manifest as ambivalence about living,

passive death wish or overt suicidality Need to assess for presence of other

health risk behaviours

Recognising depression in adolescents-IV Disturbance of behaviour:

Decrease in activity levels May no longer engage in extracurricular

activities Decrease in energy

May seem very drowsy or fall asleep in class

Tearfulness Agitation

May manifest as difficulty attending to a task until it is completed

Recognising depression in adolescents-V

Disturbance of behaviour (cont.): Change in social interaction Substance use Change in sleep &/or appetite Loss of sexual interest

Difficult to assess in adolescents Somatic complaints

May manifest as frequent visits to “sick bay”

Gender Differences in Adolescent Depression From adolescence, females twice as likely

to develop a depressive illness than males Gender differences in coping with

depressed mood (Nolen-Hoeksema) Ruminative vs. instrumental strategies

Gender differences in subjective meaning of puberty

Confluence of demands for adolescent females e.g., pubertal changes, school transition

Treating Adolescent Depression-I Evidence for the efficacy of CBT &

IPT & pharmacotherapy Adjunctive group and/or family

therapy can also be useful Important to provide psycho-

education for client and her/his family May need to address beliefs that

adolescent is just “lazy”

Treating Adolescent Depression-II Provide honest feedback to your client

Diagnosis (explain it) Formulation

Provide clear rationale for any treatment strategies you suggest This will hopefully maximise engagement &

likelihood of compliance Importance of using appropriate language Don’t be put off by the non-completion of

homework Be flexible with treatment strategies

Suicide in Adolescence-I There has been a steady increase in the

rates of youth suicide (15-24 years) in Victoria & Australia since 1960 in males, but not in females

Adolescent females more likely to attempt suicide than adolescent males

Gender differences in methods: Females more likely to overdose or jump from

heights or under vehicles Males more likely to use firearms & car

exhausts

Suicide in Adolescence-II A history of suicide attempts is a risk factor

for suicide completion ~50% of adolescents who attempt suicide will

make subsequent attempts Of those, between 0.1% & 11% will eventually

complete suicide The presence of psychopathology is a risk

factor for suicidality BUT: not all adolescents who attempt suicide are

depressed not all adolescents who are depressed are also

suicidal

Assessing for Suicide Risk in Adolescents-I There is no evidence that asking

someone about suicide will make them suicidal

Ideation Be frank

Plan Realistic? Perceived & actual lethality?

Intent How serious? Compare with plan & means

Assessing for Suicide Risk in Adolescents-II Means Despair & hopelessness Presence of psychopathology History of suicide attempts

Take thorough history Family history of suicide Suicide in community Significant psychosocial stressor

Consider adolescent’s perception of stressor

Assessing for Suicide Risk in Adolescents-III

Physical health Change in status, e.g., STD, HIV,

unplanned pregnancy, onset/exacerbation of chronic illness)

Coping skills Inflexibility, impaired ability to

generate possible solutions Impulsivity

Assessing for Suicide Risk in Adolescents-IV

Trust your clinical judgment If in doubt, consult with a

colleague Remember that confidentiality is

not absolute

Deliberate Self-Harm-I DSH is defined as hurting oneself with the

intention of inflicting pain, rather than to die e.g., cutting, burning, scratching skin, punching

walls, head banging Suicidality & DSH usually occur on a

continuum Important to conduct risk assessment, as

adolescents may not realise the potential lethality of the DSH

Deliberate Self-Harm-II Important to be flexible with your

definition of DSH when working with adolescents e.g., starving oneself, train surfing,

substance use, risky sexual practices Difficult to establish prevalence rates,

as young people don’t often seek medical advice for DSH & there is a lack of clarity about definition of DSH

Why Do Adolescents Engage in DSH? Expression of emotional turmoil Expression of self hatred Lack of ability to express difficult emotions

(sadness, anger, guilt, shame) As a means of feeling something if “numb” Physical pain welcome relief from

emotional pain Patterns of DSH can be hard to break

because usually involves facing intense emotions and/or memories

Managing DSH-for the clinician Highly anxiety-provoking for clinician Importance of self care Labour intensive for clinician Disrespectful attitudes of some

workers. Can be punitive, angry, disrespectful, not take the young person seriously or witholding of appropriate treatment

Managing DSH – for clients If in doubt, ask the adolescent why

(s)he engages in this behaviour Conduct a cost-benefit of DSH Acknowledge that the young person

is doing the best that (s)he can to manage intense emotional distress

If a pattern of DSH has been established, improvement will take time

Managing DSH – for clients Important to encourage clients

when they take small positive steps

Take them seriously Young people who engage in DSH

can & do accidentally kill themselves

Adolescent Substance Use - I Adolescence is a peak time for the initial

use of many substances, including tobacco, alcohol & illicit drugs

potential for serious sequelae: school failure medical problems psychiatric morbidity fatal accidents suicide violent crimes

Adolescent Substance Use - II Future patterns of drug use often

result from drug exposure and use in adolescence

incidence of illicit substance use in adolescents is increasing

evidence that “gateway” use (of cigarettes & alcohol) can lead to illicit substance use & SUD

Adolescent Substance Use - III

Australian studies consistently identify 1-2% of secondary students whose pattern of alcohol, tobacco or other drug use is problematic

having an initial episode of a SUD places adolescents at risk of developing subsequent episodes

Adolescent Alcohol Use Approximately 30% of Australian

adolescents engage in problematic alcohol consumption

alcohol-related deaths in young people are underestimated

alcohol use is higher in young people not enrolled in schools (cf. students)

Adolescent Cannabis Use Cannabis is the illicit drug that is

most commonly used by Australian adolescents

adolescents who use cannabis are more likely to progress to using other illicit substances

early cannabis use associated with escalation of use

Problems Associated with Use Habitual use can result in decrease

in functioning social stigma associated with use

can impact on availability of services health risks associated with illicit

substance use regulation of composition

Assessing Problematic Substance Use in Adolescents - I

Majority of adolescents do not develop problematic patterns of substance use

when assessing use, should be able to categorise use according to: initiation of use continuation of use maintenance & progression within class of

drugs progression across class of drugs cessation relapse

Assessing Problematic Substance Use in Adolescents - II

important to assess why the young person engages in substance use: relief from boredom weight control coping with stress avoiding negative emotional states conformity social reasons to avoid withdrawal

Assessing Problematic Substance Use in Adolescents -

III

Important to also assess misuse of legal substances (alcohol, inhalants) & prescribed medications if you don’t ask, they probably won’t tell you may need to educate yourself & client re

risks associated with pattern of use principles of motivational interviewing

are useful need to understand what the adolescent

thinks is good about using the substance

Managing Adolescent Substance Use

Don’t pretend you know which drugs are which - ask the adolescent if unclear

Acquaint yourself with the local drug & alcohol service, either individually or by setting up regular secondary consultation important to inform yourself & advise

client with accurate information (e.g., signs of intoxication, withdrawal, dangers of overdose, etc.)

Harm Minimisation

Common & useful policy of youth agencies in Australia cf. zero tolerance policy, common in US

some strategies are specific to particular substances (e.g., SSRIs & ecstasy, size of bags with chroming), but others are relevant to all substances

Harm Minimisation Principles Don’t use alone. Try to use with

friends & nominate one sober person know your limits (safe vs. unsafe

intoxication) dangers of illicit substance use use a regular dealer have a “taste” first, i.e., test

strength of substance (useful with heroin injection & ecstasy tabs)

Personality Disorders: Background Clients diagnosed with a PD have

historically been perceived as untreatable. This is not necessarily the case, but reflects the lack of RCTs in the area

lack of rigour associated with diagnosis of PDs complexity (time needed) importance of gathering information

across time (many clinicians don’t do this)

Personality Disorders: Background

Clients with PDs can evoke difficult emotions in clinicians

important difference between: Axis I (by definition episodic in nature) Axis II (by definition pervasive &

longstanding) definition of personality traits are “stable

& enduring” in PDs it is these that lead to distress or

impairment

Personality Disorders: Background

Important to assess how your client’s personality impacts upon those around her/him

for Dx of PD: need evidence that the client’s way of interacting is maladaptive

can be difficult to differentiate between a PD & an Axis I disorder, especially if Axis I disorder has an early onset & is stable over time e.g., social phobia & Avoidant PD

Personality Disorders in Adolescence Can be difficult to identify during this

time, as onset is usually in adolescence or early adulthood

difficulties associated with assessing how your client’s personality impacts upon those around her/him: nature of adolescent relationships can be

intense & rapidly changing frequent increase in conflict with parents:

evidence of PD or normative?

Eating Disorders in Adolescence - I

Symptoms usually emerge in adolescence (cf. low prevalence in childhood)

Associated with extensive mortality & morbidity 20% mortality rate for AN at 20yr

follow up symptoms usually stable over time

Eating Disorders in Adolescence - II

subthreshold symptoms are prevalent in a number of cultures 13% of US adolescents report purging predictive of full blown disorders subthreshold symptoms associated with

significant dunctional impairment dieting is a risk factor for the

developments of eating disorders 60% of Australian 15yo females diet at a

moderate level ( Patton et al., 1999)

Associated Features

Depressive Symptoms (especially for BN)

DSH Substance abuse Suicide attempts Poor school performance Withdrawal from peer relationships Deterioration in family relationships Physical complications *

Physical Complications - I

Amenorrhea Starvation syndrome

Reduced metabolic rate Bradycardia Hypotension Anaemia Intolerance to cold

Lanugo

Physical Complications - II Delayed gastric emptying Electrolyte abnormalities

Can lead to potentially fatal cardiac arrhythmia

Renal problems Erosion of dental enamel Oesophageal tears Reduction in bone density

Management of Eating Disorders

in Adolescents - I

Know how to calculate a BMI Be aware that I/P treatment may

be needed (especially for AN) Be ready to work in conjunction

with a medical practitioner Limitations of psychological

treatment if young person is physically compromised

Management of Eating Disorders

in Adolescents - II

Evidence for the efficacy of CBT & IPT in the treatment of BN May also need to treat comorbid depressive Sx

For AN literature is less clear Treatment is rarely brief

Adjunctive family therapy is often very useful

Use of support groups/organisations for families e.g., EDFV