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