Textbook of Adolescent Psychiatry (Arnold Publication)

Textbook of adolescent psychiatry

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Textbook of adolescent psychiatry Edited by

RICHARD ROSNER MD Clinical Professor, Department of Psychiatry, New York University School of Medicine Director, Forensic Psychiatry Residency, New York University Medical Center Medical Director, Forensic Psychiatry Clinic, Bellevue Hospital Center President (2003–2004) American Society for Adolescent Psychiatry New York, NY, USA

A member of the Hodder Headline Group LONDON

First published in Great Britain in 2003 by Arnold, a member of the Hodder Headline Group, 338 Euston Road, London NW1 3BH http://www.arnoldpublishers.com Distributed in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2003 Arnold All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1T 4LP. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies’ printed instructions before administering any of the drugs recommended in this book. Finally, nothing in this book is to be considered as the rendering of legal advice for specific cases, and readers are responsible for obtaining such advice, or directing that such advice be obtained, from their own or their patient’s legal counsel. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 0 340 80924 8 1 2 3 4 5 6 7 8 9 10 Commissioning Editor: Serena Bureau Development Editor: Layla Vandenbergh Project Editor: Anke Ueberberg Production Controller: Deborah Smith Cover Design: Stewart Larking Typeset in 10/12 Minion by Charon Tec Pvt. Ltd, Chennai, India Printed and bound in the UK by Butler & Tanner Ltd What do you think about this book? Or any other Arnold title? Please send your comments to [email protected]

To the new generation: John Hannon Rose, James Prescott Rose, Anne Elizabeth Rose Kathryn Pearl Cahn Alexander Edward Streich Rebecca Anne Rosner Rayzel Beryl Rosner, Romayne Ann Rosner Jett Bond Rosner

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Contents

Preface List of contributors

xi xiii

SECTION 1 SPECIAL ISSUES IN ADOLESCENT PSYCHIATRY Edited by Robert Weinstock

1

1.1

The emergence of the adolescent patient Vivian M. Rakoff

3

1.2

Ethical issues in adolescent psychiatry Robert Weinstock, Gregory B. Leong, and J. Arturo Silva

10

1.3

Ethics in managed care in adolescent psychiatry Jeremy A. Lazarus

19

1.4

Research in adolescent psychiatry Daniel Offer and Caryn Stoller

26

1.5

Cultural influences on adolescent development and treatment J. Arturo Silva, Gregory B. Leong, and Robert Weinstock

31

1.6

Post-traumatic stress disorder in adolescents Mohan Nair

36

1.7

Consultation–liaison psychiatry with adolescents Everett P. Dulit

45

1.8

Principles of adolescent medicine for psychiatrists Martin M. Anderson and Robert E. Morris

51

1.9

The history of adolescent psychiatry in the United States Bertram Slaff

68

1.10

Adolescent psychiatry as a psychiatric subspecialty Sidney Weissman, Sharon Weissman, and Kathryn Weissman

73

1.11

Education and training in adolescent psychiatry Richard Rosner

76

SECTION 2 RISK BEHAVIOR, RISK-TAKING, AND SEXUALITY Edited by Lynn E. Ponton

83

2.1

Normal sexual development Alayne Yates

85

2.2

Adolescent risk-taking and risk behavior Lynn E. Ponton and Ralph J. DiClemente

93

viii Contents 2.3

Alcohol and substance abuse among adolescents: prevention and intervention Donald A. Paoletti, Katharine E. Stewart, and Ralph J. DiClemente

101

2.4

Adolescent violence: implications for intervention Arlene Rubin Stiffman, Jennifer A. Abeloff, Ester B. Kaggwa, Donald E. Meissner, Michael G. Regier, and Catherine A. Winn

112

2.5

The effects of sexual abuse on adolescent development and adaptation Graeme Hanson

125

2.6

Pregnancy and parenthood during adolescence Larry K. Brown and Kevin J. Lourie

132

2.7

High-risk sexual behavior associated with sexually transmitted diseases and human immunodeficiency virus infections among adolescents Ralph J. DiClemente

2.8

Adolescent homosexuality William M. Womack

SECTION 3 NORMAL DEVELOPMENT Edited by Donald A. Swanson

145 155

163

Introduction Donald A. Swanson

164

3.1

Sociocultural issues in adolescent development Ian A. Canino and Nilda M. Gonzalez

165

3.2

Cognitive development Humberto Quintana

171

3.3

Adolescent moral development Roy Lubit and Stephen B. Billick

180

3.4

Adolescent interpersonal relationships Christopher J. Kratochvil and Martin J. Harrington

193

SECTION 4 ASSESSMENT OF THE ADOLESCENT Edited by Gary J. Gosselin

199

Introduction Gary J. Gosselin

200

4.1

The clinical interview of the adolescent Gary J. Gosselin and Yiu Kee Ng

201

4.2

Family assessment Richard A. Oberfield

207

4.3

Psychosocial assessment Gary J. Gosselin and Yiu Kee Ng

215

4.4

Medical assessment Elizabeth Kay Spencer

221

4.5

Biological assessment Brian J. Klee

226

4.6

Psychological assessment Alan S. Elliot and Enrique Gular

231

4.7

Cultural assessment Phill V. Halamandaris and Tanya R. Anderson

237

Contents ix 4.8

Educational assessment Edward A. Mainzer

243

4.9

Assessment and treatment planning Glenn S. Hirsch and Richard Gallagher

248

SECTION 5

CLINICAL CONDITIONS: PSYCHIATRIC DISORDERS IN CHILDHOOD, ADOLESCENCE AND YOUNG ADULTHOOD Edited by Richard M. Sarles

255

5.1

Pervasive developmental disorders and adolescence Harinder S. Ghuman and Jaswinder K. Ghuman

257

5.2

Obsessive–Compulsive Disorder and Tourette’s Syndrome in children and adolescents Mai Karitani, Kenneth C. Rickler, Douglas A. Beer, Susan E. Swedo, and Henrietta L. Leonard

265

5.3

Anxiety disorders during adolescence Mohammad Haerian, Gloria Reeves, and Sushma Jani

278

5.4

Mood disorders and suicide in children and adolescents Paramjit T. Joshi and Jay A. Salpekar

284

5.5

Eating disorders and disordered eating Lynn E. Ponton

295

5.6

Personality disorder in adolescence Glen T. Pearson

303

5.7

Disruptive behavior disorders David Mullen and Robert L. Hendren

315

5.8

Adolescent substance abuse Marsha E. Bates and Robert L. Hendren

328

5.9

Psychotic disorders Lois T. Flaherty

341

SECTION 6

PSYCHIATRIC TREATMENT Edited by Michael G. Kalogerakis

347

Introduction Michael G. Kalogerakis

348

6.1

Forming a therapeutic alliance with teenagers Ghislaine D. Godenne

349

6.2

Cognitive behavior therapy with adolescents David B. Wexler

357

6.3

Psychoanalytically informed psychotherapy for adolescents Shelley R. Doctors

366

6.4

Adolescent psychopharmacology Glen R. Elliott

373

6.5

Family therapy Richard A. Oberfield

383

6.6

Group psychotherapy with adolescents Paul Kymissis

390

6.7

Adolescent inpatient and other milieu treatments Alan Ravitz

397

x Contents 6.8

Community-based treatment Harinder S. Ghuman, Lance D. Clawson, and Mark D. Weist

403

6.9

Multimodal dynamic psychotherapy and the adolescent’s world Michael G. Kalogerakis

410

SECTION 7

ADOLESCENT PSYCHIATRY AND THE LAW Edited by Richard A. Ratner

417

Introduction Richard A. Ratner

418

PART 1

LEGAL ASPECTS OF MENTAL HEALTH TREATMENT

421

7.1

Legal issues in inpatient and outpatient psychiatric treatment Abigail English

423

7.2

Custody, visitation and relocation issues in adolescence Alex Weintrob and Sandra G. Nye

430

PART 2

MENTAL HEALTH IN LEGAL SETTINGS

441

7.3

The juvenile justice system: delinquency and status offenders Wade C. Myers

443

7.4

The psychiatrist in the juvenile justice system: evaluation of offenders Richard A. Ratner

450

7.5

Treatment of juvenile offenders Lee H. Haller

456

PART 3

SPECIAL PROBLEMS IN DELINQUENCY ASSESSMENT AND TREATMENT

463

7.6

Substance abusers Steven L. Jaffe

465

7.7

Violent offenders Rusty Reeves

470

7.8

Adolescent sex offenders Roy J. O’Shaughnessy

482

7.9

Juveniles and the adult criminal justice system: transfer/waiver to adult court Carl P. Malmquist

489

7.10

Juveniles and the adult criminal justice system: the death penalty Richard A. Ratner

495

7.11

Dependency court: the handling of abuse and neglect cases Kathi L. Grasso

499

Index

504

Preface

The Textbook of Adolescent Psychiatry has been edited as an independent project by members of The American Society for Adolescent Psychiatry (ASAP). The editors and authors have sought to set forth areas of general agreement (wherever possible) and to describe as fairly as is feasible the major contending views on those topics that lack consensus. The Textbook of Adolescent Psychiatry is offered as one constructive response to the problem of insufficient numbers of personnel able to address the mental health needs of adolescents. The Textbook of Adolescent Psychiatry is designed to be a foundation work in the field; that is, to provide the core, essential information needed by competent mental health practitioners and administrators. The intended audience includes: (1) practicing general psychiatrists, psychologists, clinical psychiatric social workers, and mental health administrators responsible for the assessment and treatment of adolescents; (2) adolescent psychiatry specialists who want a convenient, one-volume reference book to assist them in their work; (3) residents in general psychiatry taking an extended elective in adolescent psychiatry; (4) residents in adolescent psychiatry specialty programs; (5) residents in combined child and adolescent psychiatry specialty programs; (6) psychiatrists preparing for the specialty examination of the American Board of Adolescent Psychiatry, Inc.; (7) forensic psychiatrists, forensic psychologists and forensic clinical psychiatric social workers seeking to acquire additional competence in the evaluation and treatment of adolescents in the juvenile and adult criminal and civil justice systems; and (8) judges, attorneys, probation officers, parole officers and administrators of juvenile and adult detention centers.

The Textbook of Adolescent Psychiatry is of special relevance for forensic practitioners because the Family and Domestic Relations Courts, the Criminal Courts, the juvenile justice detention system, and the adult criminal justice detention system all contain a large population of adolescents with under-served mental health needs. The Textbook of Adolescent Psychiatry was initially proposed by ASAP’s Accreditation Council on Fellowships in Adolescent Psychiatry (ACFAP). The feasibility of developing this textbook initially was demonstrated by the Syllabuses assembled by Mark Chenven MD for the Review of Adolescent Psychiatry educational programs that he organized and implemented for several of ASAP’s annual conventions. While Dr. Chenven’s materials ultimately were not used in this book, the editors of this volume are indebted to him for the model provided by those Syllabuses.

Suggested reading Carnegie Council on Adolescent Development: Great Transitions: Preparing Adolescents for a New Century: Concluding Report. Carnegie Corporation of New York, New York, 1995. Rosner, R., Schwartz, H. (eds), Juvenile Psychiatry and the Law. New York: Plenum Publishing Corporation, 1989. Rosner, R. Report of the Accreditation Council on Fellowships in Adolescent Psychiatry. In Flaherty, L., Horowitz, H. (eds), Adolescent Psychiatry, Volume 21. Hillsdale, NJ: The Analytic Press, 1997, pp. 389–407.

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List of contributors

Jennifer A. Abeloff MSW MS Miami, FL USA Martin M. Anderson MD MPH Professor of Pediatrics Director, Adolescent Medicine Program David Geffen School of Medicine and Mattel Children’s Hospital University of California Los Angeles, CA USA Tanya R. Anderson MD Assistant Professor of Psychiatry Associate Director Comprehensive Assessment and Response Training System Department of Psychiatry University of Illinois Chicago, IL USA Marsha E. Bates PhD Research Professor Rutgers University Center of Alcohol Studies Piscataway, NJ USA Douglas A. Beer MD Director, Child and Adolescent Psychiatry Elmhurst Hospital Center Elmhurst, NY USA Stephen B. Billick MD Clinical Professor of Psychiatry New York Medical College Vice President and Treasurer American Society for Adolescent Psychiatry New York, NY USA

Larry K. Brown MD Associate Professor Bradley/Hasbro Research Center Department of Psychiatry Rhode Island Hospital Brown University School of Medicine Providence, RI USA Ian A. Canino MD Deputy Director of Training Division of Child and Adolescent Psychiatry Clinical Professor of Psychiatry College of Physicians and Surgeons Columbia University New York, NY USA Lance D. Clawson MD Private Practice Cabin John, MD USA Ralph J. DiClemente PhD Charles Howard Candler Professor Rollins School of Public Health and Emory University School of Medicine Department of Psychiatry and Behavioral Sciences Department of Pediatrics Division of Epidemiology, Infectious Diseases and Immunology Associate Director Center for AIDS Research Emory University School of Medicine USA Shelley R. Doctors PhD Faculty and Supervising Analyst Institute for the Psychoanalytic Study of Subjectivity Faculty and Supervisor Institute for Child, Adolescent and Family Studies Faculty and Supervisor National Institute for the Psychotherapies, Adult Program in Psychoanalysis and Psychotherapy, and Child and Adolescent Training Program

xiv List of contributors Secretary The International Society for Adolescent Psychiatry New York, NY USA Everett P. Dulit MD PhD Emeritus Clinical Associate Professor Department of Psychiatry Albert Einstein College of Medicine Yeshiva University New York, NY USA Alan S. Elliot PhD Clinical Assistant Professor of Psychiatry Director, New York University, Bellevue Internship Program in Psychology Department of Psychiatry New York University School of Medicine Director, Child and Adolescent Psychology Service Division of Child and Adolescent Psychiatry Bellevue Hospital Center New York, NY USA Glen R. Elliott PhD MD Associate Professor and Director Children’s Center at Langley Porter University of California, San Francisco San Francisco, CA USA Abigail English JD Director, Center for Adolescent Health & the Law Chapel Hill, NC USA Lois T. Flaherty MD Lecturer on Psychiatry Harvard University Cambridge, MA Adjunct Associate Professor of Psychiatry University of Maryland Baltimore, MD Past President American Society for Adolescent Psychiatry USA Richard Gallagher PhD Assistant Professor of Psychiatry Director, The Parenting Institute NYU Child Study Center Coordinator of Cognitive Behavior Therapy Training Division of Child and Adolescent Psychiatry Department of Psychiatry New York University School of Medicine New York, NY USA

Harinder S. Ghuman MD Professor of Psychiatry and Pediatrics Director, Child and Adolescent Psychiatry The University of Arizona College of Medicine Tucson, AZ USA Jaswinder K. Ghuman MD Associate Professor of Psychiatry and Pediatrics Director, Infant and Preschool Program The University of Arizona College of Medicine Tucson, AZ USA Ghislaine D. Godenne MD LFAPA Professor of Psychology, Psychiatry, Pediatrics and Mental Hygiene Johns Hopkins University Director Emerita of Counseling and Psychiatric Services Johns Hopkins University Clinical Professor of Psychiatry University of Maryland School of Medicine Baltimore, MD USA Nilda M. Gonzalez MD Director, Psychiatry PDD Psychopharmacology Clinic Assistant Professor of Child Psychiatry Department of Psychiatry, Kennedy Krieger Institute Johns Hopkins School of Medicine Baltimore, MD USA Gary J. Gosselin MD Chief, Adolescent Inpatient Unit Division of Child and Adolescent Psychiatry Bellevue Hospital Center Clinical Assistant Professor of Psychiatry Department of Psychiatry New York University School of Medicine New York, NY USA Kathi L. Grasso JD Former Director, Child and Adolescent Health Law Program American Bar Association Center on Children and the Law Washington, DC USA Enrique Gular PhD Director of Psychology Gouverneur Hospital Clinical Assistant Professor of Psychiatry New York University School of Medicine New York, NY USA

List of contributors xv Mohammad Haerian MD Associate Professor Division of Child and Adolescent Psychiatry University of Maryland, School of Medicine Baltimore, MD USA Phill V. Halamandaris MD Clinical Assistant Professor of Psychiatry Department of Psychiatry New York University School of Medicine New York, NY USA Lee H. Haller MD Clinical Associate Professor of Psychiatry and Behavioral Sciences George Washington University School of Medicine Clinical Assistant Professor of Psychiatry Georgetown University School of Medicine Washington, DC USA Graeme Hanson MD Clinical Professor of Psychiatry and Pediatrics University of California Langley Porter Psychiatric Institute Director of Training for Child and Adolescent Psychiatry University of California San Francisco San Francisco, CA USA Martin J. Harrington MD Assistant Professor of Psychiatry Division of Child and Adolescent Psychiatry University of Nebraska Medical Center Omaha, NE USA Robert L. Hendren DO Professor of Psychiatry Executive Director, MIND Institute Chief, Child and Adolescent Psychiatry University of California Davis Sacramento, CA USA Glenn S. Hirsch MD Assistant Professor of Psychiatry Medical Director NYU Child Study Center New York University School of Medicine Medical Director Division of Child and Adolescent Psychiatry Bellevue Hospital Center New York, NY USA

Steven L. Jaffe MD Professor of Psychiatry Emory University School of Medicine Clinical Professor of Psychiatry Morehouse School of Medicine Atlanta, GA USA Sushma Jani MD Baltimore, MD USA Paramjit T. Joshi MD Chair, Department of Psychiatry and Behavioral Sciences Children’s National Medical Center Professor of Psychiatry, Behavioral Sciences and Pediatrics George Washington University School of Medicine Washington, DC USA Esther B. Kaggwa MSW Silver Spring, MD USA Michael G. Kalogerakis MD Clinical Professor Department of Psychiatry New York University School of Medicine Past President American Society for Adolescent Psychiatry Past President International Society for Adolescent Psychiatry New York, NY USA Mai Karitani AB Child and Family Psychiatry Rhode Island Hospital Providence, RI USA Brian J. Klee MD Assistant Professor of Clinical Psychiatry Department of Psychiatry New York University School of Medicine New York, NY USA Christopher J. Kratochvil MD Associate Professor of Psychiatry Assistant Director Psychopharmacology Research Center University of Nebraska Medical Center Omaha, NE USA

xvi List of contributors Paul Kymissis MD Clinical Professor of Psychiatry and Pediatrics New York Medical College Chief of Psychiatry, Children’s Village Dobb’s Ferry, New York, NY USA Jeremy A. Lazarus MD Clinical Professor of Psychiatry University of Colorado Health Sciences Center Denver, CO USA Henrietta L. Leonard MD Professor of Psychiatry and Human Behavior Director of Training Child and Adolescent Psychiatry Brown University School of Medicine Rhode Island Hospital Providence, RI USA Gregory B. Leong MD Clinical Professor of Psychiatry University of Washington School of Medicine Seattle, WA Staff Psychiatrist Center for Forensic Services, Western State Hospital Tacoma, WA USA Kevin J. Lourie PhD Director, Child and Family Services Toll Gate Psychiatric Associates Warwick, RI Investigator, Brown University School of Medicine Brown University Department of Anthropology Providence, RI USA Roy Lubit MD PhD Assistant Professor, Department of Psychiatry Mount Sinai School of Medicine New York, NY USA Edward A. Mainzer MA MSEd EdD School Counselor, Manhattan Transition Center Manhattan School for Career Development New York City Department of Education New York, NY USA Carl P. Malmquist MD MS Professor of Social Psychiatry Department of Sociology University of Minnesota Minneapolis, MN USA

Donald E. Meissner MSW St Louis, MO USA Robert E. Morris MD Professor of Pediatrics Department of Pediatrics David Geffen School of Medicine at UCLA University of California Los Angeles Los Angeles, CA USA David Mullen MD Mental Health Programs Department of Psychiatry, School of Medicine University of New Mexico Albuquerque, NM USA Wade C. Myers MD Associate Professor of Psychiatry and Chief Division of Forensic Psychiatry, University of Florida Gainesville, FL USA Mohan Nair MD Assistant Clinical Professor of Psychiatry University of California Los Angeles School of Medicine Los Angeles, CA USA Yiu Kee Ng MD Director, Special Needs Clinic New York Presbyterian Hospital Assistant Clinical Professor of Psychiatry Columbia University College of Physicians and Surgeons New York, NY USA Sandra G. Nye JD MSW Formerly Assistant Professor of Jurisprudence in Psychiatry Abraham Lincoln School of Medicine Lecturer Jane Addams School of Social Work University of Illinois Principal Law offices of Nye and Associates Ltd. Chicago, IL USA Richard A. Oberfield MD Clinical Associate Professor of Psychiatry Child Study Center, Department of Psychiatry New York University School of Medicine Chief, Pediatric Psychiatry Unit Division of Child and Adolescent Psychiatry Bellevue Hospital Center

List of contributors xvii Director, Family Therapy Unit Bellevue Hospital Center New York, NY USA Daniel Offer MD Professor of Psychiatry Northwestern University Medical School Chicago, IL USA Roy J. O’Shaughnessy MD Clinical Director Youth Forensic Psychiatric Services Ministry for Children and Families Province of British Columbia President (2002–2003) American Academy of Psychiatry and the Law Bayswater Group Vancouver, BC Canada Donald A. Paoletti MD Grayson & Associates, PC Birmingham, AL USA Glen T. Pearson, Jr MD Medical Director, Youth and Family Centers Dallas Independent School District Clinical Professor Department of Psychiatry University of Texas Southwestern Medical School at Dallas Dallas, TX USA Lynn E. Ponton MD Professor of Psychiatry Department of Psychiatry and Langley Porter Psychiatric Institute University of California San Francisco, CA USA Humberto Quintana MD Associate Professor of Psychiatry Department of Psychiatry Louisiana State University Health Science Center School of Medicine at New Orleans New Orleans, LA USA Vivian M. Rakoff MD MB BS FRCP(C) Professor Emeritus Center for Addiction and Mental Health University of Toronto Toronto, ON Canada

Richard A. Ratner MD Clinical Professor of Psychiatry and Behavioral Sciences The George Washington University School of Medicine Past President American Society for Adolescent Psychiatry Washington, DC USA Alan Ravitz MD Associate Professor of Psychiatry Director of Child and Adolescent Inpatient Psychiatry University of Chicago Chicago, IL USA Gloria Reeves MD Assistant Professor Division of Child and Adolescent Psychiatry University of Maryland, School of Medicine Baltimore, MD USA Rusty Reeves MD Assistant Professor of Psychiatry University of Medicine and Dentistry of New Jersey Newark, NJ USA Michael G. Regier MSW Washington University School of Medicine St Louis, MO USA Kenneth C. Rickler MD Clinical Associate Professor Department of Clinical Neurosciences Department of Psychiatry and Human Behavior Brown University School of Medicine Providence, RI USA Richard Rosner MD Clinical Professor of Psychiatry Department of Psychiatry New York University School of Medicine Visiting Professor of Psychiatry Department of Psychiatry Albert Einstein College of Medicine Yeshiva University Adjunct Clinical Professor of Psychiatry Department of Psychiatry New York Medical College Lecturer Department of Psychiatry College of Physicians and Surgeons Columbia University

xviii List of contributors Medical Director Forensic Psychiatry Clinic Department of Psychiatry Bellevue Hospital Center Director, Forensic Psychiatry Residency, New York University Medical Center President (2003–2004) American Society for Adolescent Psychiatry New York, NY USA Jay A. Salpekar MD Director, Outpatient Services Department of Psychiatry and Behavioral Sciences Children’s National Medical Center Assistant Professor of Psychiatry & Behavioral Sciences and Pediatrics George Washington University School of Medicine Washington, DC USA Richard M. Sarles MD Professor of Psychiatry and Pediatrics Division of Child and Adolescent Psychiatry University of Maryland, School of Medicine Baltimore, MD Past President American Society for Adolescent Psychiatry USA J. Arturo Silva MD Staff Psychiatrist National Center for Post-Traumatic Stress Disorder Clinical/Education Division Palo Alto Veterans Health Care System, Menlo Park Division Palo Alto, CA USA Bertram Slaff MD Clinical Associate Professor Department of Psychiatry Mount Sinai School of Medicine, New York Past President American Society for Adolescent Psychiatry New York, NY USA Elizabeth Kay Spencer MD Clinical Assistant Professor of Psychiatry Department of Psychiatry New York University School of Medicine New York, NY USA Katharine E. Stewart PhD MPH Associate Professor of Health Behavior and Health Education Associate Dean of Student and Academic Affairs College of Public Health

University of Arkansas for Medical Sciences Little Rock, AR USA Arlene Rubin Stiffman PhD Barbara A. Bailey Professor of Social Work George Warren Brown School of Social Work Washington University St Louis, MO USA Caryn Stoller MD Chief Resident Department of Psychiatry Northwestern University Medical School Chicago, IL USA Donald A. Swanson MD Director of Child and Adolescent Psychiatry University of Nebraska Medical Center Department of Psychiatry Omaha, NE USA Susan E. Swedo MD Chief, Pediatrics and Developmental Neuropsychiatry Branch National Institute of Mental Health Bethesda, MD USA Robert Weinstock MD Clinical Professor of Psychiatry University of California Los Angeles School of Medicine Los Angeles, CA USA Alex Weintrob MD Past President American Society for Adolescent Psychiatry Clinical Associate Professor of Psychiatry Cornell University Medical College New York, NY USA Sidney Weissman MD Professor and Director of Psychiatric Residency Training Department of Psychiatry and Behavioral Sciences Feinberg School of Medicine Northwestern University Academic and Clinical Progams and System Analyst VISN 12 Veterans Health Administration Chicago, IL USA Sharon Weissman MS Kathryn Weissman MA

List of contributors xix Mark D. Weist PhD Professor and Director School Mental Health Program Department of Psychiatry University of Maryland School of Medicine Baltimore, MD USA

William M. Womack MD Associate Professor Department of Psychiatry and Behavioral Sciences Division of Child Psychiatry University of Washington School of Medicine Seattle, WA USA

David B. Wexler PhD Executive Director Relationship Training Institute San Diego, CA USA

Alayne Yates MD Professor of Psychiatry Division of Child and Adolescent Psychiatry Department of Psychiatry Queen’s Medical Center Honolulu, HI USA

Catherine A. Winn MSW Raleigh, NC USA

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SECTION

1

Special issues in adolescent psychiatry EDITED BY ROBERT WEINSTOCK

1.1

The emergence of the adolescent patient Vivian M. Rakoff

3

1.2

Ethical issues in adolescent psychiatry Robert Weinstock, Gregory B. Leong, and J. Arturo Silva

10

1.3

Ethics in managed care in adolescent psychiatry Jeremy A. Lazarus

19

1.4

Research in adolescent psychiatry Daniel Offer and Caryn Stoller

26

1.5

Cultural influences on adolescent development and treatment J. Arturo Silva, Gregory B. Leong, and Robert Weinstock

31

1.6

Post-traumatic stress disorder in adolescents Mohan Nair

36

1.7

Consultation–liaison psychiatry with adolescents Everett P. Dulit

45

1.8

Principles of adolescent medicine for psychiatrists Martin M. Anderson and Robert E. Morris

51

1.9

The history of adolescent psychiatry in the United States Bertram Slaff

68

1.10 Adolescent psychiatry as a psychiatric subspecialty Sidney Weissman, Sharon Weissman, and Kathryn Weissman

73

1.11 Education and training in adolescent psychiatry Richard Rosner

76

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1.1 The emergence of the adolescent patient VIVIAN M. RAKOFF

My grandmother – and probably also your great-grandmothers – was married at the age of sixteen years. She was neither a delinquent nor promiscuous (although the retroactive virginalization of the old and deceased seems to be an atavistic and normative mechanism of idealization). She was in fact my grandfather’s second wife, and she took her place after the death of his first wife, her older sister, during childbirth – an ancient and accepted arrangement about which I never heard a single word of complaint, either directly or indirectly. She assumed the responsibility of her sister’s surviving daughter and immediately started to bear her own family. She had her own son before my grandfather left for South Africa. He worked there for ten years before sending for her to join him – and, when she finally did, she immediately became pregnant and had, as fast as is humanly possible, another three sons. My grandfather was probably aged eighteen years when he got married. Altogether he fathered six children. All this happened at the turn of the century, and it is not a particularly remarkable story as it can be reduplicated thousands of times. Nor was it true only of poor Eastern European Jews. Young lords and ladies were locked into marriage and childbearing at about the same age, and also peasants and workers in Europe were fixed in their niches – economic, geographic, and marital – very early in life. Where, one asks, were the opportunities for ‘authenticity,’ the temptations into ‘identity diffusion,’ the experimental role playing and, explorations of the adolescent ‘moratorium’? Compared with many of her contemporaries, my timid grandmother was a great adventurer. She left her hometown village and voyaged with two children to the end of the earth. Although context clung to her like the clods of earth adhering to the roots of a fallen tree, and although she may not have known anything about the revolutionary process responsible for her voyaging, she was, in her modest way, one of the makers of a new way

of realizing life’s possibilities. But did she or thousands like her have, in our terms, an ‘adolescence’? To ask the question – let me say right off – is not to invalidate the concepts. After all, the playfulness of a relatively unencumbered ‘good enough’ childhood and the normative dependence and modestly expressed sexuality are real, even though for much of mankind child labor, begging, shepherding, gooseherding, mine working, chimney sweeping, silk cocoon unraveling, lace making, domestic labor, newspaper vending, and so on might have seemed to appallingly common – so almost universal – that the whole notion of psychology of a dependent, nurtured childhood could be questioned, radically questioned and discussed either as a bourgeois luxury or as an interesting but isolated anthropological curiosity. Even babyhood and infancy are not inescapably ‘given’; the psychological, sociological, and biological components are variously expressed (Aries 1962). However, we know – sociology, anthropology, and economics aside – that the epigenetic unfolding of infancy, childhood, puberty, adolescence, and adulthood as purely biological phenomena is universal. Babies are small and vulnerable, their survival predicated on an ethological choreography of signals sent back and forth between parent (mother) and babe, a hard-wired near reflex pattern of interchange that allows a noisy, dirty, almost parasitic stranger, a consumer of time, energy, sleep, and economic resources, to be perceived as valuable, delightful, cute, and a source of joy. That is a baby! The child is obviously malleable and growing, not yet wise enough or strong enough for true independence, capable of being helpful or exploitable, but not full grown mentally, physically, or sexually. And it is clear that childhood comes to an end with puberty. The endocrine storm works its well-known transformational magic, and out of a process that metaphorically recapitulates labor, or from another point of view adumbrates the legend of a phoenix, the child gives birth to a new changed

4 Special issues in adolescent psychiatry

but continuing self – the adolescent, the hairy, sexually fired, intellectually adept adolescent – the focus of our preoccupations. Something, however, sets the adolescent phase, stage, or condition apart from the preceding stages; infancy manifestly comes to an end with weaning, walking, and speech; childhood ends with puberty. With the census of 1851, the British authorities declared fifteen years to be the end of childhood and, after that, adulthood began. In modern terms, adolescence begins with puberty; but where does it end? The other stages have an inescapable biological framework, a strong physical cage that contains all the varieties of anthropological and economic circumstance, which will affect both somatic and psychological characteristics. Poor nutrition, lack of opportunity, and disaster may all affect the potential capacities of infant and child, but they will remain, however distorted, recognizably as being within a particular life state. The adolescent phase is curiously indeterminate in its later boundary. Indeed, the entity itself has been recognized or labeled as a discrete life stage only very recently. Aries places its specific recognition at the end of the nineteenth century, and, while Freud’s collected works have more than 150 references to puberty in the cumulative index, there are only six (perhaps seven) to adolescence. Certainly, in his consideration of puberty in the Three Essays on the Theory of Sexuality (Freud 1905), Freud addressed the specific task of achieving a mature sexual identity – something most of us would consider an essential characteristic of what we call adolescence. But he does so in the context of biological puberty, and he does not label it adolescence. He was writing, if I may remind you, not far from the place where my grandmother had waited to be sent for from South Africa and only two years after she had rejoined her husband (after a wait about as long as Ulysses’ odyssey). He also wrote in Vienna where the crown prince had had his fatal love affair with Marie Vesera, a seventeen-year-old aristocrat. She was barely older than the often-cited fourteen-yearold Juliet, but she was ‘in society,’ ready for a relationship full of secrecy and disastrous potential. And she did not speak out of a top window on a ladder; she was jeweled and gowned and pushed into the matchmaking whirl of balls and parties where sexual intrigue and courtship were an accepted and, in fact, central purpose. She was – this kid caught in a tragedy – young, youthful, a ‘suesses maedel’ (Salvendy 1988), but not in her society’s terms what we call adolescent. Thus, when Anna Freud (1958) suggests that the interest and discovery of adolescence is attributable to psychoanalysis, she is only partially correct. It is associated with the development of psychoanalysis, and both psychoanalysis and, I suggest, adolescence are products of a particular phase of historical development – a theme to which I will return. But her work was a major step towards defining the adolescent as a specific kind of person and a specific kind of

patient. She was preceded by others but their contributions were less focused and less influential. The first major work specifically devoted to the ‘adolescent’ is Hall’s (1904) twovolume Adolescence. Freud’s three essays were published in 1905, and it was not until the 1920s that Jones (1922) produced his single essay, Some Problems of Adolescence, and Bernfeld (1923) published his important book on troubled young people. From then on, there was an accumulating body of papers that have become the classical milestones of psychodynamic theory in this area: Anna Freud’s (1936) postulation of normative turmoil, chaotic defenses; Blos’s (1967) elaborate exegesis of the attainment of sexual and social adulthood in a kind of rebirth of the mature self from the psychic gestation of the pre-pubertal years; and Erikson’s (1964) magisterial formulation of the tasks of adolescence. Together, these and many others defined an entity that we now all recognize – the adolescent of the twentieth century. Not that it is true only of the twentieth century. There are early adumbrations in the almost clichéd notions of youth with its associations of love, adventure, recklessness, energy, beauty, lack of foresight, and excess of emotion. But none of this approaches the definition of adolescence as a discrete life phase that has emerged during the past fifty or sixty years (Rakoff 1980). While psychoanalysis and psychiatry were becoming aware of youth and adolescence, other non-psychological (if there are such things) currents in society were giving increasing support to the idea that human beings at various life stages required support and recognition. Babies, as I have said, are obviously babies but, as Aries (1962) has documented, children were not always obviously children. They required free public schooling, child labor laws, and public free hospitals to emerge from their role as miniadults, often rachitic, undersized, doomed to forced labor and an early death.1 Adulthood, if adulthood means responsibility and a fixed point of social status, earnings, and an end to experimentation and mobility, started frighteningly early – by our standards – for most of mankind. If little children – again by our standards – were dressed and treated like adults with the full expectation of assuming more responsibility for their economic lives, how much more so were the postpubescent youths who would not be called adolescent. There is a poignant picture in Richard Hoggart’s (1957) The Use of Literacy in which a group of workingclass British teenagers are dressed much as their fathers were. They were doing as workers what they expected to be doing for the rest of their lives, and their income would hardly increase. Barely beyond their first growth of body hair, they were fixed in their adult identity for 1

In his survey of child labor undertaken for the British Government, Gray remarked that children as young as four could be expected to earn their own living by the work of their hands. They could sweep and braid straw. The problem of child labor at that time was not work, but the lack of it. Poor families needed the money.

The emergence of the adolescent patient 5

life. I have referred to this picture in the past, but I failed to make the observations that, if they were made old before their time, their fathers, by the same historical token, were stultified in their mature years. Deprived of what we would consider a full adolescence, they were also deprived of their full range of adult capacities; locked into dead-end, unfulfilling jobs, without many options, barely literate or illiterate, their life situation was not something to which youngsters could ambitiously aspire – because in most significant ways the young men had, only too quickly, become their fathers. There was very little intermediate phase between childhood and adulthood – one fell into adulthood. And that did not last very long for most: average life expectancies in Britain, for example, at the time when it was the most developed country in Europe, ranged from 51 years for ‘gentlemen’ in the county of Rutland, to 15 years for laboring men in the London dockyards. It is very difficult for those of us brought up in even modestly prosperous circumstances in cities to appreciate the full degree of constriction of working-class lives as recently as fifty or sixty years ago here in North America. (I am fully aware that there are groups even today who probably suffer in similar ways.) On a personal note, it became vividly clear to me when I once had the privilege of appearing on a panel with Buckminster Fuller. After the meeting, we found ourselves housed side by side in guest apartments in the university. As is well known, he was a marvelously talkative man, endlessly anecdotal and reflective. He had the interesting characteristic that as he told one story he also speculated about the general implications of what he was talking about. He eventually told me about his troubles as a late adolescent. He had got into trouble at Harvard, had a bad emotional experience, and squandered a lot of money. He ran away from Boston and worked for a while in a factory in Sherbrooke, Quebec. I will quote what he had to say: ‘I never swear, and I made a decision with myself never to swear because when I was working in the factory with grown men, big men with beards and wives and children, I realized that they knew nothing. They could not read, they could not write, and their talk was nothing but swear words. They were not stupid men; I think a lot of them were a lot smarter than I was. But their lives were as small as a walnut. Anybody who thinks that it was so grand back then should know that for most people, life was horrible and without any kind of vision, except, I suppose, they went to church on Sundays.’ I am perhaps overstating matters: boys did run away from home to go to sea,2 to join the army, to become

horribly vagrant, or they were contracted into apprenticeship. But the greater number stayed where they were and did what their fathers before them did. Their period of transition was marked in many societies by initiation rites: the circumcision rituals of Africa and other simple societies and the simple rituals for young girls were more or less associated with the menarche. Even these brief rites of passage were often lost in the great move from countryside to city that accompanied the Industrial Revolution and the alteration of social structure and social expectation which was heralded by the American and French revolutions. Of course, there was always a small group of young people who did have some leisure, some years of relative freedom from intense economic pressure, some time for experimentation. These were the cadets referred to by Aries or students or young aristocrats allowed a year or two for travel and ‘sowing wild oats.’ Yet, for all the appearance of freedom, they too had to settle for a relatively restricted range of adult responsibilities determined by hereditary class and fortune. However, compared with the great majority of mankind and indeed the women of their own class, they had many degrees of choice. They could mold their destinies through talent and character. The literature of any society is a fair reflection of both ‘what is’ and what society thinks ‘should be.’ Until the nineteenth century, there are few serious characters in the drama who were not gentry of one degree or the other. Dr. Johnson remarked that tragedies happen to a ‘very fine fellow.’ Let us consider tragedy: in its most classical sense, a tragedy happened to a fundamentally virtuous man betrayed by a characterological flaw in a crisis. The essence of the tragedy is the play of character in action, not economic opportunity or mere circumstance. It implied the choice – as I have just noted – available to the socially privileged, notions of personality as an attribute fundamentally affecting the outcome of one’s life. The sufferings of the humble by contrast were not tragic but ‘comic,’ which is to say ‘not real.’ In classical times, the comedy at the end of the tragic trilogy was a ‘satyr play’ acted in grotesque masks and huge swollen phalli. The characters were often ordinary people caught in the silly plots of mistaken identity, twins substituted for one another, the stuff of farce through Roman times until today. Ordinary people, although obviously human, did not have the density of personality or effectiveness in the world of the aristocrats. In that sense, they were deprived of ‘the right to tragedy’ (Rakoff 1970). In the nineteenth century novel, the literacy form of capitalism reflected a different social perception. Merchants, small landowners, orphans, and laborers were given

2

was more usual. It often required political and family influence to achieve this. The army was also filled with poor unwilling recruits, many of whom were discharged without skills at seventeen years or younger to join the tuberculosis-plagued ranks of dock laborers.

Running away to sea was written about as disastrous. Rural men and boys were often press-ganged into involuntary servitude on ships. Yet, for the upper classes, being accepted as a midshipman was considered a great privilege. Boys as young as nine were taken into the navy for officer training, although eleven or twelve

6 Special issues in adolescent psychiatry

the right to character previously granted to ‘my lord.’ While the church had always believed in the democratic distribution of souls and physicians plied their craft in the democracy of anatomy, the nineteenth century was the democratization of choice and the right of character to influence major life events. The forces that brought about these changes were fundamentally political, and they represented a transfer of concerns for every individual from the domain of theology – the church – to the social and political. Being true to oneself, as Polonius sententiously instructed Hamlet, became a democratic virtue. Obedience to the law, to the ethical commands of the church, to the king, duke, landowner, or one’s parents or fashion was no longer as pressing as it had been up to the end of the eighteenth century. ‘Sincerity’ became a new kind of virtue (Trilling 1972). Am I being excessive if I suggest that the central task of the Eriksonian adolescent, the establishment of a secure identity, is first sketched out (as Trilling suggests) in Diderot’s Rameau’s Nephew, in which the demands of hierarchical authority are placed against the inner needs and feelings of a spontaneous creative man? By the end of the nineteenth century, the vocabulary of Erikson’s description of the adolescent had been developed along both its positive and its negative axes: ‘alienation’ and ‘anomie,’ the economic and social components of disconnectedness and meaninglessness underlying identity diffusion, were the negative pole, whereas ‘authenticity’ and adventurousness, choices made in good faith, were at the positive pole. But before Erikson, Anna Freud, and Blos, Freud had constructed his mode of psychological man. Whereas Freud’s particular understanding of the psyche was a unique achievement, he was very much a product of his time and the inheritor of intellectual structures that had been developed – one could almost say matured – during the preceding century. As a rough starting point, the dialectic ‘invented’ by Hegel suffused subsequent European thought in one form or the other. The dialectic was itself a product and reflection of the sociopolitical forces that had erupted in the French and American revolutions. Stable, eternal, secure fixity had been lost, and in its place was constant struggle between opposing forces that were, however, contrasting aspects of a containing unity: thesis, antithesis, synthesis. The map of history and economics, throughout the nineteenth century, became the map of psychological man, transformed by Freud into the knot of Id, Ego, and Superego. It was as though the challenge to fixed and eternal verities, the sociopolitical emphasis on individual rights and individual struggles, the bourgeois assertion of the single person’s entrepreneurial right and capacity, were all reflected in a shift of the locus of psychological concerns from the ‘objectively moral’ to the subjectively experienced. Subjectivity became something of a philosophical cause. I have already alluded to Marx’s ‘alienation,’ Kierkegaard’s ‘authenticity,’ Nietzsche’s call to

move beyond ‘good and evil’ to a self-defined life’s journey, and, as a warning bell, Durkheim’s ‘anomie.’ The rights and dangers were becoming clearer, and knowing oneself was translated from the cool, rational Socratic task to the complex irrational exploration of the subjective. It will by now be apparent where this too quick and simple argument is leading: let me try to make it explicit. A vision of human life and opportunity had been hammered out by a wide range of thinkers of whom Freud was the conduit to the medicopsychological. As Reiff (1959) suggested, Freud transformed questions of moral–ethical struggle into medical problems to be examined dispassionately and correctly in a context of the therapeutic, with the hope of cure at the end. The process also defined the patient in terms of a cultural hero of our time – a subjectively guided explorer of life’s opportunities, intent on discovering the true self, refusing to be defined by economic and political tradition. If not a new human type, then a new emphasis on some perennial human capacities had been fashioned. And the notion of self-determination, allied with economic opportunity and a distrust of received historical forms, accompanied the emergence and definition of adolescence as an epoch of development. The striking thing is that the adolescent, as we have come to describe him, is not simply a young adult or an older child but perhaps more than any other patient group conforms to the model of the culture hero of our time: idealistic, authentic, adventurous, choosing among many alternatives, a model for all the adult life stages. Within the larger category of the adolescent patient, it may be useful to make some distinctions between three categories of concern: the ailments and adjustments surrounding the pubertal phase; the disorders of young adulthood; and the problems of historically fostered adolescence. The distinctions may be arbitrary or inconclusive, but the immediate self-discovery of physical and intellectual powers and the realization of sexual and emotional characteristics following the transitions of puberty are perennial and historic, affecting all humankind and all social classes. These things did not happen because of the rise of entrepreneurial capitalism, the American and French revolutions, the migration from country to city, the growth of prosperity, and the extension of middle-class options and choices in the twentieth century. They were, are, and will be normative components of development. The disorders of young adulthood for psychiatry are the onset of the major psychoses during the teenage years and the early twenties. Schizophrenia, alas, has appalling uniformity in its time of onset and its epidemiology across all cultures (with minor arguable variations). It appears to be true that characterological disorders or turbulence postulated by Anna Freud as stage specific in adolescence are, according to the studies of Offer (1975) and Masterson (1967), not phase specific. Indeed, Offer demonstrated that most adolescents pass through the phase without

The emergence of the adolescent patient 7

experiencing the turmoil depicted as normal by Anna Freud. However, when the young person manifests problems, these problems should not be regarded as normative or ‘privileged.’ They should be treated with concern as they may be the warnings of lifelong or at least long-lasting problems. The turbulence of the adolescent years appears to be in many instances simply the entry to adult turbulence. In recent years, there has been an increasing emphasis on empirical investigation of pathology and treatment during the adolescent period, more in the tradition of Offer than in the theoretical mode of Anna Freud and Erikson. Specifically, epidemiological studies and pharmacological approaches are reported without paying homage to the tradition of psychoanalytically based speculation (e.g., Kutcher (1979) in his book Child and Adolescent Psychopharmacology carefully compiles, as far as is possible, empirical data free of the theoretical speculations of earlier times). However, there do appear to be syndromes generated by the epoch-dependent or historically determined adolescence about which we have been speaking: most notably the increase in suicide and depression during the years fifteen to twenty-five, anorexia nervosa, substance and drug abuse, and subtle forms of religious malaise and anomic rootlessness. The list is not exhaustive, but will serve to focus discussion. I am not here proposing to replace the useful and well-established categories of early adolescence, mid-adolescence, and late adolescence. Nor am I discounting the flowering of talents, intellectual capacities, and sometimes pathology in the adolescent period. Rather, I am proposing that there is a particular aspect of the entire period that is characterized by dilemmas and opportunities of choice and the expression of individual personality. It is this era-dependent or historically permitted adolescence that may, indeed, as I am about to suggest, extend far beyond the period we normally designate as adolescence. Adolescent suicide as a major public health problem is not a perennial phenomenon. There are, however, anecdotal reports of waves of suicide, but these are unconfirmed and express romantic yearning and weltschmerz carried to an extreme.3 However, Klerman (1988) writes, ‘For each successive birth cohort in the twentieth century there are increasing cumulative rates of illness and particular earlier age of onset rates for females higher than males.... Cohorts born after 1936 who reached adulthood after World War II have early age of onset (of melancholy) and higher rates of depression than the cohort born earlier in the century’ (Klerman 1988, pp. 8–9). 3 The classical model for this phenomenon is Goethe’s Sorrows of Young Werther, a tale of thwarted late adolescent love leading to suicide, published in 1797. Werther’s sorrows were not only romantic, he was also ‘not a gentleman,’ banned from aristocratic society and yearning to be accepted and respected ‘for himself.’ He became a model for young romantic men; they dressed like him in blue coat, buff breeches and boots. And, the story goes, his fate was the model for a wave of copy-cat suicides.

In every birth cohort the rates are higher in women than in men. Klerman is concerned with the influence of a given ‘period’ on the epidemiology of melancholy and its expression in suicide and depression. He is in this study particularly involved with the baby-boom generation and afterward – the group who generated the chilling statistic: suicide as the second highest cause of death in the ‘later adolescent period.’ He asks a question that he does not attempt to answer. What is the mysterious pathogenic factor – the agent blue – in this period that generates increased melancholia? It is unlikely that the biochemical make-up of youths has changed in the post-World War II period, or to posit a new, peculiar change in the genetic pool of the population. The new and necessary empiricism still yields little understanding of the major psychopathology of youths in the developed and developing world. A tragic example: the suicide rate among young Canadian Indians and Inuit has become a topic of national concern. Malcolmson (personal communication 1988) reports that at least one-third of the teenagers in a particular settlement had attempted or completed suicide during the past four years. When asked if they knew the cause of these suicides, the other youngsters invariably used the same words: those who killed themselves were ‘bored.’ The populations considered by Klerman and those described by Malcolmson are very different. Klerman’s youths (like those in most studies of adolescent suicide) were principally urban, from the most developed and prosperous countries in the world, whereas the Inuit youths are little different from the inhabitants of the oasis described by Haliburton (1933). Is there indeed a common pathognomic factor? Perhaps Durkheim (1950, p. 252) still holds the key to the pathogenic ‘factor blue.’ As he considered the apparent increase in suicide in Europe toward the end of the nineteenth century, he wrote: ‘When society is disturbed by some painful crisis or by beneficent but abrupt transitions, it is momentarily incapable of exercising this influence; thence come the sudden rises in the curve of suicides. But the man who has always pinned all his hopes on the future and lived with his eyes fixed upon it has nothing in the past as a comfort against the present affliction. For the past was nothing to him but a series of hastily experienced states. What blinded him to himself was his expectation always to find further on the happiness he had so far missed. Now he is stopped in his tracks; from now on nothing remains behind or head of him to fix his gaze upon. Weariness alone, moreover, is enough to bring disillusionment, for he cannot in the end escape the futility of an endless pursuit.’

Adolescent suicide, however, is not simply a stagespecific phenomenon. It reflects, as do other characteristics of adolescence, the almost prototypical reflection of

8 Special issues in adolescent psychiatry

general social phenomena. The rate of adolescent suicide has increased as suicide in general has increased. Although adolescent suicide rates have increased more than the rate for the general population has (Sakinofsky and Roberts 1987), there are other significant variations: for example, whereas male suicide rates have increased steadily from 1944, female suicide has remained fairly steady for the past fifteen years. But, in most of the statistics-keeping world, the suicide rate has shown a steady increase except in Japan, where rates are declining (Kato 1969). Like suicide, anorexia nervosa/bulimia has shown a similar rate of increase in the Western world. Jones et al. (1980) reported that the incidence of anorexia doubled in the period 1970–1976 compared with the period 1960–1969, and the condition has always been associated with economic prosperity (although the class showing tends not to affect male patients). For the purposes of our discussion, it is important to note Garfinkel and Garner’s (1982) observation that the condition appears to be spreading to lower economic levels. Anorexia nervosa is not a new disorder. Its classic description as a clinical entity goes back to Gull and Laseque in the 1870s, and there are obscure earlier reports, but it too has become democratized in the past few decades. Does the ‘agent blue’ responsible for the increase in suicides also generate the increase in cases of anorexia/ bulimia? Garner et al. (1980) have charted the profound effect of fashion on the growth of anorexia nervosa/ bulimia. But fashion as ‘agent blue’ begs the question: What does fashion reflect? From where does a fashion derive that women should look like men or that ‘thinness’ is almost a moral condition? Fat is not only ugly and nonsexy, it is a moral lapse. Yet, it is intensely demonstrative and is not secret and intimate. It is a signal to the field that, in addition to any other messages, also conveys, See how I can control myself (and you). In short, it is contextual and manifests a considerable degree of field dependency, a conformity to some ideal perceived by the patient as necessary for self-acceptance and acceptance (Rakoff 1983). An audience of adolescent psychiatrists does not need a reminder of the peculiarly adolescent phenomena of cult-seeking and religious preoccupation, the various fluctuations but the persistence of substance abuse, or the horrifying fact that automobile accidents are the major cause of death in the age group. Taking the family car on a seemingly empty highway and guiding it like a rocket in an ecstasy of self-determination – the goal is not a place but a state, a state of being powerful, and in some celebratory way anomic. Bernfeld (1923) commented on the ‘protracted adolescence for males going on for longer than even we allow for adolescence’ and emphasized the positive components of the phenomenon: ‘tendency toward productivity whether artistic, literacy, or scientific and by a strong bent toward idealistic aims and spiritual values.’ The argument I have been developing takes this notion

several stages further: adolescence, in addition to being a life stage bracketed between puberty and adulthood, is also a set of characteristic social expectations and opportunities that may extend throughout much of the life cycle. When the circumstances permit, adolescent behavior reappears not so much as a regression but as the mobilization of a constant potentiality. The openness of choice and self-determination may present in mature individuals with the same or similar enthusiasm or difficulty as it does for youths or young adults. In its positive aspects, it promotes the capacity for adventure, risk taking, creative change, enthusiasm, ideality, and healthy skepticism. The negative is the fostering of anomie, alienation, and despair with the accompanying phenomena so frequently noted of suicide, alcoholism, increased accident rate, divorce increase, and so on, and at a less serious level the so-called mid-life crisis, which rarely affects the unsuccessful or those people whose jobs are closely tied to the simple business of earning a living. The adolescent, while being a young adult, is also the essential embodiment of the social opportunities and dilemmas developed during the past two centuries, reaching an accelerated crescendo during the past fifty years – opportunities in the idea – available to people of every age. The increase in suicide in adolescence accompanies a general increase in suicide rates that probably reflects the anomic forces in society to which the adolescent, like the older lonely male, is especially vulnerable. The components of anomie – detachment, mobility (paradoxically), the drive to the future, and the discontent with the present – which affect the whole of Western society, particularly affect the adolescent. Marriage is delayed; career choice is fostered; mobility is an ever-present possibility. The question can be asked: How does this describe the Inuit, the native Indian youth, the young ghetto blacks who also kill themselves more frequently than previously? Opportunity for them is severely limited, but they are embedded in a societal context that pours in on them, invalidating their actuality with television and movie visions of tormenting and sometimes spurious models of possibility. As Durkheim (1950) wrote, ‘With increased prosperity desires increase. At the very moment when traditional rules have lost their authority, the richer prize offered these appetites stimulates them and makes them more exigent and impatient of control. The state of deregulation or anomie is thus further heightened by passions being less disciplined precisely when they heed more disciplining’ (p. 253). He emphasized the danger of expectation without fulfillment. There are some expectations that cannot be fulfilled: perfect authenticity, total satisfaction with one’s place in the world, being virtuous enough, for some being rich enough, beautiful enough, or tragically (frivolous though it may sound) thin enough. When these tormenting expectations are experienced without a sustaining set of guiding values, the groundwork of many different kinds of trouble is laid down.

The emergence of the adolescent patient 9

CONCLUSIONS Perhaps a blanket term can cover – to some degree – these problems: disorders of aspiration. The label cannot capture all the nuances or psychodynamics of identity diffusion, adolescent suicide, drug and substance abuse, anorexia nervosa, traffic accidents involving young people, or devotion to cults; but it relates to a crucial component of all these. Durkheim described the dissatisfaction with the given, the daily, as a factor in anomic suicide. It affects, I suggest, all those who yearn painfully for ‘the orgiastic future’ or whose actual circumstances have been depleted of local myth and history to be replaced by a cargo cult of distant riches. It is also clearly a component of anorexia nervosa: young women with enough money but little power exert their will on what is closest to them, and they sculpt their bodies into existential art. They rarely know what motivates their ‘relentless pursuit of thinness,’ but the percolated-down fashion with its signals of lightness, fleetness, control, and peculiar asexual sexuality gets through to them. At is most subtle, the disorder of aspiration affects many lives with a sense of inadequate achievement. It shows itself in constant self-doubt, erratic behavior, restless yearning, and searching. The great currents of history and social change do express themselves in individual opportunity and individual pain. Opportunity as we all know is both a privilege and a threat. When the opportunity is coupled with the ethos of achievement, an intense concern with individuality, and what Durkheim called ‘the morbid desire for the infinite,’ fragile, self-doubting, deprived, or in other ways vulnerable individuals, left to their own resources, feel themselves unequal to the opportunity and unable to cope. That inability may be reflected in a variety of clinical syndromes, only a few of which have been addressed in this chapter.

REFERENCES Aries, P. Centuries of Childhood. London: Cape, 1962. Bernfeld, S.S. Uber eiune typische Form der Mannlichen Pubertat. Imago 9: 169–188, 1923. Blos, P. The second individuation process of adolescence. Psychoanalytic Study of the Child 22: 162–186, 1967. Durkheim, E. Suicide: A Study in Sociology. New York: Free Press, 1950. Erikson, E. Childhood and Society. New York: Norton, 1964. Freud, A. The Ego and Mechanisms of Defense. New York: International Universities Press, 1966.

Freud, A. Adolescence: Psychoanalytic Study of the Child 13: 255–278, 1958. Freud, S. Three essays on the theory of sexuality. Standard Edition 7: 125–230, 1985. Garfinkel, P.E., Garner, D.M. Anorexia Nervosa: A Multidimensional Perspective. New York: Brunner/ Mazel, 1982. Garner, D.M., Garfinkel, P.E., Schwartz, D., Thompson, M. Cultural expectations of thinness in women. Psychology Reports 47: 483–491, 1980. Haliburton, R. The Flying Carpet. London: Bliss, 1933. Hall, G.S. Adolescence. New York: Appleton, 1904. Hoggart, R. The Uses of Literacy. London: Chatto & Windus, 1957. Jones, D.J., Fox, M.M., Babigan, H.M., Hutton, H.E. Epidemiology of anorexia nervosa in Monroe County, New York: 1960–1976. Psychosomatic Medicine 42: 551–558, 1980. Jones, E. Some problems of adolescence. In Papers on Psychoanalysis. London: Baillière, Tindall & Cox, 1922. Kato, M. Self-destruction in Japan: a cross-cultural epidemiological analysis of suicide. Folio of Psychiatry and Neurology 23: 291–307, 1969. Klerman, G. Youthful melancholia. British Journal of Psychiatry 152: 4–14, 1988. Kutcher, S. Child and Adolescent Psychopharmacology. Philadelphia, PA: W.B. Saunders & Co., 1979. Masterson, J.J. The symptomatic adolescent five years later: he didn’t grow out of it. American Journal of Psychiatry 123: 1338–1345, 1967. Offer, D. Adolescent turmoil. In Esman, A. (ed.), The Psychology of Adolescence. New York: International Universities Press, 1975. Rakoff, V. The Longing for Significance. Toronto: CBC, 1970. Rakoff, V. History in adolescent disorders. Adolescent Psychiatry 8: 85–99, 1980. Rakoff, V. Multiple determinants of family dynamics in anorexia nervosa. In Darby, P.E., Garfinkel, D., Garner, P.E., Coscina, D.V. (eds), Anorexia Nervosa: Recent Developments in Research. New York: Liss, 1983. Rieff, P. Freud: The Mind of a Moralist. Chicago: University of Chicago Press, 1959. Sakinofsky, I., Roberts, R. The ecology of suicide in the provinces of Canada. In Cooper, B. (ed.), Psychiatric Epidemiology. Baltimore: John Hopkins University Press, 1987. Salvendy, J. Royal Rebel: A Psychological Portrait of Crown Prince Rudolf of Austria-Hungary. London: University Press of America, 1988. Trilling, L. Sincerity and Authenticity. Cambridge, MA: Harvard University Press, 1972.

1.2 Ethical issues in adolescent psychiatry ROBERT WEINSTOCK, GREGORY B. LEONG, AND J. ARTURO SILVA

Adolescence has been conceptualized only in the last two centuries. In the past, with shorter life spans and less extensive education, adulthood was considered to occur at the onset of biological maturity. Piaget’s last stage of cognitive development, the formal stage (Flavel 1963), is first attained during adolescence, but many adolescents and adults never will reach the final stage. Pre-formal adolescents are cognitively immature and unable to conceive of alternative possibilities. They may act impulsively to eliminate a problem by the only solution they can conceptualize, despite generally being able to perform adequately on simple cognitive tests. Adolescents also are less emotionally mature than adults. Although society has determined that adolescents are incapable of exercising certain privileges and responsibilities regardless of an individual adolescent’s capabilities, simple cognitive tests of the kind used for adults increasingly are used for punishment. Adolescents have cognitive capacities and emotional maturity intermediate between childhood and adulthood. Although the law sometimes fails to recognize these factors as well as potential professional ethical conflicts, that does not lessen the need to consider issues from the ethics perspective. ‘Legally best protective’ of the doctor is not synonymous with the best ‘clinical’ or most ‘ethical’ course of action, and these sometimes conflict. The psychiatric profession, not the law, determines ethical standards in psychiatry. Attorneys, although knowledgeable about law and liability avoidance, should not be relied upon to determine what is ethical or clinically desirable. The safest thing legally may not be the best ethical or clinical course of action. Attorneys generally should not be asked what is the best course of action. Instead, after an adolescent psychiatrist decides on the best clinical and ethical action, an attorney should be consulted in complex cases to give advice about what may be the safest legal way to do what is indicated. Usually, the best clinical and ethical decision is safer legally than following a rule so rigidly that it leads to actions that even lay

people could see as inappropriate and self-serving. This chapter focuses on some of the special ethical problems and challenges in adolescent treatment.

CONFIDENTIALITY Adolescents rarely pay for their own treatment, almost always depending on their parents or outside agencies. As a result, these others may consider themselves entitled to receive information or even dictate treatment, thereby creating pressures and incentives for adolescent psychiatrists to violate confidentiality. Although psychiatrists often should and frequently do meet with and speak to the patient’s family, such actions should be done with the knowledge of and usually concurrence by the adolescent patient. Often the family are involved with treatment and, sometimes, the psychiatrist treats the family as well as the adolescent and there can be conflicting responsibilities and loyalties. Usually that is best handled by having a different psychiatrist or a social worker treat the family if the family is treated on an ongoing basis. If the family and the individual adolescent are treated or there is an occasional family meeting, any limitations on confidentiality should be clarified with the adolescent and other family members if seen individually. The American Psychiatric Association (APA) Model Law states that persons aged at least 12 years may give consent for the disclosure of confidential information and that except when necessary to prevent harm, such information should not be disclosed to parents or others without the adolescent’s permission (APA 1979). Of course, a therapist could try to overcome resistance when parental involvement is important. Reports to outside agencies should be made only with the adolescent’s consent. An exception may occur in a case of mandated treatment if the adolescent is made aware of this at the start of treatment.

Ethical issues in adolescent psychiatry 11

Confidentiality and its limitations should be clarified in advance to adolescents, without unrealistic assurances of unconditional confidentiality. In one study, 64 per cent of primary care physicians who discussed the issue gave inappropriate unconditional confidentiality assurances to adolescents, and on average the studied group discussed confidentiality with only 53 per cent of their adolescent patients (Ford and Millstein 1997). Psychiatrists are unlikely to do significantly better. Adolescents in a randomized study expressed a willingness to discuss sensitive information and return more often when confidentiality was discussed, but were even more likely to return when given inappropriate unconditional confidentiality assurances. The challenge is to discuss confidentiality realistically in a way that would still be reassuring (Ford et al. 1997). Confidentiality is as essential in the treatment of adolescents as it is with adults. Parents need to be informed that although they will often be involved in the process, the adolescent’s confidentiality must be maintained as a necessity for meaningful treatment to occur. Even though paying for treatment, they cannot direct it. Nevertheless, the psychiatrist will contact them in situations of danger or serious self-destructive behavior by the adolescent. In contrast, the parents should not be promised confidentiality but should be apprised at the outset that information given by them may be shared with the adolescent patient at the psychiatrist’s discretion (Weintraub 1994). In situations in which confidentiality must be breached, adolescents should be informed in advance, and if at all possible their consent obtained. Third-party payers and others often request sensitive information, the confidentiality of which, despite safeguards, cannot be realistically assured for adolescents any more than for adults, once the clinical information is transmitted and subsequently stored in a computerized database. Consequently, from the outset adolescents should be involved in decisions to release clinical information. The psychiatrist, because of ethical and legal fiduciary responsibilities, should call to the attention of an adolescent and parent the potential problems that can result from a release of confidential information to outside agencies. This responsibility of an adolescent psychiatrist may be greater with adolescents than adults, since adolescents may be less able to foresee potential problems.

ROLE OF THE ADOLESCENT PSYCHIATRIST Problems of multiple agency, i.e., multiple responsibilities and concurrent divided loyalties, can lead to challenging ethical dilemmas in adolescent treatment. Multiple agency conflicts can result for school (or college) psychiatrists insofar as adolescent welfare can conflict with the interests of the school (or college). Adolescent needs similarly can

conflict with those of other institutions, including health care facilities. Evaluation for legal purposes can be especially complex. Psychiatrists in these forensic situations should try to separate such roles from treatment and have them performed by different psychiatrists. The evaluating psychiatrist should not have access to the treating psychiatrist’s notes when both are at the same institution, and they should not discuss the case without the patient’s permission, whether or not it is permissible legally to do so. In circumstances in which one psychiatrist performs both treating and evaluating roles, the patient should be clearly informed of this potential conflict. When treating an adolescent, the patient’s welfare should be the highest priority, despite any other additional competing responsibilities and duties. Treating psychiatrists have legal fiduciary and ethical responsibilities to be vigilant of their patient’s welfare. The source of compensation, whether it is from parents or a third-party payer, should not influence a psychiatrist’s ethical behavior and clinical responsibilities. Because of the adolescent’s immaturity, an adolescent psychiatrist usually needs to be more active and directive than in the treatment of adults. Neither the adult nor the child model applies fully. When forensically evaluating an adolescent, the traditional psychiatrist–patient relationship is secondary to the forensic role and legal purpose of the evaluation. Values such as patient welfare, confidentiality, and doing no harm lose their primacy, but not necessarily all relevance. According to the ethical guidelines for forensic psychiatry practice promulgated by the American Academy of Psychiatry and the Law (AAPL 2002), it is necessary for psychiatrists performing forensic evaluations to be sensitive to ‘slippage’ – the process in which the initial explanations at the outset of the evaluation lose their effect over the course of the assessment. Thus, explanations and warnings to evaluees may need to be reinforced periodically. Because of a possible tendency by some adolescents, as well as children and adults, unequivocally to trust doctors as healers, there is a need to make certain that the adolescent does not begin to think the psychiatrist is in a helping therapeutic role. Empathy, appropriate and helpful in a treatment capacity, can be insidious in the forensic context and lead to inappropriate trust. It is also important to keep in mind that although psychiatric and medical ethics considerations generally lead to actions consistent with legal requirements, this is not always so. Some actions are ethically but not legally required, or vice versa. In rare instances they even conflict. Although medical ethics never requires psychiatrists to violate the law, some psychiatrists out of ethical concerns occasionally may consider it necessary to do so. Such actions can be both ethical and courageous, albeit legally risky. Sometimes, professional ethical requirements conflict with other ethical requirements, creating ethical dilemmas.

12 Special issues in adolescent psychiatry

Deontological (duty) ethics may conflict with consequentialist (utilitarian) ethics. Some principles of bioethics may conflict with other bioethical principles (Beauchamp and Childress 1994). Avoiding trouble by not violating written professional ethical guidelines is only the most minimal and basic ethical consideration. The fact that an action is not found to be unethical by an ethics committee investigation does not mean necessarily that it is ethical. Hopefully, most psychiatrists aspire to a higher ethical standard than the basic minimum and aspire to do the ‘right’ professional thing, even if it is not clearly spelled out in guidelines. Such considerations have been called ‘aspirational’ ethics (Dyer 1988) and are especially relevant whenever there are conflicting responsibilities and loyalties, with no clear generally accepted appropriate course of action. Adolescent psychiatrists should make efforts not to follow prejudices uncritically or bow to unavoidable financial and political pressures, whether or not a specific behavior is addressed in an enforceable ethical guideline. The psychiatrist’s subjective motives might be the distinguishing factor in assessing actions in some ambiguous situations. These can be impossible for others to determine and may therefore preclude enforcement, but the ethical adolescent psychiatrist still should make every effort to determine the most ethical action.

INFORMED CONSENT Informed consent (or refusal) necessitates the ability to weigh the risks and benefits of a treatment and its alternatives, including the no-treatment option. Informed consent for adolescent treatment usually necessitates not only obtaining the informed consent of the parent but also, if possible, the adolescent’s informed consent or at least assent. Assent, according to the Committee on Bioethics of the American Academy of Pediatrics, should be an interactive process between physician and patient (Committee on Bioethics 1995), and not assent forms or routine legalistic procedures. Assent, minimally, should involve helping the adolescent achieve a developmentally appropriate awareness of the condition. They should be informed what to expect with planned tests and treatment. A clinical assessment should be made of the patient’s understanding of the situation, including factors such as inappropriate pressure that may influence how the patient is responding. An expression of the adolescent’s willingness to accept the proposed care should be solicited, but only if it will be weighed seriously. Adolescents should not be deceived. If they will receive unwanted medical care regardless of their wishes, they should be so informed. In such instances they should at least receive an explanation of what will happen consistent with their ability to understand.

Age alone, although legally important, may not be the most significant ethical factor in determining to what extent adolescents should be involved in the decisionmaking process. Issues such as cognitive and emotional development are crucial. Economic and psychological dependence on parents also affects ethical, legal, and clinical considerations in determining the degree to which the adolescent should give informed consent in addition to and sometimes instead of the parent. If the adolescent is sufficiently independent and mature the law may recognize their ability to give a valid independent consent (i.e., emancipated or mature minors). When a parent is making decisions that are clearly harmful to the adolescent in an important situation, the psychiatrist may want to bring the situation to the attention of an appropriate agency or court. In general, when parents refuse life-sustaining treatment for an adolescent, the courts have not permitted the parents to make such decisions for an adolescent, even if the parents legally can make such decisions for themselves. Instead, the courts will usually appoint a surrogate decision-maker. Ethically the adolescent psychiatrist should do whatever possible to obtain clearly needed treatment for an adolescent. According to the tradition of English common law, children under the age of majority were considered to lack the legal capacity to give consent to medical treatment or services necessitating consent by a parent, guardian, or other legally authorized representative. There was an assumption that a child lacked the capacity to give informed consent and the parent or guardian would act in the child’s interest. However, in recent years it has become increasingly clear that in some cases parents do not act in the child or adolescent patient’s interest. Except in an emergency, providing medical care without the consent of an authorized person can constitute a battery. Legislation over the past half-century has produced both general emancipation statutes for lawfully married minors, minors on active military duty, and minors over the age of 15 years living apart from parents or legal guardian and financially independent from them, as well as limited medical emancipation statutes for specific designated conditions. The Committee on Bioethics of the American Academy of Pediatrics has stated that adolescents, in contrast to children, generally have the capacity to give informed consent, so in most instances informed consent and not merely assent should be obtained (Committee on Bioethics 1995). Examples include performing a pelvic examination, honoring a request for oral contraceptives, and prescribing longterm antibiotic treatment for acne. They state that adolescent patients have both the decision-making capacity and the legal authority to accept or reject interventions such as these, so they state that no requirement to obtain parental permission exists even though parental involvement in such cases is recommended (Committee on Bioethics 1995).

Ethical issues in adolescent psychiatry 13

The age of majority varies by state, ranging from sixteen to twenty-one years (Macbeth 1992). Besides this absolute demarcation, in some situations adolescents who have not attained the chronological age of majority and are not legally emancipated may still have certain decision-making rights and privileges. For example, in California, unemancipated adolescents are legally able to consent to oral contraceptives, abortion, and outpatient psychotherapy on their own without parental consent, but they generally need parental consent for psychotropic medication, except in an emergency. They can consent to hospital, medical and surgical care related to pregnancy, obtain medical care related to the diagnosis and treatment of any infectious, contagious, or communicable disease including a sexually transmitted disease, and medical care related to rape or sexual assault. Medical care and counseling related to the diagnosis and treatment of a drug or alcohol problem can be obtained by an adolescent aged twelve years or older without parental consent. If parental consent were necessary, many such patients out of embarrassment or fear of parental response might defer needed treatment. States differ in their laws regarding the ability of adolescents to consent to abortions without parental consent or judicial authorization. The American Academy of Pediatrics, strongly supportive of respecting an adolescent’s ethical right to give consent for medical procedures, entered into a lawsuit against the state of California in which the Academy prevailed. In American Academy of Pediatrics v. Lungren (1997), the California Supreme Court ruled that the state could not require a pregnant minor below eighteen years to secure parental consent or judicial authorization prior to obtaining an abortion. This decision was based in part on the explicit right to privacy found in the California constitution, but not in the federal constitution. However, Judge Mosk, in a dissenting opinion, stated that there is no presumption of competence in adolescents, and the medical emancipation statutes were designed to apply to limited circumstances and conditions. Although the American Academy of Pediatrics notes that empirical data suggest that adolescents, especially age 14 and older, may have attained adult-level decisional skills for making informed healthcare decisions, out of concern for an adolescent’s welfare for both legal and ethical reasons it may sometimes be necessary to oppose adolescents who wish to make seriously unwise decisions.

RESEARCH Research on adolescents is essential, but presents special ethical and legal considerations. The unique problems with doing research on adolescents have led to a paucity of relevant scientific data. For example, very little research has been conducted on the use of most medications for

adolescents because of consent problems, particularly with regard to efficacy or side effects. The American Academy of Child and Adolescent Psychiatry (AACAP) Code of Ethics distinguishes between research that has potential therapeutic benefit to an adolescent and research that does not (AACAP 1970). In cases of potential therapeutic benefit, an understanding of the risks and benefits should be communicated to the parents or guardians as well as to the involved adolescent just as in the usual treatment case. In research not related to potential therapeutic benefit to the adolescent or to other direct positive outcomes, the level of risk becomes critical. When the risk is minimal, such as in standardizing new psychological tests, or obtaining urine or blood samples for analysis, only parental consent and adolescent assent are needed. If the risk is more than negligible, such as taking a biopsy or administering a chemical agent, the adolescent, if developmentally capable of understanding the procedure, risks, and larger benefits, should have the right to refuse to participate regardless of parental or guardian consent.

CIVIL COMMITMENT Civil commitment of adolescents presents special issues and challenges. Currently, adolescents have some legal rights, but not so many as adults in such situations. Adolescent psychiatrists have ethical responsibilities to protect the best interests of their adolescent patients and to try to ensure that they are not abused by parents or by the state. Until the 1970s, parents had the right ‘voluntarily’ to admit adolescents against their will for ‘acting out’ behavior that the parents did not find acceptable. Consequently, adolescents were hospitalized for lengthy periods for marijuana or other drug use or for what the parents perceived to be promiscuous sexual activity. Sometimes these hospitalizations were beneficial and protective for a self-endangering adolescent. At other times they represented efforts by parents to impose their will upon rebellious adolescents. In Parham v. J.R. (1979), the United States Supreme Court held that the risk of error inherent in parental decisions to have children institutionalized for mental health care is sufficiently great that some kind of inquiry by a ‘mental factfinder’ is necessary. Although a hearing by a judicial or administrative official is not required, the decision-maker must have the authority to refuse admission. The reviewer must carefully probe the child’s background, utilizing all available sources. The Supreme Court also required periodic reviews by similar independent procedures. A staff physician suffices, as long as he/she can provide an independent evaluation of the child’s need for treatment as well as their mental and emotional condition.

14 Special issues in adolescent psychiatry

The Supreme Court did not believe that judges are better able than physicians to make these determinations. Unlike court decisions for adults, the Supreme Court decision regarding minors seems to give a higher priority to patient wellbeing as opposed to liberty interests. It also placed greater reliance on and therefore gave greater ethical responsibility to the psychiatrist. States though are not prohibited from requiring hearings and giving greater legal protection to an adolescent’s liberty. For example, the California Supreme Court in In re Roger S (1977) held that minors old enough independently to exercise their right to due process could not be deprived of their right to a hearing but were not entitled to all the same procedural protections accorded to an adult in the same situation.

CHILD ABUSE Mandated reporters, including adolescent psychiatrists, must notify the agency designated by the state in which they practice of situations in which an adolescent is being abused by an adult. Many states require reporting if there is even a suspicion of abuse. Since it has become evident that abuse of children is not rare, such legislation is essential to the welfare of children and adolescents. Nonetheless, child abuse reporting laws can present ethical dilemmas for the adolescent psychiatrist. In all states a child abuse report can lead to prosecution of the offender, and such an action may not always be in the best interests of the minor. In some states, overworked child protection agencies essentially have given up on treatment and devote their energies almost entirely toward prosecution and not necessarily even toward what is best for the adolescent. In states such as California, the reporting psychiatrist can be forced to testify against the perpetrator even if the adolescent patient or the parent objects (People v. Stritzinger 1983). Sex between adolescents can become complex, such as when, for example, sexual relations occur between an 18- and a 16-year-old, or when both parties are underage adolescents. The general rule in the past had been that sex with an adolescent or child becomes abuse only when there is more than a five-year age difference unless such behavior between minors is a result of parental neglect (abuse), but increasingly, zealous prosecutors may prosecute such cases. In some states the age of 14 years is the cut-off, so a 15-year-old could be prosecuted for consensual sex with a 13-year-old. Failure to make a mandated child abuse report can subject the psychiatrist to criminal sanction in some states, and loss of licensure. The psychiatrist must adhere to this reporting requirement, despite a belief sometimes that reporting could harm the adolescent patient as well as the putative perpetrator. In most states there is a limited time period such as 36 hours to file a report, and the

psychiatrist is allowed no discretion because of the overriding need to stop child abuse. However, the adolescent psychiatrist is not required to become an ‘undercover’ police detective or use subterfuge to uncover evidence in potential child abuse cases. There is no obligation to get details from patients without telling them if the information is being collected for reporting purposes. Informed consent or assent with adolescents should be part of all psychotherapy, including child abuse assessments. On some occasions, mental health clinicians might consider it ethically appropriate to remind the adolescent or parent of the child abuse reporting requirement or to inform them for the first time if no previous warnings were given, before any potentially incriminating information is revealed, since they may falsely assume that confidentiality applies and feel betrayed when it is violated. Ethical dilemmas can arise as the treating psychiatrist must weigh the potential benefits and harms of warning or reminding, since it may lead to withholding of information versus not warning or reminding, as well as how often to do so (Leong et al. 1988). Quick judgment is essential, since it is too late once the pertinent identifying and incriminating information is disclosed. In many instances, the adolescent will want the information reported, and will want to reveal details so no ethical problem will arise. It can be therapeutic for many adolescents to finally do something about the abuse. In addition to not misleading a patient, there may be other reasons for trying to avoid obtaining details that would enable prosecution of the offender or warn a patient before details are given. A therapist may believe that the problem would more effectively be resolved through therapy, and that state intervention would be likely to exacerbate the problem of abuse of the victim and the law takes away any options for the therapist once the information is revealed. Sometimes, if the abuse happened in the distant past to an adolescent, there may be a legal reporting requirement, but such a report might in reality be a useless action that might even do harm. However, in ongoing seriously harmful situations it is necessary to obtain the pertinent information to enable authorities to intervene. The adolescent psychiatrist might not in such circumstances want to bring the need to report to the patient’s or parent’s attention or remind the patient of such a need until after the information is obtained. The psychiatrist may consider obtaining the detailed information essential to stop seriously harmful ongoing abuse. Analogously, few psychiatrists would warn a suicidal or homicidal patient of the potential consequences of revealing the details (e.g., involuntary hospitalization or a need to protect the potential victim) because in such situations action is essential to protect the patient in addition to others. These decisions are ethically complex, and obtaining information by misleading patients about the purpose or allowing them to have false beliefs about confidentiality may not always be the best

Ethical issues in adolescent psychiatry 15

ethical solution even if the law allows immunity for child abuse reports and for violating confidentiality under such circumstances. Adolescent psychiatrists must appreciate though that the law allows no discretion by the psychiatrist in making such reports regardless of whatever harm they may cause. No one should disobey the law. Failure to make a mandated report is a serious legal infraction that can lead to both civil and criminal penalties, including a jail sentence, as well as serious actions by licensing boards that even could result in loss of a medical license, and some states require reports even if the child abuse is only suspected. Hopefully, child abuse agencies will use discretion and sensitivity in their investigations. There is no guarantee though that sensitivity will be shown, since overworked bureaucracies can lead to information not being communicated to the investigator, or an overzealous investigator can cause problems. Alternatively, serious instances of abuse may not be adequately investigated, and this has become an increasing problem in recent years. Such situations necessitate intervention by the adolescent psychiatrist to resolve the problem therapeutically. Nevertheless, child protection agencies often are more effective than a psychiatrist in stopping child abuse. Child and adolescent abuse is a very serious problem, and reporting laws have helped focus national attention on it. On some occasions in which the abuse has stopped or is questionable but a mandatory report may still be legally required, reminders of the reporting requirement might well be appropriate. Choices about reminders and warnings may be the only discretion that the law permits a psychiatrist. In unclear situations, consultation with an attorney or a child abuse reporting agency may be helpful. In states such as California there is immunity for any child abuse report no matter how ill-founded, so only ethical and therapeutic considerations could influence decisions that the threshold of suspected child abuse is not met, or the need to remind the patient about legal requirements. California recently made emotional abuse grounds for mandated reporting instead of the previously optional reporting. These parameters especially are unclear, as many parents occasionally say emotionally harmful things to an adolescent.

DEATH PENALTY AND FORENSIC EVALUATIONS Performing forensic psychiatric evaluations of adults can be ethically complex and lead to ethical dilemmas (Rosner and Weinstock 1990; Rosner 1997; Weinstock 2001). Performing forensic evaluations of adolescents can be even more challenging ethically, since juvenile courts have moved from their original rehabilitative focus with few legal protections to an increasingly punitive orientation.

In recognition of this trend, even as far back as 1967, the United States Supreme Court in the Gault decision, a case involving a 15-year-old boy, accorded minors in juvenile court most of the legal rights of adults (In re Gault 1967). Currently, most states allow adolescents to be transferred (waived or bound over) to adult court for trial and disposition if the crime is serious and/or the adolescent is determined after clinical evaluation to be unsuitable for rehabilitation. States such as California have a list of circumstances in which adolescents can be tried as adults. Although the entire picture should be considered, any one of these factors can in fact be sufficient to have the adolescent tried as an adult if the crime is serious. Juvenile transfer can result in adolescents becoming eligible to receive adult penalties, including capital punishment. States such as Florida and California allow prosecutors to decide to try juveniles as adults. Ethical dilemmas result when testifying for the prosecution in a death penalty case, and even more so when presenting aggravating or victim impact statements to assist the prosecution to obtain a death penalty verdict. Some psychiatrists see nothing wrong with any role prior to participating in the execution itself, but see something wrong with performing a competence to be executed evaluation for any side since the determination more directly could lead to the individual’s execution. It is generally accepted as inappropriate to treat people to make them competent to be executed. Regardless of how a psychiatrist feels about the death penalty, many psychiatrists still see something ethically wrong in a physician helping the prosecution punish an individual with death. That can be a special problem with adolescents. Some forensic psychiatrists in contrast see death penalty concerns as a only a personal ethical and moral issue, and have no problem with playing roles that assist the prosecution to obtain a death penalty. The United States is the only western democracy still retaining the death penalty. According to the United Nations, except for China, the United States has most expanded the use of the death penalty (Crossette 1997). Capital punishment is a source of continuing debate in this country. The consequent significant ongoing ethical controversy for American psychiatry (Foot 1990; Leong et al. 1993; Weinstock et al. 1992) and medicine (Michalos 1997) as well, without a consensus, has resulted in no clear ethical guidelines for many aspects of psychiatric participation in capital cases. Opinions differ regarding the ethical propriety of many death penalty roles for psychiatrists based on personal ethical, moral, or religious considerations, or individual views regarding what should be ethically acceptable or desirable on a professional basis. Special legal considerations also apply to adolescent death penalty sentences. In 1988, the United States Supreme Court in Thompson v. Oklahoma prohibited a juvenile death penalty for those adolescents who were under age sixteen years at the time of the commission of

16 Special issues in adolescent psychiatry

the crime (Thompson v. Oklahoma 1988). However, in the subsequent cases of Stanford v. Kentucky and Wilkins v. Missouri, the Supreme Court explicitly permitted adolescents aged at least sixteen years at the time they committed a capital crime to be executed (Stanford v. Kentucky and Wilkins v. Missouri 1989) and they have not changed that position. Individual states nevertheless can require a higher minimum age or prohibit capital punishment altogether. In those states with a juvenile death penalty, adolescence still can be a mitigating factor that the defense can present during the penalty phase of trial. It has been pointed out that the arguments against a juvenile death penalty may not be valid, since most adolescent defendants meet the minimum cognitive standards necessary for defendants to be competent to be executed (Leong and Eth 1989). Also, most adolescents – because of appeals – have become adults by the time death penalty sentences are carried out. Therefore, at the time of an execution, they would be as competent as an adult to be executed, regardless of their immaturity at the time they committed the crime. Although most adolescents can meet cognitive tests for competence to be executed, competence to stand trial, and meet the cognitive test that precludes a M’Naghten insanity defense (Miller 1994), these cognitive tests do not take emotional and cognitive immaturity into account. Achievement of the Piaget’s formal stage of reasoning, necessary for reflective thought, makes conceptualization of alternative courses of action possible. In contrast, pre-formal adolescents may be unable to conceptualize alternatives and therefore may act impulsively. Formal thought makes regulation of affect and behavior possible (Overton et al. 1992). This issue can be introduced as a mitigating factor in the sentencing phase of trial, even though it may not be relevant to an insanity defense. It is ironic that immaturity is considered automatically when denying certain privileges to adolescents, but is not recognized automatically when sentencing a defendant to death for a capital crime committed during adolescence. Adolescents are not permitted to vote, to drink, or to drive below a certain age (determined by the local jurisdiction). No cognitive test is used to identify those adolescents who do have the intellectual capacity and emotional maturity to perform those acts. However, when it comes to the death penalty, simple cognitive tests are employed that do not take adolescent immaturity into account. If an adolescent meets these cognitive tests, death can be imposed. In the United States, fear of crime and the high rate probably result in the recent focus on increasingly harsh punishments for adolescents as well as adults. Despite the legal permissibility of most professional roles in capital cases, adolescent psychiatrists must become aware of the ethical considerations involved when they participate in such cases, since facilitating death is most in conflict with traditional medical roles. Psychiatrists can be

asked to present aggravating circumstances to help obtain a death penalty verdict, find fault with mitigating circumstances presented by a defense psychiatrist, or treat an adolescent to make him/her competent to be executed. In the absence of clear generally accepted ethical guidelines for most facets of death penalty case involvement, adolescent psychiatrists individually must assess carefully the ethics of various professional roles in capital cases and make their own determinations of what is ethically acceptable or desirable.

RELEVANT ETHICAL GUIDELINES FOR ADOLESCENT PSYCHIATRISTS Although the American Society for Adolescent Psychiatry publishes position statements, it does not have ethical guidelines. The American Academy of Child and Adolescent Psychiatry has written a useful Code of Ethics covering a number of pertinent areas (AACAP 1970). However, the AACAP does not enforce the Code but instead reports alleged violations to the local district branch of the American Psychiatric Association (APA) for those child psychiatrists who are members of the APA. For child psychiatrists who are not members of the APA, the AACAP refers complaints to the state medical boards for assessment. The American Medical Association (AMA) has published its Principles of Medical Ethics, and their Council on Ethical and Judicial Affairs has given Opinions elaborating on the Principles (AMA Council on Ethical and Judicial Affairs 2001). These are pertinent to all medical practice. The APA follows the AMA guidelines and has annotated them for use in psychiatric practice (APA 2001a), and the APA Ethics Committee has published opinions about these annotations (APA 2001b). Moreover, the APA enforces these ethical rules by review and/or hearings conducted by the local APA district branch if there is an ethics complaint against a member. In forensic psychiatry, the American Academy of Psychiatry and the Law has developed ethical guidelines for forensic psychiatric evaluations of all individuals of any age (AAPL 2002). The AAPL Ethics Committee has also published opinions in its Newsletter (Weinstock 1992, 1995) and is examining new revisions to the guidelines. The AAPL does not enforce its ethical guidelines, but complaints are referred for further inquiry and possible sanctions to the local APA district branch for APA members, the state licensing boards for non-APA members, or to foreign psychiatric organizations for members from foreign countries. The American Academy of Forensic Sciences (AAFS 2002) also has a Code of Ethics for all forensic sciences. AAFS has its own Ethics Committee that makes determinations and holds hearings when there is an ethics complaint against a member. AAFS enforces its Code by its Board of Directors that

Ethical issues in adolescent psychiatry 17

determines sanctions on the basis of recommendations by its Ethics Committee. Professional ethical codes and guidelines determine minimal ethics requirements. Just as in the criminal justice system in which failure to prove guilt beyond a reasonable doubt does not prove innocence, failure to sanction a practitioner for an ethics violation does not necessarily mean the behavior was professionally ethical. In addition to professional ethical concerns, whether or not elucidated in guidelines and whether or not generally accepted, practitioners can have personal ethical concerns based on personal ethical, moral, or religious values. If ethical concerns are of a personal and not a professional nature, the case in most instances should be referred to another psychiatrist. Most adolescent psychiatrists want to do more than meet only minimal standards. True ethical concerns reach beyond that. Adolescent psychiatrists most likely aspire to a higher ethical standard both on a professional and on a personal basis. In cases of conflicting requirements and duties, more than one type of action would likely meet minimal ethical standards, but all potential actions are not thereby ethically equivalent. Ethical dilemmas should be carefully considered and analyzed. Care should be taken that individual biases and prejudices are not misrepresented as conclusions based primarily on years of professional training and experience. Conflicting responsibilities and/or financial considerations can easily lead to temptations to place these factors above the adolescent patient’s welfare. Of course, adolescent psychiatrists are not alone in facing such dilemmas, which have increasingly become part of the therapeutic landscape. However, the ethical complexity can be greater than in the treatment of children or adults because of potential conflicting responsibilities to adolescents, parents, institutions, and society and because the adolescent is more capable than a child of having a meaningful independent opinion. In difficult situations ethical consultation should be obtained. Ethical practice should involve learning how to analyze complex ethical dilemmas by first determining the relevant principles and considerations and then deciding how much weight to assign to each and balancing the factors (Hundert 1990). Such analysis is likely to lead to a meaningful ethical decision with a rational appreciation of alternative options for action as opposed to opinions based solely on emotions and biases. Adolescents often present unique ethical considerations. Consequently, ethical vigilance, coupled with clinical knowledge and understanding, is especially salient for the adolescent psychiatrist. The recent societal emphasis on cost cutting as its highest healthcare priority is likely to result in increasing pressures to sacrifice clinical quality and ethical standards in the service of fiscal savings. These trends are likely to make professional ethics considerations more important than ever to assist current

and future adolescent psychiatrists in their efforts to maintain their focus on what should be their primary concern, the adolescent’s welfare.

REFERENCES American Academy of Child and Adolescent Psychiatry Code of Ethics, 1970. American Academy of Forensic Sciences. Code of Ethics in Membership Directory. Colorado Springs, 2002. American Academy of Pediatrics v. Lungren. California Supreme Court No. 884574, filed August 5, 1997. American Academy of Psychiatry and the Law. Ethical guidelines (revised, 1995). In AAPL Directory. Bloomfield, Connecticut, 2002. American Medical Association Council on Ethical and Judicial Affairs. Code of medical ethics. In Current Opinions with Annotations. Chicago: American Medical Association, 2001. American Psychiatric Association. The APA model law on confidentiality of health and social service records. American Journal of Psychiatry 136: 138–147, 1979. American Psychiatric Association. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Washington, DC: American Psychiatric Association APA, 2001a. American Psychiatric Association. Opinions of the Ethics Committee on the Principles of Medical Ethics. Washington, DC: American Psychiatric Association, 2001b. Beauchamp, T.L., Childress, J.F. Principles of Biomedical Ethics, 4th edition. New York: Oxford University Press, 1994. Committee on Bioethics (American Academy of Pediatrics). Informed consent, parental permission, and assent in pediatric practice. Pediatrics 95: 314–317, 1995. Crossette, B. UN monitor investigates American use of death penalty. New York Times, September 30, 1997. Dyer, A.R. Ethics and Psychiatry Toward Professional Definition. Washington, DC: American Psychiatric Press, 1988. Flavel, J.H. The Developmental Psychology of Jean Piaget. Princeton: Van Nostrand, 1963. Foot, P. Ethics and the death penalty. In Rosner, R. and Weinstock, R. (eds), Ethical Practice in Psychiatry and the Law. New York: Plenum, 1990, pp. 207–217. Ford, C.A., Millstein, S.G. Delivery of confidentiality assurances to adolescents by primary care physicians. Archives of Pediatrics and Adolescent Medicine 151: 505–509, 1997. Ford, C.A., Millman, S.G., Halpern-Felsher, B.L., et al. Influences of physician confidentiality assurance on adolescents’ willingness to disclose information and seek future health care: a randomized controlled trial.

18 Special issues in adolescent psychiatry Journal of the American Medical Association 278: 1029–1034, 1997. Hundert, E.M. Competing medical and legal ethical values: balancing problems of the forensic psychiatrist. In Rosner, R., Weinstock, R. (eds), Ethical Practice in Psychiatry and the Law. New York: Plenum, 1990, pp. 53–72. In re Gault, 387 US 1, 87 S.Ct. 1426 (1967). In re Roger S, 19 Cal. 3d 921 (1977). Leong, G.B., Eth, S. Behavioral science and the juvenile death penalty. Bulletin of the American Academy of Psychiatry and Law 17: 301–309, 1989. Leong, G.B., Silva, J.A., Weinstock, R. Ethical considerations of clinical use of Miranda-like warnings. Psychiatry Quarterly 59: 293–305, 1988. Leong, G.B., Weinstock, R., Silva, J.A., Eth, S. Psychiatry and the death penalty: the past decade. Psychiatric Annals 23: 41–47, 1993. Macbeth, J.A. Legal issues in the psychiatric treatment of minors. In Shetky, D.H., Benedek, E.P. (eds), Clinical Handbook of Child Psychiatry and the Law. Baltimore: Williams & Wilkins, 1992, pp. 53–74. Michalos, C. Medical ethics and the executing process in the United States of America. Journal of Medicine and Law 16: 125–167, 1997. Miller, R.D. Criminal responsibility. In Rosner, R. (ed.), Principles and Practice of Forensic Psychiatry. New York: Chapman & Hall, 1994, pp. 198–215. Overton, W.R., Steidel, J.H., Rosenstein, D., et al. Formal operations as regulatory context in adolescence.

In Feinstein, S.R. (ed.), Adolescent Psychiatry, Volume 18. Chicago: University of Chicago Press, 1992. Parham v. J.R., 99 S.Ct. 2493, 442 US 584 (1979). People v. Stritzinger, 34 Cal. 3d 505, 668 P. 2d 738 (1983). Rosner, R. Foundations of ethical practice in the forensic sciences. Journal of Forensic Sciences 42: 1191–1194, 1997. Rosner, R., Weinstock, R. (eds), Ethical Practice in Psychiatry and the Law. New York: Plenum, 1990. Stanford v. Kentucky, Wilkins v. Missouri, 109 S.Ct. 2969 (1989). Thompson v. Oklahoma, 101 L.Ed. 2d 702 (1988). Weinstock, R. AAPL’s committee on ethics: additional opinions. Newsletter of the American Academy of Psychiatry and the Law 20(2): 51, 1995. Weinstock, R. Opinions by AAPL’s committee on ethics. Newsletter of the American Academy of Psychiatry and the Law 17(1): 5–6, 1992. Weinstock, R., Leong, G.B., Silva, J.A. The death penalty and Bernard Diamond’s approach to forensic psychiatry. Bulletin of the American Academy of Psychiatry and Law 20: 197–210, 1992. Weinstock, R. Commentary: a broadened conception of forensic psychiatric ethics. Journal of the American Academy of Psychiatry and the Law 29: 180–185, 2001. Weintrob, A. Confidentiality and its dilemmas in child and adolescent psychiatry. In Rosner, R. (ed.), Principles and Practice of Forensic Psychiatry. New York: Chapman & Hall, 1994, pp. 323–330.

1.3 Ethics in managed care in adolescent psychiatry JEREMY A. LAZARUS

INTRODUCTION The history of ethics in psychiatry dates back to 2000 BC with the Code of Hammurabi, followed by that of Hippocrates in 200 BC. Modern medical ethics traces back to a Code of Medical Ethics by Thomas Percival in 1847. The code of the American Medical Association (AMA) was based on Percival’s code (AMA 1994). The AMA Principles of Medical Ethics forms the basis for the American Psychiatric Association’s Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry (APA 1995). The American Psychiatric Association (APA) also publishes Opinions of the American Psychiatric Association Ethics Committee (APA Opinions 1995) which provides guidance on numerous ethical questions. Managed care encompasses many different forms of cost control in healthcare systems, from closed panel Health Maintenance Organizations (HMO), open panel HMOs, Preferred Provider Organizations (PPO), Physician Hospital Organizations (PHO), Utilization Review Organizations, and other entities which ‘manage’ the care of patients. Mental health services can be provided as an integral part of these organizations, or can be ‘carved out’ – meaning that mental health and/or substance use services are contracted to an entity outside of the managed care organization. At the present time, these carve out organizations manage the care of over 100 million Americans. Managed care companies and techniques are used in private systems, public systems and in academic medical centers. Although it is unclear whether managed care will in the long run control healthcare costs, it is clear that the market is rewarding these burgeoning companies with increased business as measured by their rapid growth over the past decade. Massive changes in the healthcare system have created unprecedented change in systems and for individual health practitioners. Psychiatrists and psychiatric patients have been deeply concerned that managed care would add another level of administrative bureaucracy which

would affect the already underfunded and stigmatized psychiatric patient. Concurrently, however, mental health professionals have stood together to fight for parity for the mentally ill. Recent legislative successes at the Federal level (albeit modest) have provided parity for lifetime caps similar to all other illnesses. The passage of a children’s health bill in 1997 with parity for mental health treatment for children in public sector systems is a good sign in this direction. As managed care has evolved, there has been a shift away from prolonged hospitalization, and indeed most managed care programs allow hospitalization only for stabilization of those patients who are suicidal, homicidal, severely dysfunctional, or whose treatment cannot be administered safely on an outpatient basis, for example those patients with complex medical problems requiring electroconvulsive treatment (ECT). Prior to this evolution of managed care there were adolescent-specific inpatient units both in free-standing psychiatric hospitals and psychiatric units in general hospitals. The dramatic decrease in length of stay has been accompanied by the use of less restrictive levels of care, such as partial hospitalization, intensive outpatient treatment and residential care. Also, many adolescents who might have been hospitalized with severe behavioral problems or who required significant social assistance are no longer deemed to require psychiatric admission. Ethical dilemmas in these systems occur when there is a difference of opinion between the treating psychiatrist and the managed care organization regarding the appropriate level of care. The treating psychiatrist is obliged to advocate for the care judged necessary. The goal of the managed care organization is to provide adequate treatment at the lowest cost. These two positions may clash, leading to difficulties on both sides. Unfortunately, the patient may be caught in the middle as the two parties try to come to a resolution. Insofar as this leads to inadequate or inappropriate treatment, there is a significant problem for the treating psychiatrist and patient. If, on the other hand, the managed care organization offers

20 Special issues in adolescent psychiatry

appropriate alternatives to the type of care that is being recommended by the treating psychiatrist, and if the psychiatrist agrees, then there is no ethical problem. The underlying ethical principles involved in these dilemmas stem from the dual obligation of the treating psychiatrist, and for that matter administrative psychiatrists, to the care of the individual patient while not providing unnecessary care. It is ethically appropriate to provide less costly care if the same beneficial outcome is reached. Unfortunately, we are currently going through a transition where valid outcome research comparing different forms of treatment intervention is still years away. We are left often with the best medical judgment of the treating psychiatrist versus the judgment of the managed care organization. While many of the larger managed (or behavioral health) mental health organizations provide treating professionals their guidelines or protocols for treatment, they are not universally available. This often leaves the treating psychiatrist frustrated in not knowing on what basis or by what scientific principles a particular treatment or level of care requested is being denied. Psychiatrists working within or for such organizations should insist that any guidelines for treatment or for benefit administration follow accepted scientific guidelines which are part of a national or community standard. This would not permit decision making at the managed care level to supersede sound medical and clinical judgment. Children and adolescents have often been discriminated against in mental health benefits. For example, one of the most common complaints brought to the APA’s Managed Care Hotline was about failure to cover the diagnosis and treatment of Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder. In addition, many children or teens with behavioral or conduct disorders were denied treatment on either an inpatient or an outpatient basis. Many psychiatrists have been frustrated as they attempted to have a safe environment within which to conduct a more thorough evaluation or provide comprehensive treatment in a controlled setting. On the other hand, some psychiatrists have been able to adapt to a managed care model or continuum of care in which a patient is moved from more restrictive to less restrictive levels of care as the clinical situation warrants. When these decisions are made for good medical reasons and without disruption of the treatment there is no ethical problem. When these decisions are made on purely monetary grounds there are often significant ethical problems.

which include autonomy, beneficence, non-maleficence, and justice. Beneficence relates to more traditional or Hippocratic medical ethics, namely doing the most for each individual patient. The principle of non-maleficence or doing no harm is currently supported not only by ethical principles but also by government regulatory agencies. The principle of autonomy which has come to play a more predominant role in ethical decision making arose out of the women’s movement, the civil rights movement, and the Holocaust. It relates to patient informed consent in medical decision making. Current writings regarding ethics in managed care approach the issue of allocation of healthcare resources and look more to the principle of justice to advocate for the fair distribution of resources amongst a population of patients (Sabin and Daniels 1994). The policies and positions of the AMA and APA agree that physicians need to be involved in resource allocation decisions, but that those decisions should not be made at the bedside or in the consulting room. The issue of resource allocation is especially pertinent when related to adequate resources for the treatment of children and adolescents. Competing groups of those with mental illness from those with the most severe to the most acute, from young to old, from different cultures, from those with limited or unlimited personal resources, all create allocation dilemmas. The arguments for fair distribution of healthcare resources for mental illness needs to start from a place of equality in the original distribution of the healthcare dollar.

Ethics in managed care Ethical issues in managed care have been described in detail elsewhere (APA 1992; Morreim 1991). The principal areas of conflict appear to cluster around the following areas:

• • • • • •

Informed consent Disclosure Conflicts of interest Confidentiality Interference in the doctor–patient relationship Relationships with other mental health professionals.

While these areas are not unique to managed care, there has been a considerable increase in concern in all of these amongst psychiatrists and other mental health professionals. Methods of dealing with and mitigation of these concerns will be discussed in the remainder of this chapter.

ETHICAL PRINCIPLES INFORMED CONSENT In addition to the Ethical Principles as published by the AMA and APA, many physicians have followed a set of bioethical principles (Beauchamp and Childress 1994)

The relationship of the treating psychiatrist to an adolescent and their family places multiple burdens on the

Ethics in managed care in adolescent psychiatry 21

psychiatrist for informed consent. The psychiatrist must inform not only the patient, but also the family or legal guardian of the options for treatment. In addition, options which are unavailable within a managed care plan, benefit limits of the plan which might limit care, and special treatments or treatment settings which are not available within the plan must be discussed with both adolescent and family. Of course the presenting factors in the patient’s problems might limit the extent to which such information will be discussed. However, as with every case, patient autonomy requires the ethical psychiatrist to discuss all of these issues with patients. The varieties and complexity of treatment options and limitations in managed care place an extra burden on the psychiatrist. This burden can be mitigated if the managed care plan explicitly details some of these issues for those purchasing the plan. Unfortunately, there is no uniform method or regulation in all states requiring the type of detail that would appear to be ethically appropriate. Various states have enacted patient protection acts and some of these require uniform disclosure of this type of information, e.g., Colorado. The critical issue is that the patient (and family) should be aware of the most beneficial treatment option in their case, even though some of those options might not be available through the managed care plan.

your recommended setting, you should inform both patient and family and discuss other ways of funding the recommended treatment. If there is no other option from a funding standpoint you would need to determine with the family whether other less desirable or comprehensive treatment approaches would be safe and at least partially effective. If you do not feel that treatment can be undertaken in a safe fashion because of the limitations, you would be free to withdraw from the case assuming you can arrange some alternative treatment setting for the patient. This example raises one of the painful realities of ethics in a managed care environment. Because of benefit limitations or network limitations it may not be possible to treat patients in what might be the most effective setting. However, this is not a new problem. Without mental illness coverage in insurance, patients were often referred into public systems of care. Unfortunately, public systems continue to be underfunded and are unable to absorb all of those patients who would benefit from treatment. Although managed care may have opened up some initial access for some, if it is not able to provide ongoing treatment in appropriate settings and there is no alternative treatment setting funded by public dollars there is a recipe for many unhappy and undertreated individuals.

CASE EXAMPLE CASE EXAMPLE You are a psychiatrist and have agreed to contract with a managed care company which specifically excludes treatment in specialized inpatient units for eating disorders. You have evaluated a fourteen-yearold girl who has a serious eating disorder resulting in both psychological and physical danger to herself. In your area of the state there are only general psychiatric beds in community hospitals. It is your professional opinion, based on your evaluation and best medical judgment, that treatment in a setting with a defined eating disorder program for adolescents is most appropriate. What should you tell the patient, family and managed care organization? Discussion You should clearly inform the patient and family of your assessment and recommendations. You should clarify that from your understanding the managed care organization does not cover treatment in the type of specialized setting that you recommend. You should attempt to advocate for your patient by indicating why an exception should be made in this situation and continue advocating through all levels of appeal within the managed care organization. You might also suggest that the family do likewise. If the managed care organization will not cover the treatment in

You are a psychiatrist in a group which has a contract with a managed care organization. Your group has a large and comprehensive network of mental health professionals but does not include all of the mental health professionals in the area. You evaluate a fifteenyear-old Hispanic adolescent. It is your determination that a Hispanic psychiatrist would be best suited to treat this teenager, but there are no Hispanic psychiatrists in your network. What should you do? Discussion It is your obligation to inform the parents and teenager of your recommendation. As in the case above, if competent treatment cannot be rendered within the network you should advocate within your group for payment to a competent Hispanic psychiatrist in the area. If the treatment that you can render within the group is adequate but not optimal, you should inform the patient and parents and come to an informed decision in your discussions with them.

CASE EXAMPLE You are the medical director for a managed care company. Your organization is gathering data on treated

22 Special issues in adolescent psychiatry

patients for an outcome study. The data requested includes patient-specific information regarding diagnosis, any medications used, and suicidality. Your organization would like you to query the database to gather this information without informing the treated patients. Is this ethical? Discussion No. Patients have an ethical right to know and to approve information about them and their treatment which is used for purposes other than their direct treatment. They should also have a right to refuse to participate in such a study. This would be equally true if there was a waiver signed when insurance was initially purchased. Informed consent contemporaneously with the treatment being given is critical. In the case of adolescents, particular attention needs to be paid to assure complete trust in the therapeutic relationship.

DISCLOSURE Assumed in the doctor–patient relationship is honesty. In order to honor that principle, it is important to disclose to patients anything related to the specifics of their managed care coverage which will affect treatment. With adolescents this could run the gamut of disclosure of treatment options, benefit restrictions, utilization review which might limit treatment, and the presence or absence of supportive services (e.g., educational) which might prove beneficial. Often, it would be the parents who would be more interested in such information, but the adolescent should be informed as appropriate. For those physicians working for or within managed care entities, the importance of disclosure is no less important. Indeed, the public looks towards physicians to advocate and support on their behalf. Full disclosure by a managed care entity works towards that goal. Disclosure is another important facet required in various patient protection acts.

CASE EXAMPLE You have contracted with a managed care company which only allows initial assessment of patients followed by group therapy in almost all cases. Many adults and adolescents you evaluate have a need for more focused individual treatments. What should you do? Discussion If you choose to continue with your contract, it would be ethical to inform the patients of the method the managed

care company uses to provide ongoing treatment. You should not imply that group therapy is the preferred therapy unless it truly is. As noted above, you must advocate on behalf of the patient for the care that you believe is the most appropriate. If that cannot be provided by way of the insurance benefit, you must decide whether you can provide a level of care that, although not optimum, might be helpful. With adolescents the necessity for clear and unambiguous disclosure of these issues may help to cement a therapeutic alliance.

CONFLICTS OF INTEREST Conflicts of interest in managed care generally revolve around financial issues (APA 1989). Many of the financial arrangements entered into by psychiatrists and managed care entities have built-in conflicts which may pit the psychiatrist’s financial interest against the best treatment of the patient. The form that these conflicts take is on a continuum and relates to how much financial risk the psychiatrist assumes. For example, capitation for a group of patients places a physician or group of physicians at full or partial risk for that group. If more services are provided the group, and therefore individual members of the group, will receive less reimbursement. If fewer services are provided, the group may benefit by increased reimbursement. The degree to which this might influence physician behavior may be mitigated by there being adequate funds in the capitation pool, a defined method of utilization review so that all members in the group follow the same guidelines, providing treatment under scientifically approved professional guidelines and utilizing patient outcome studies. The same conflicts can arise with other payment arrangements, such as withholds or bonuses for utilization targets. These conflicts can pertain to the treating physician or to administrative physicians who might benefit by placing their personal interests above those of patients. The appropriate way to deal with conflicts of interest in interaction with the adolescent patient and family is to fully disclose any such conflict. The patient then is on notice that you may have a conflict and could question you should the need arise. If it is clear to you that the conflict is impairing your ability to objectively assess and treat patients, you should discontinue participation in these situations. Concerns have been raised about psychiatrists in administrative positions who receive financial incentives linked to utilization targets. These incentives may place the administrative psychiatrist in a conflict of interest between advocating for appropriate care and his or her own financial wellbeing. For these reasons, conflicts of interest should be resolved in favor of patients if they occur.

Ethics in managed care in adolescent psychiatry 23

CASE EXAMPLE You are part of a group which has a capitated contract through a managed care company. You evaluate a teenager who has suicidal ideation and who you believe may be at risk for suicide. Your group has had a good deal of inpatient utilization in this month and you are aware that your reimbursements for this month may be considerably less than in previous months. As you weigh the benefits and risks of considering inpatient hospitalization for the teenager you become aware that your conflict regarding finances may be affecting your decision making. What should you do? Discussion Assuming that you have previously informed both patient and family of your potential conflict of interest related to the method of treatment financing, you should consider discussing the case with a consultant or supervisor who is a financially disinterested party in the matter. It would also be appropriate for the group as a whole to discuss how the financial issues are affecting treatment decisions and to find ways of dealing with these conflicts that place patient interests above personal interests.

CONFIDENTIALITY Confidentiality between doctor and patient is the bedrock of medical and especially psychiatric treatment. The principle of confidentiality was articulated in the Hippocratic Oath and has been supported over the centuries. The underlying issue has to do with the ability of a patient to trust that what is revealed to the psychiatrist will remain between the two. When treating adolescents, the situation is complicated by the need, at times, to reveal to parents or guardians information that is confidential but is required for the safety of the adolescent. Such situations most often encompass suicidality or other behavior so potentially destructive as to cause serious harm to the teenager. In the spirit of informed consent these exceptions to the general rule of confidentiality should be spelled out to the adolescent early in treatment. With those exceptions, however, the adolescent should feel confident that there will be no breaches of confidentiality. Yet managed care provides a minefield where information related to that adolescent may be shared with utilization reviewers, case managers, and psychiatrist medical directors. The teenager should be notified if information about their treatment is being shared with others. The exact nature of the information revealed should be discussed and approved by the patient. In the best case scenario it would be possible to include the patient in the discussion process with the managed

care company. This provides the advantage of including the patient in treatment planning issues and reducing any concern that the adolescent might have about breaches of confidentiality. If there are changes in laws allowing greater access to information from patient records either for the purpose of healthcare research or by law enforcement agencies, there would be even greater levels of concern about adolescents’ ability to trust in the healthcare system. A recent survey of adolescents indicated their increased uneasiness about sharing information with healthcare providers if they were not assured of confidentiality.

INTERFERENCE IN THE DOCTOR–PATIENT RELATIONSHIP One of the critical issues in the proper treatment of an adolescent is the ability to establish a good working relationship based on trust. That trust can be affected by any of the issues previously discussed, but also by a more subtle element. That is the ability of the treating psychiatrist to place the needs and interests of the patient above all others and to attend to the patient unencumbered by concerns outside the treatment relationship. While that may sound like a lofty ideal – at least in previous public or private settings – the ability to predict what resources would or would not be available was quite clear-cut. There is a multiplicity of managed care plans, methods of payment, methods of utilization review or case management, and interactions between psychiatrist and company and patient (or parent) and managed care company. The level of such outside involvement can often place a wedge between the psychiatrist and patient. Such a wedge is quickly perceived by adolescents who are fearful that adults will not be on their side but will be listening to a different master. Of particular concern are those adolescent patients who will benefit from psychotherapy. If the treating psychiatrist does not feel free to provide the type of psychotherapy that is appropriate, and if there is an unreasonable amount of outside interference, there can be a disruption in the therapeutic field necessary for a good psychotherapeutic alliance. We do not accurately know how often there has been this damaging disruption in treatment. However, judging by both the numbers and passions of psychiatrists who have complained to the APA’s Managed Care Hotline about interference, there appears to be a substantial number who are deeply disturbed and angered. One possible solution to these problems is for managed care companies to decrease or eliminate multiple reviews of individual patients. It would be better patient care to allow for a course of treatment with a review of that treatment if reasonable goals are not being achieved. Another solution is for the managed care organization to allow considerable autonomy to those psychiatrists who

24 Special issues in adolescent psychiatry

appear to be following scientifically appropriate guidelines and appear to have good patient outcome. It is the anecdotal experience of many that the best outcome treatment is most often the least costly.

CASE EXAMPLE You are treating a fifteen-year-old girl who was the victim of prolonged incest between the ages of seven and nine. Over the course of three months of evaluation and psychotherapy, there is the beginning of some treatment alliance but little resolution of initial symptoms of depression and anxiety. You have been requesting twice-weekly psychotherapy from the managed care organization and have continued to consider the adjunctive use of antidepressant or anti-anxiety medications. In your current review with the managed care organization you request an additional three months of twice-weekly psychotherapy. The case manager indicates approval for one psychotherapy visit on a bi-weekly basis and asks whether you are planning to begin medications. What is the ethical course to follow?

Discussion The ethical course is to continue to advocate for the type and frequency of treatment which you think is most appropriate. If you believe that the course of treatment is consistent with your previous education and experience in this type of case, you should feel comfortable in requesting through all levels of appeal in the company for the services you deem appropriate. Regarding the use of medications, you might request to speak with the company’s psychiatric medical director and be assured that he or she has had at least as much training in similar cases as yourself. If you and the managed care personnel continue to disagree, you might request an outside consultation, though you might be reluctant to place the patient in another situation where she might feel retraumatized. This type of case raises the specter of psychiatrists performing heroic acts in terms of time and advocacy to make certain that appropriate treatment is carried out. The degree to which psychiatrists are willing to fight for their patients may indeed fade if many cases result in such conflict. As a profession we should not abandon the difficult, chronic or more long-term patients in favor of those who respond more quickly.

RELATIONSHIPS WITH OTHER MENTAL HEALTH PROFESSIONALS The treatment of adolescents in all levels of care frequently requires working with a team of mental health

professionals. One professional might work primarily with the adolescent while another works with the family system. Another professional might work individually with parents. Managed care systems often limit the scope of practice by psychiatrists to primarily the management of the medications. In such divided treatment arrangements, another mental health professional would be providing the psychotherapy for the patient. Such divided or collaborative treatment has its own unique set of ethical and legal dilemmas. These dilemmas fall into the following general areas of concern:

• • • • • •

Competence of all mental health professionals. Ensuring the licensure and malpractice coverage of the other mental health professional. Ensuring that adequate time is spent between the collaborating professionals communicating about the treatment. Ensuring that the psychiatrist is not used as a figurehead. Ensuring that medical duties are not delegated to non-medical mental health professionals. Improper fee arrangements (such as fee splitting).

Paying attention to these important areas of potential ethical pitfalls will at least keep the psychiatrist alert to potential problems. Without attention to these areas, the psychiatrist may be placing him or herself in ethical (and often legal) jeopardy.

CASE EXAMPLE A psychiatrist agrees to provide medication assessment and treatment to a sixteen-year-old boy who is being seen by a psychologist for treatment of major depression. The psychiatrist agrees to start the boy on antidepressant medications and to communicate with the psychologist about his findings and treatment. During the course of the treatment, the psychiatrist becomes aware that the psychologist has failed to communicate suicidal ideation and behavior to the psychiatrist. What should the psychiatrist do? Discussion Even though the psychiatrist is providing only the medications in this case, he is ethically and legally responsible for anything that might happen to this boy. If the failure in communication was an oversight and the psychiatrist is assured that it will not recur, he might feel comfortable in going ahead in the treatment. If the psychologist is unwilling or unable to provide the type of communication and collaboration that the psychiatrist deems adequate, he should consider withdrawing from the case or discussing with patient and parents transfer to a different psychologist.

Ethics in managed care in adolescent psychiatry 25

CASE EXAMPLE A group of mental health professionals asks you to work part-time in their office and to provide medication assessment and treatment for patients that they are seeing in therapy through managed care contracts. You are to be paid a set fee for each patient and the group asks that you return 30 per cent of the fees to them to cover the cost of overhead. Is this ethical? Discussion Probably not. Even if the 30 per cent figure approximates the cost of overheads, there is the appearance of a feesplitting arrangement whereby it appears you are paying the group back 30 per cent of your fees for the purpose of receiving the referred patients. A better arrangement would be for you to reimburse the group for the actual and agreed upon costs of overheads.

are coming under new assaults as fundamental questions about treatment, confidentiality, and the doctor–patient relationship are being challenged. When the changes that come about occur with patient benefit, they should be studied along with other forms of treatment. When the changes that occur result in patient harm, we must protest by refusing to cooperate in unethical systems. If a managed care system creates an atmosphere in which adolescents can be adequately and safely treated while being prudent in the use of healthcare resources, then psychiatrists can contribute their time and expertise. The inherent challenges in treating adolescents can be aided by good high cost case management or complicated by unnecessary intrusions into the treatment relationship. Hopefully, as systems continue to evolve, the ethical principles which have guided the practice of medicine and psychiatry will be more carefully paid attention to in managed systems of care.

REFERENCES CASE EXAMPLE You are working in a multidisciplinary adolescent clinic and are the only psychiatrist in the clinic. There are several mental health professionals who provide most of the psychotherapy. Because of your very large caseload, the other professionals suggest that you leave a series of signed prescription blanks for commonly prescribed antidepressants and anti-anxiety agents which they will then distribute to patients based on their collaboration with you. Is this ethical? Discussion No. You should not delegate to a non-medical mental health professional duties for which they are not licensed or trained. The only exception might be with advanced practice nurse practitioners who have extensive medical training and already have independent or supervised prescription authority.

CONCLUSIONS This chapter has covered some of the basic principles underlying ethical practice in any setting. These principles

American Medical Association Council on Ethical and Judicial Affairs. Code of Medical Ethics, Current Opinions with Annotations. Washington, DC: American Medical Association, 1994, 2000–2001. American Psychiatric Association Ethics Newsletter. Conflicts of Interest. 5: No. 2, 1989. American Psychiatric Association Ethics Newsletter. Managed Care. Vol. VIII, No. 1, 1992. American Psychiatric Association. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Washington, DC: American Psychiatric Association, 1995, 2001. American Psychiatric Association. Opinions of the Ethics Committee on the Principles of Medical Ethics. Washington, DC: American Psychiatric Association, 1995. Beauchamp, T.L., Childress, J.F. Principles of Biomedical Ethics. New York: Oxford University Press, 1994. Morreim, E.H. Balancing Act: The New Medical Ethics of Medicines New Economics. Dordrecht, the Netherlands: Kluwer Academic Publishers, 1991. Sabin, J., Daniels, N. Determining ‘medical necessity’ in mental health practice. Hastings Center Report 24: 5–14, 1994.

1.4 Research in adolescent psychiatry DANIEL OFFER AND CARYN STOLLER

INTRODUCTION The purpose of this chapter is to demonstrate that clinical research in adolescent psychiatry is an important part of the field. Using a variety of methodologies, research endeavors can help to shed light on areas which are of great interest to adolescent psychiatry. Although the types of research vary, we will follow Hulley and Cummings’ (1988) descriptions. First, there is the observational study, in which the investigator observes events without altering them (i.e., the behavior of adolescents on an inpatient unit). Second, there is the experimental design, where an intervention is applied (i.e., therapy) and the effect on outcome is observed. Third, there is the cross-sectional study, when each subject is examined, but only on one occasion (i.e., the emotional make-up of juvenile delinquents). Fourth, there is the longitudinal study, where a previously identified subject is followed over time, perhaps from adolescence to adulthood. It is not our intention to present a ‘how to do research’ chapter. Obviously we cannot, within the limits of this chapter, cover the whole field, and those readers interested in how to design clinical research are referred to two excellent monographs: Designing Clinical Research (1988) by Hulley and Cummings, and Research Design in Clinical Psychology (1992) by Kazdin. In this chapter, we will illustrate the role of research in adolescent psychiatry by discussing three important areas, as seen through the eyes of a clinical investigator.

PSYCHIATRIC TREATMENT OF ADOLESCENTS Adolescent psychiatry, like the rest of psychiatry, was heavily influenced by psychoanalysis at the end of World War II. During the 1950s and 1960s, adolescent units were opened in a large number of psychiatric hospitals

throughout the United States. Adolescents with a variety of psychiatric disorders, including personality disorders, psychotic disorders, mood disorders, and substance abuse disorders, were admitted to these units. Treatment progressed slowly, and the adolescents were kept in the hospital for relatively long periods; indeed, it was not unheard of for an adolescent to stay in the hospital for nine to twelve months, with insurance covering the associated costs. As late as 1974, the average stay for an adolescent at Michael Reese Hospital in Chicago on the private service was 106 days (30th Annual Report 1975). Suffice to say that psychiatry in general – and adolescent psychiatry in particular – lost an excellent opportunity to study the effectiveness of therapy. Almost no one at the time was interested in what Howard and his colleagues (1996) said were the three fundamental questions, namely: 1 Does the treatment work under special, experimental conditions? 2 Does the treatment work in practice? 3 Is the treatment working for this particular patient? These questions raise in turn a host of new questions. For example, what is meant operationally by the term ‘work’? When can a patient be reasonably considered as ‘improved’? When is he or she free of symptoms? When does he or she no longer act out? When is he or she happy? As psychiatry became more biologically based, the influences of psychoanalysis diminished. At the same time, the insurance companies began to ask questions about the efficacy of not only inpatient investigations but of psychotherapy in general. Over the next two decades, coverage for mental illness has spiraled continuously downward as those individuals in charge of managing the insurance programs wanted ‘proof’ that treatment worked. As a result we are now at a crossroads for the field, as in 1997 Congress passed the law that required insurance companies to treat physical and mental illness the same way.

Research in adolescent psychiatry 27

We believe that, during the 1960s and 1970s, psychiatry lost an excellent chance to develop a scientific basis for a better understanding of the factors involved in successful therapy, as well as the factors responsible for failure in therapy. It was assumed, incorrectly, that we knew enough about psychological development and psychotherapy – that all we needed to do was to train clinicians and send them out into the field to cure the mentally ill. When we were challenged about the efficacy of the treatment offered to the adolescent patients, it was found that we did not have the information needed to convince impartial observers (i.e., non-colleagues) that the treatment actually worked. We had many testimonials (i.e., case reports), but no objective, statistically based, data. Consequently, it is the function of those conducting research in adolescents during the 1990s and beyond to undertake clinical investigations on psychiatric treatment that will demonstrate what works, how it works, who should deliver it, and on whom it works. And when we have found out the answers to these questions, we can determine who should pay for it. As an example of requirements in the area of research into psychotherapy for adolescents, let us look briefly at childhood and adolescent depression. As pointed out by Holmes and Wagner (1992), there is paucity of outcome studies on psychotherapy treatments of childhood and adolescent depression, and the subject is lagging far behind equivalent research in adults. These authors also point out that, of the existing research data available, the majority of studies relate to single-case reports, and that these have three main problem areas:

• • •

The lack of ability to generalize. The uncertainty and unreliability of the results. The difficulty in determining what specifically in the therapeutic environment is responsible for the change measured (i.e., the objectivity of the observations).

For the researchers of adolescents in the 1990s and beyond it is essential to bear the following in mind. It is important to use standardized measures, both in establishing the diagnosis to be used in the study as well as in measuring the dependent variables. If depression is to be studied in adolescents, then the following factors must be considered: 1 The number of adolescents needed (for example, 30). 2 To ensure that the diagnosis is based on agreed upon agreed criteria, for example, established standardized measures such as the Reynolds Adolescent Depression Scale (RADS). 3 To decide on the type of research strategy employed. If one is interested in the efficacy of psychotherapy, then it is important to assess the adolescent before, during, and after treatment in order to determine whether therapy has led to changes. Another way to study efficacy might be to compare two groups of adolescents – one group with

therapy, and another group without therapy (i.e., patients on the waiting list). Like the first proposed study, this could determine whether therapy is helpful. If there is an interest in comparing psychotherapy with psychopharmacotherapy, then it would be possible to use either of the methods discussed above. It is also important to consider the ‘dosage’ of either the medication or the therapy (i.e., number of therapy sessions per week) being studied, as this will affect the outcome. The more ambitious studies are those that compare three or four different types of therapy in a large sample of adolescents. Although this type of study has been carried out in adults (Klerman et al. 1984), no study of this magnitude (to our knowledge) has ever been performed with adolescents. Finally, it is important to stress that studies with long-term follow-up are essential in order to determine which factors are stable across time, and which are not. If a study of adolescents with depression demonstrates a significant improvement after six months, it remains unclear whether this improvement will hold over a period of years. Indeed, this type of study is entirely missing from the field of adolescent psychiatry at present.

ADOLESCENT TURMOIL There is no subject in the field of adolescent psychiatry which raises more heated discussion than ‘adolescent turmoil.’ The term has, according to Offer (1969): ‘been utilized freely by psychiatrist and psychoanalysts when describing disturbed adolescents, as well as when discussing the developmental process of normal adolescence. The concept can be traced to B. Stanley Hall (1904) who, in his two-volume treatise Adolescence, introduced the phrase ‘Sturm und Drang’ (‘storm and stress’) to characterize the psychology of adolescents. Hall stated that it is typical for adolescents to oscillate between the various extremes of psychological functioning. The adolescent will feel happy and altruistic one day, and on the next day will feel nothing but hopelessness and depression. Apathy and enthusiasm are present almost concurrently, so that ‘Promethean enthusiasm’ and deep romantic ‘Weltschmerz’ represent the basic psychological characteristics of adolescents.’ Offer (1969, p. 174).

The term ‘adolescent turmoil’ is defined as an emotional condition that represents significant disruption in psychological equilibrium leading to fluctuation in moods, confusion in thought, rebellion against one’s parents, and changeable and unpredictable behavior. The term has been used freely by psychiatrists, psychologists, and other health professionals to describe the developmental process of normal adolescence, as well as to describe disturbed adolescents, and this has led to major

28 Special issues in adolescent psychiatry

conceptual confusion. Typical (or normal) adolescents, it has been thought, need to experience adolescent turmoil; if they do not, they remain over-dependent on their parents, have trouble developing their sense of identity, and have difficulties relating well to their peers (Freud 1958; Blos 1961; Erickson 1964). We would like to examine the concept of ‘adolescent turmoil’ from a research perspective. The condition is still very much alive in the current text; for example, Bloch (1995) recently discussed the term to great extent, and showed particular interest in bridging the psychoanalytic theory with newer empirical findings. In the past, clinicians assumed that the patients they saw in their clinical practice were representative of the population at large. For example, Gardner (1959) assumed that the characteristics of the normal could be clearly seen by looking at the patient: ‘By way of illustration … I shall present and discuss our intake interview with a sixteen-year-old girl and the subsequent intake interview with the mother. In my opinion, these two interviews highlight most of the problems and anxieties (and defenses against anxieties) that one will meet in an essentially normal adolescent.’ One could also use Anna Freud’s (1958, p. 275) wellknown statement that ‘the upholding of steady equilibrium during the adolescent process is in itself abnormal,’ as begging the question: can the adolescent never be a ‘normal’ person? When examining a concept such as ‘adolescent turmoil’ from a research perspective, it is necessary to pass through a number of steps. These steps are not specific to the problem we have; rather, they are general and can be used for other concepts, theories, or hypotheses. The first step is to determine whether the concept is defined in the same, or in a very similar, way by different investigators. Are the methods by which information was obtained the same, or at least very similar? For the purpose of our presentation, we will say that, yes, the concept is used in similar fashion by almost all clinicians. By tracing the origin of the concept we would find what we have already described above. Next, we need to ascertain the population of teenagers to which this concept is applicable. To our surprise, we find that clinicians believe that it is applicable to all adolescents, irrespective of whether they are psychologically disturbed or not. The second step is to select a sample of non-patients in order to determine whether they too undergo ‘adolescent turmoil.’ In a previous investigation (Offer 1969) it was found that although this situation was true for some adolescents, it was not true for the majority. Other theories had to be developed for the majority of the nonpatient groups. As the vast majority of adolescents are non-patients, this was a major finding. The next step in the research process was to determine how representative this group of non-patients was of the adolescent population in general.

In step three, in recent years the numbers of epidemiological studies of representative groups of adolescents have increased dramatically. In general, the finding has been that adolescents are no more disturbed than either children or adults. The studies confirmed that the percentage of disturbance among adolescents is identical to that of adults, namely 20 per cent (Myers et al. 1984). We can therefore say that, from an epidemiological point of view, we have determined that 20 per cent of any given population of adolescents is disturbed and therefore may fit the ‘adolescent turmoil’ theory. For the other 80 per cent, we need to develop another theory that would explain their development. The fourth step, which is not only the most difficult and time-consuming research task but also the most rewarding, is the predictive study. This can be either naturalistic or hypothesis testing. In the naturalistic study, one would select a representative group of infants and study them throughout their life cycle. During adolescence one can determine the childhood background of those adolescents who later develop ‘adolescent turmoil,’ and also follow them into adulthood. The best known study of this type is the Berkeley study (see for example, Block 1971). These studies are very expensive and difficult to undertake, and therefore there are only a handful have been conducted. The hypothesis testing study selects two very different groups: one that would be most likely to develop ‘adolescent turmoil’, and one that would be least likely. These groups are then followed through adolescence in order to determine their outcome, thereby either confirming or denying the original theory. Finally, the field of psychiatry is not a difficult science. Therefore, any thesis is often only partially correct, and it is the researcher’s task to determine which part is viable and which part is not. The researcher often challenges the clinician because his or her perspective is different, even if the goals are similar, essentially to help the adolescent who is in trouble.

ADOLESCENT SUICIDE One topic of adolescent psychiatry that currently receives much attention is that of adolescent suicide. There is a great deal of misconception about adolescent suicide, and it is believe by many that more adolescents commit suicide than adults. This is incorrect. According to the National Center for Health Statistics (1993), as quoted in Holinger et al. (1994), during 1990 a total of 22 out of 100 000 males aged 15–24 years committed suicide compared with 32.2 out of 100 000 males aged 65–74 years. Among females, 3.9 out of 100 000 aged 15–24 years committed suicide compared with 6.7 out of 100 000 aged 65–74 years. The suicide rate among adolescents, excluding children, is the lowest in the life cycle, and that in older adults (aged 65–74

Research in adolescent psychiatry 29

years) is the highest. One possible reason for this misconception is that although suicide is the third leading cause of death among adolescents, the actual number of deaths due to any cause for fifteen- to twenty-four-year-olds is very low. According to the National Center for Health Statistics (1993), the statistics for 1990 showed that among males and females of all races and aged 15–24 years there were 4864 suicides (the third leading cause of adolescent death), 7354 homicides (the second leading cause) and 12 607 motor vehicle accidents (the first leading cause). Any death of a child, including adolescents, is a tragic event and attracts much attention. It is estimated that there are more than 100 suicide attempts for adolescents for every completed suicide (Smith and Crawford 1986). Surveys conducted during the 1980s report that 10–15 per cent of adolescents have made a suicide attempt (Boggs 1986; Shaffer et al. 1988; Smith and Crawford 1986). The public has responded by increasing the number of suicide research projects and suicide prevention and response programs targeted at teenagers. Research into adolescent suicide presents a unique set of challenges. The study designs applicable to research on adolescent depression cannot be applied to research in adolescent suicide. Although one has the opportunity to study those adolescents who might have suicidal thoughts or who have made suicide attempts, it is impossible to obtain an actual study sample of those who have completed suicide. Investigators have attempted to circumvent this limitation by developing the psychological autopsy. This consists of a series of exhaustive studies of everyone who knew the adolescent who committed suicide, including family, friends, and teachers. An attempt is then made to re-create the psychological environment that existed when the adolescent committed suicide. The investigators then attempt to weigh the different factors and decide what ‘caused’ the suicide. Much information has been gained through these studies, but the method cannot answer the basic question of why the adolescent ‘pulled the trigger’ and, more importantly, what might have prevented such a tragedy from happening. Researchers conducting investigations into adolescent suicide have utilized both experimental and pragmatic paradigms to approach this area. The experimental approach is exemplified by Blumenthal and Kupfer’s (1987) overlap model of five risk domains: biology; psychosocial life-events; personality traits; family history and genetics; and psychiatric disorder. The relative strength of each of these five areas has not been sufficiently developed for us to determine the individual or joint impact of a particular adolescent. According to Kalafat and Neigher (1991), the pragmatic model must be developed, keeping the special needs of a community in mind. These programs are preventive in nature, and their ultimate goal is to reduce the rate of suicide, but to our knowledge they have not been successful to date (Shaffer and Bacon 1989).

SUMMARY AND CONCLUSIONS Psychotherapy with adolescents was always assumed to be helpful to the adolescent, but little attempt was ever made to demonstrate its efficacy. Adolescent turmoil was considered to be a universal phenomenon until it was tested for in a non-patient population and found not to be present. Adolescent suicide is a serious problem, but it does not help if assumptions are made about its frequency and prevention without the necessary back-up data being available. Adolescent psychiatry is an exciting field. Working with young people provides the opportunity to try new approaches and develop new ideas. Some of the new approaches will stand the test of time, but others will not. It is incumbent upon us to continue to ask questions, as we have seen in the three brief examples in this chapter, though this is not always done.

REFERENCES Bloch, H.S. Adolescent Development, Psychopathology, and Treatment. Madison, Conn.: International Universities Press, Inc., 1995. Block, J. Lives Through Time. California: Baucroft Books, 1971. Blos, P. On Adolescence. New York: Free Press, 1961. Blumenthal, S.J., Kupfer, D.J. Overview of early detection and treatment strategies for suicidal behavior in young people. Journal of Youth and Adolescence 17: 1–23, 1988. Boggs, C. Project Life Save: Child and Adolescent Suicide Prevention in Two School Systems. Dayton Ohio: Suicide Prevention Center, Inc., 1986. Erikson, E. Insight and Responsibility. New York: W.W. Norton and Co., Inc., 1964. Freud, A. Adolescence. The Psychoanalytic Study of the Child 13: 255–278, 1958. Gardner, G. Psychiatric problems of adolescence. In Arieti, S. (ed.), American Handbook of Psychiatry. New York: Basic Books, 1959, pp. 870–894. Hall, S.G. Adolescence; Its Psychology and Its Relations to Physiology, Anthropology, Sociology, Sex, Crime, Religion and Education. New York: D. Appleton and Co., 1904. Holinger, P.C., Offer, D., Barter, J.T., Bell, C.C. Suicide and Homicide Among Adolescents. New York: The Guilford Press, 1994. Holmes, W.D., Wagner, K.D. Psychotherapy treatment for depression in children and adolescents. Journal of Psychotherapy Practice and Research 1(4): 313–323, 1992. Howard, K.I., Moras, K., Brill, P.L., et al. Evaluation of psychotherapy. American Psychologist 51(10): 1059–1062, 1996.

30 Special issues in adolescent psychiatry Hulley, S.B., Cummings, S.R. (eds), Designing Clinical Research. Baltimore: Williams & Wilkins, 1988. Kalafat, J., Neigher, W.D. Experimental and pragmatic approaches to the incidence of adolescent suicide. Evaluation and Program Planning 14: 377–383, 1991. Kazdin, A.E. Research Design in Clinical Psychology. Boston: Allyn and Bacon, 1992. Klerman, G.L., Weissman, M.M., Rounsaville, B.J., et al. Interpersonal Therapy of Depression. New York: Basic Books, 1984. Myers, J.K., Weissman, M.M., Tischler, G.L., et al. Six-month prevalence of psychiatric disorders in three communities. Archives of General Psychiatry 41: 959–978, 1984. Offer, D. The Psychological World of the Teen-ager. New York: Basic Books, Inc., 1969.

Shaffer, D., Garland, A., Gould, M., et al. Preventing teenage suicide: a critical review. Journal of the American Academy of Child and Adolescent Psychiatry 27: 675–687, 1988. Shaffer, D., Bacon, K. A Critical Review of Preventive Intervention Efforts in Suicide with Particular Reference to Youth Suicide. In Report of the Secondary Task Force on Youth and Suicide, DHHS. Pub. No. 89-1623. Washington, DC: US Government Printing Office, 1989. Smith, K., Crawford, S. Suicidal behavior among ‘normal’ high school students. Suicide and Life Threatening Behavior 3: 313–325, 1986. Thirtieth Annual Report, 1975–1978. Published by the Institute for Psychosomatic and Psychiatric Research and Training. Chicago: Michael Reese Hospital.

1.5 Cultural influences on adolescent development and treatment J. ARTURO SILVA, GREGORY B. LEONG, AND ROBERT WEINSTOCK

INTRODUCTION Adolescents, like children and adults, are strongly influenced by the cultural milieu in which they develop and live. Therefore, an appreciation of cultural aspects is an essential part of understanding adolescence and the psychiatric issues relevant to this stage of development. Culture itself represents a complex multi-faceted process. Culture weaves a rich tapestry of shared cognitions and affects that include philosophical and diverse religious beliefs, attitudes about social interactions, aesthetic standards, and areas of knowledge that extend from religion to science. Culture emphasizes human communication and interactions. Since it evolves in numerous forms shaped by prior and current experiences, its boundaries are necessarily related to specific human groups that are continually adapting (Le Vine 1984). Culture is not a static phenomenon; rather, it should be conceptualized as a process intrinsic to the evolution as well as the present configuration of the human species (Lewin 1993). As such, culture can be best understood from an integrated perspective that includes several levels of human organization. First, people may be seen as individuals and organismic biological entities that develop in interaction with the nuclear family. Eventually, the growing person also will be shaped by the community in which he or she lives through important societal institutions such as schools, jobs, and the political system. Beyond this we need to take into account that the historical period in which a person matures also intimately affects the outcome of that life. Therefore, one way to best understand culture is to conceptualize it as a dynamic socioecological process embedded in personal developmental as well as historical time (Silva and Liederman 1986). Culture, the environment, and the human life-span are intrinsically interconnected with each other; and consequently, various phases of human development can be best explained via culturally

informed paradigms. Therefore, in this chapter we adopt an approach that views culture as embedded in human ecologies that comprise both psychological and physical infrastructures (Bronfenbrenner 1979). These ecologies are in turn explicated by the multiplicity of cultural factors developed by different groups in order to adapt effectively to their social and physical environment.

ADOLESCENCE AS A CULTURAL PHENOMENON It has become fashionable to view human development as a more or less orderly process encompassing several stages, of which adolescence is one (Erikson 1963). However, recent research indicates that there are many variations of developmental stages across cultures depending on the meanings and emphasis that different cultures give to these stages (Cole 1996). For example, it was not very long ago when adolescents and even children were viewed as small adults rather than developmentally unique human beings (Aries 1962). A comparative cultural perspective can also shed light on the nature of adolescence. For example, families from a traditional agrarian Mexican culture may emphasize an early transition toward adulthood, in contrast to the contemporaneous United States mainstream where adolescence may be relatively prolonged. In Mexican rural settings adolescence is minimized by marriage soon after the attainment of childbearing potential, and subsequent separation from the nuclear family by the establishment of autonomous households by young couples. In comparison, teenagers in the United States are expected to live with the nuclear family or a family-selected arrangement with independence from the family unit occurring several years later than in rural Mexico. The latter

32 Special issues in adolescent psychiatry

arrangement allows for a greater opportunity for attempts at autonomy to be played out within the family of origin.

CULTURAL AND MINORITY ADOLESCENTS IN THE CONTEXT OF UNITED STATES SOCIETY Even when the cultural and racial minority adolescents develop well within the context of their culture, their lives in the United States are likely to be influenced by mainstream society. These adolescents face potential conflicts of values and identity as well as educational and economic challenges. This multi-faceted problem is dramatically exemplified by Native American adolescents who are raised on the reservations. Problems faced by these adolescents include living below the poverty line, family disintegration due to economic woes, and the after-effects of past United States governmental efforts aimed at undermining tribal cultural cohesiveness by separating Native American children from their parents (La Framboise and Low 1989; Sue and Sue 1990; White 1991). Against this backdrop, complicating problems arise such as low morale, pessimism for the future, and psychiatric and psychosocial problems such as alcoholism, depression, domestic violence, and high suicide rates (La Framboise and Low 1989; Sue and Sue 1990). The Native American adolescent can at the same time derive positive psychological support from having culturally familiar role models in an environment containing culturally congruent values and religion. These adolescents will ponder the question of whether to leave the reservation and forsake their ancestral culture. In the end, the adolescent must successfully negotiate these conflicting factors and values. Since American society does not find value in traditional tribal values, the adolescent faces the decision to abandon the culture of origin in search of success. If successful, the adolescent (or adult) may have some desire to return to the reservation, but then could risk a return to a prior level of socioeconomic dysfunction. At such critical decision points, the Native American adolescent is at increased risk for anxiety, depression, isolation, and loss of self-esteem. Racism remains a powerful force in the United States. Although significant strides in promoting social and cultural equality arose from the civil rights movement of the 1960s, during the 1990s ominous trends threatened to neutralize or even retard earlier progress. Current antiaffirmative action campaigns have received strong support (Berry 1996), and this trend can serve as a backdrop to lowering of already poor self-esteem and increased alienation from mainstream society by minority adolescents. From a mental health perspective, this may translate as an increased frequency or worsening of existing depressive and anxiety disorders. Such psychological

responses have been already observed in persons facing downward socioeconomic mobility and/or societal alienation. Nonetheless, this present atmosphere continues to aggravate historical trends and lends to a persistent hostile relationship between the minority adolescent and the greater society, which may include a higher frequency of aggressive behaviors. The observed higher frequencies of violence and criminality in many minority communities may in part stem from the disenfranchisement of adolescent minority youth from mainstream society. Opportunities for intervention may have to be carried out in the problematic surroundings of juvenile halls and correctional facilities instead of the psychotherapist’s office. Mental health intervention for minority adolescent youth, even outside the criminal context, can present with special challenges for the treating clinician. Recognition of and sensitivity to historical and current disenfranchisement and alienation from mainstream society should be considered in the treatment equation. The extent to which these factors affect a particular case varies as a function of the individual adolescent, his or her family, and numerous sociocultural variables. Perhaps an equally troubling trend are the declining resources available to local governments to adequately fund public institutions, including public mental health clinics that serve minority populations. Part of the many reasons behind this trend is the loss of tax base by the demographic shifts, with the middle class migrating further from the central city and industry and business moving to areas of the country promising tax breaks. Although such movement may on its face be economically motivated, racism may be a significant factor in this decision in many cases. In any case, the net unfortunate result is the loss of mental health resources for the minority adolescent.

LANGUAGE Regardless of the stage of human development, language plays a central role in an individual’s maturation. Utilization of language can be a determining factor in one’s educational success, formation of a viable social network, or utilization of healthcare services, including mental health services. Language may play an especially pivotal role in mental health service utilization as it can have clinical significance for both the adolescent and the therapist. Language plays an especially important role during adolescence. It serves not only as a primary mode of communication, but also as a catalyst that helps to foster the beginning of separation of adolescents from their parents. This is best exemplified by the language that adolescents as a group develop in their quest for autonomy. This phenomenon can be more pronounced when adolescents

Cultural influences on adolescent development and treatment 33

are already better adapted to a host culture than that of their parents. In this situation adolescents may use the language of the host culture as a means to differentiate themselves from their parents. Just as adolescent ‘jargon’ can be used to communicate within a family as a barrier, having an adequate command of the host culture language can function as a formidable barrier for less acculturated members of the family as these family members may not be linguistically proficient in the language of the host culture. This can result in alienation between the adolescent and older family members. In some cases, hybrid variants of two languages have developed that also are used by adolescents as a vehicle for generational differentiation. This is the case for the Pachuco argot of the southwestern and western United States, a mix of Spanish and English used by Mexican-American youth, which is used for generational differentiation from their parents (Barker 1975). Pachuco argot is also utilized as a vehicle to rebel against mainstream society which the young view as having rejected them. Similarly, some African-American youth speak English variants that originate in the cultural milieu in which they are raised. These variants can also serve the function of emancipating African-American youth from their parents, but also can represent a defiant expression toward the alienation of mainstream society. The recent controversy over ‘Ebonics’ underlies these and other related issues (Harris 1997). Language can be a critical factor in the evaluation and treatment of adolescents. The therapist must be aware that communication with the adolescent should be sensitive not only to the language nuances of adolescents, but also to the very real possibility that these adolescents may switch spontaneously between standard English and their particular terminology. When dealing with parents, the therapist should recognize that different members of a family may have different commands of English as well as with their first language. This problem can be readily identified among some Asian and Hispanic adolescents and their first-generation grandparents, as neither generation can communicate with the other because the grandparents speak only the language of the country of origin and their grandchildren only speak English. This language barrier can be especially disruptive to the traditional family set-up in which elders are accorded a position of high respect but fail to receive it, in part because of the language barrier. The adolescent is also precluded from benefiting from the unique knowledge and wisdom of the older generations because of the communication barrier.

ACCULTURATION Perhaps no other stage of the human life cycle highlights the intergenerational conflicts as much as adolescence.

The adolescent has a contradictory dual task of maintaining a close relationship with older generations while simultaneously seeking autonomy. This dilemma becomes particularly noticeable with newly arrived immigrants whose adolescent children often live in two dissimilar cultural universes. A recent example of this can be found among Vietnamese immigrants. Many Vietnamese fled their native country for reasons of sociopolitical survival. For the most part, they did not intend to make cultural changes and hoped to maintain the status quo in the United States. However, in many families their attempts to maintain their culture for future generations can meet with resistance and conflict in their United States-raised children. The Vietnamese adolescents may not appreciate their cultural heritage, and in fact may view mainstream society as possessing a better alternative as well as a way to effect the developmental transition from childhood to adolescence to adulthood. In the adopting part or all of the mainstream culture, some Vietnamese youth risk the formation of long-term alienation from their parents. This unfortunate development may be even more problematic in cultures where autogenocide has occurred, as exemplified by the long reign of internal Cambodian terror (Becker 1986). In this situation, Cambodian parents are likely to hold a strong ambivalent attitude about their past that can manifest itself as denial, anger, and shame. These dynamics can in turn be transmitted to their children who, as adolescents, can find it easier than their parents to move into the greater society than to establish the links with previous generations and associated cultural milieus (Huang 1989). Economic difficulties that frequently characterize migrant people may also be viewed by the adolescent with a sense of shame and rejection, rather than as a point of reference for improvement. Families that emphasize formal education and encourage their children to recognize not only the difficulties frequently encountered by members of minority groups but also the potential for improvement via family unity and formal education may in the process construct frameworks in which the minority adolescent achieves healthier development. Some cultural groups, such as JapaneseAmericans, Chinese-Americans, and Mexican-Americans, value respect for their elders, but concurrently support their children in entering mainstream society with its attendant emphasis on personal freedom, autonomy, and independence from a strong hierarchical nuclear family. Thus, the therapist who treats adolescents from cultural minorities must not only be attuned to issues raised by adolescence but will also need to understand the powerful role that cultural economic, generational, and historical factors play to shape development in these adolescents. Furthermore, therapists should be on guard not to become blinded by the cultural biases that they themselves may bring to the already complex fabric that characterizes many of these cases.

34 Special issues in adolescent psychiatry

School can present additional problems and pressures for minority students. College can represent the first time a minority student lives away from home and is directly immersed in the majority culture. Some of the students may reject their culture of origin in an effort to fit in and gain acceptance. Such behavior can lead to conflicts with the family of origin who may strongly disapprove of the student’s new values and behavior. Other minority students associate primarily with others from their background and culture and may feel alienated from the general college community. Such students may avoid needed treatment even if it is provided at no charge, since they retain stereotypes that only those who are seriously ill or ‘crazy’ receive mental health care. They may mistrust mental health clinicians from the majority culture and be especially wary of psychotropic medications. It is important to network with these students in an effort to remove barriers to needed treatment. Clinicians who treat adolescents should become familiar with the cultural impediments to the treatment of minority adolescents.

MENTAL HEALTH SERVICE UTILIZATION A long-standing and misguided myth holds that the reason why certain United States minority cultures underutilize mental health services is because such groups suffer from less mental illness thanks to efficacious interventions via the ‘folk’ medicine system (Madsen 1967). In addition, putatively respectable academicians have suggested that certain minority group members do not suffer from adversity and failures as do their Caucasian counterparts (Roser 1997). These views have been convenient for those who hold political and economic power who are otherwise expected to be held accountable to equalize opportunity in the areas of education and access to mental health care. However, the available evidence indicates that many cultural and/or racial groups, including adolescents, do not seek mental health services for other reasons. These factors include culturally congruent values that expect them to be self-sufficient because they are mistrustful of mental health professionals from other ethnic backgrounds, because they come from a cultural background in which revealing personal information is improper, or because of fears that they will be misunderstood over their poor English language skills or cultural beliefs. This barrier in part arises from the existing cultural gaps in values, language, and socioeconomic problems between minority adolescents and their families and mental health professionals who not infrequently are of different cultural or ethnic backgrounds. In the case of minority adolescents, those who most recently immigrated arguably face the greater problems in mental health. But even generational longevity in the United States may not close the cultural gaps for the minority

adolescent and needed use of mental health services may be missed, requiring special efforts to reach out to these groups. With adolescents, since it is usually the parent who brings the adolescent for treatment, reaching out to parents, educating them about mental illness and facilitating a friendly and culturally congruent atmosphere may be a significant factor as to whether effective clinical intervention can occur. This is particularly crucial in dealing with immigrant parents who may find the cultural fabric of the dominant culture threatening.

FUTURE TRENDS There are several trends that are likely to affect the mental health care of culturally sensitive minority adolescents. First, there is an unmistakable demographic trend indicating that the number of these adolescents is increasing at a rate greater than that of the remainder of the United States population (Huang and Gibbs 1989). This increase will place a greater demand on mental health services for these special populations. Second, trends in violent behavior suggest that the number of adolescents raised in socioeconomically impoverished areas is on the rise. Given that minority adolescents constitute a disproportionate number of those in these areas, their risk of involvement in violence is greater. Unless resources are shunted into primary, secondary, and tertiary prevention efforts, the violence problem will in all likelihood persist and potentially worsen. Treating this problem makes sense from a public health perspective and benefits society in general. Minority adolescents have many potential negative forces operating against them, above and beyond those that already beguile adolescent youth. Adolescence is a time not only of challenge but also of opportunity for society in general to meet these challenges, lest we continue through this new millennium without a strategic plan to address the mental health needs of adolescents, including those of minority adolescents. Addressing these needs can assist not only the minority adolescent in the present, but also society as we help to avoid serious psychiatric problems in an increasing number of these adolescents. Finally, society stands to benefit in the long run from the strengths and abilities of these adolescents as they progress to adulthood.

REFERENCES Aries, P. Centuries of Childhood: A Social History of Family Life. New York, Random House, 1962. Barker, G.C. Pachuco: an American-Spanish argot and its social function in Tucson, Arizona. In HernandezChavez, E., Cohen, A.D., Beltramo, A.F. (eds),

Cultural influences on adolescent development and treatment 35 El Lenguaje de los Chicanos. Arlington, Virginia: Center for Applied Linguistics, 1975. Becker, E. When the war is over: the voices of Cambodia’s revolution and its people. New York: Simon and Schuster, 1986. Berry, M.F. Affirmative action: why we need it, why it is under attack. In Curry, G.E. (ed.), The Affirmative Action Debate. Reading, Massachusetts: Addison-Wesley Publishing Co., 1996. Bronfenbrenner, U. The Ecology of Human Development. Cambridge, Massachusetts: Harvard University Press, 1979. Cole, M. Cultural Psychology: A Once Future Discipline. Cambridge, Massachusetts: The Belknap Press, 1996. Erikson, E.H. Childhood and Society. New York: W.W. Norton and Co., 1963. Harris, S.A. NAACP sponsors lecture on Ebonics. Linguist describes argument that it’s a separate language. San Francisco Examiner, February 8, 1997, p. A5. Huang, L.N. Southeast Asian refugee children and adolescents. In Gibbs, J.T., Huang, L.N. (eds), Children of Color: Psychological Interventions with Minority Youth. San Francisco: Jossey-Bass Publishers, 1989, pp. 278–321. Huang, L.N., Gibbs, J.T. Future directions: implications for research, training and practice. In Gibbs, J.T., Huang, L.N. (eds), Children of Color: Psychological Interventions with Minority Youth. San Francisco: Jossey-Bass Publishers, 1989, pp. 375–403.

La Framboise, T.D., Low, K.G. American Indian children and adolescents. In Gibbs, J.T., Huang, L.N. (eds), Children of Color: Psychological Interventions with Minority Youth. San Francisco: Jossey-Bass Publishers, 1989, pp. 114–147. Le Vine, R.A. Properties of culture: an ethnographic view. In Schweder, R.A., Le Vine, R.A. (eds), Culture Theory: Essays on Mind, Self and Emotion. New York: Cambridge University Press, 1984, pp. 67–87. Lewin, R. The Origin of Modern Humans. New York, Scientific American Library, 1993. Madsen, W. The Mexican-Americans of South Texas. New York: Holt, Rinehart and Winston, 1967. Roser, M.A. Jackson urges UT to fight racism. The American Statesman, September 17, 1997, pp. A1, A10. Silva, J.A., Liederman, P.H. The life-span approach to individual therapy: an overview with case presentation. In Baltes, P.B., Featherman, D., Lerner, R.M. (eds), Life-Span, Development and Behavior. Hilldale, New Jersey: Lawrence Erlbaum Associates, 1986, pp. 113–134. Sue, D.W., Sue, D. Counselling the Culturally Different: Theory and Practice. New York, John Wiley & Sons, 1990. White, R. ‘Its Your Misfortune and None of My Own’: A History of the American West. Norman, Oklahoma, University of Oklahoma Press, 1991.

1.6 Post-traumatic stress disorder in adolescents MOHAN NAIR

INTRODUCTION The effects of trauma on adolescents as a group has been less well studied than in adults and children, in whom the Vietnam War and the increasing awareness of the effects of child maltreatment during the past two decades have provided a major impetus towards such study. The extent of post-traumatic stress disorder (PTSD) is controversial as it is often undiagnosed, and its prevalence estimate would differ depending on whether narrow DSM-IV criteria are used or a broader definition is employed. PTSD symptoms in adolescents also sometimes differ from those in either children or adults. Diagnostic ambiguities in adults (Bowman 1997; March 1993; Stone 1993; Yehuda and McFarlane 1995; Yehuda 1999) are amplified in adolescents, one in twenty of whom may be affected by PTSD by some estimates, making it more common than bipolar disorder or obsessive– compulsive disorder and about as common as depression. PTSD in adolescents is an area of controversy. What, if any, is the connection between PTSD and the epidemic of juvenile violence (Garbarino et al. 1991; Osofsky 1995), substance abuse, borderline personality disorder, and psychopathy? What are the vulnerabilities and resiliencies in adolescents, families, and communities that account for persistent symptoms in some and the lack of symptoms in most? Is it over-diagnosed or underdiagnosed? Is there a discrete disorder that is common to substance-abusing adolescents (Deykin and Buka 1997; Giaconia et al. 2000), anorectics, self-mutilators (Herman 1992), sexually provocative teenagers, violent juvenile delinquents (Burton et al. 1994; Cauffman et al. 1998; Lewis et al. 1994; Schetky 1997; Steiner et al. 1997; Widom 1999; Wooden 2000), sexually predatory adolescents, and teenagers going through repeated painful medical procedures and life-threatening illnesses (Stuber et al. 1991)?

Adolescence is a period of intense psychologic change, though not one of inherent turmoil (Blos 1979). Clinicians are confronted with the fluid nature of adolescent mental structures and the counter-transference issues brought about by the intensity and urgency that characterize this period. Turmoil, suicide, and outwardly directed violence are more common in those with a history of trauma, and PTSD is a likely factor. This chapter will focus on how PTSD in adolescents differs that in from children and adults with respect to etiology, symptom formation, modulating factors, treatment, and outcome.

EPIDEMIOLOGY Traumatic events are not unusual in the lives of adolescents. Three-quarters of adults who seek treatment for PTSD note their first traumatic exposure as having occurred prior to the age of eighteen years (Freedy and Donkervoet 1995). While large-scale studies such as that conducted by Kessler et al. (1995) on adults do not exist for adolescents, a random survey of 1245 American adolescents showed that 23 per cent of them had been exposed to physical and sexual assault or were witness to violence, and that one in five of those exposed subsequently developed PTSD (Fitzpatrick and Boldizar 1993; Kilpatrick et al. 1997). Epidemiologic studies of PTSD are fraught with problems. These include issues of sampling, instruments, definitions of symptom criteria, appraisals of the intensity of traumatic exposure by examiners and subjects, the timing of the examination and social and cultural factors. Adolescents may suffer from PTSD as a result of exposure in adolescence itself or as a result of early trauma that has failed to resolve. Rape, which is associated with a high degree of PTSD (up to 60 per cent) is reported by twothirds of adults as having occurred prior to the age of

Post-traumatic stress disorder in adolescents 37

fifteen years (Koss et al. 1995). We do not know to what extent childhood abuse causes PTSD in children (McLeer et al. 1988) or persists through adolescence into adulthood. A substantial portion of child sexual abuse survivors who seek treatment as adults attribute PTSD to such events (Goodwin 1989; Rowan et al. 1994). Retrospective studies may over-estimate PTSD, especially in clinical populations, and both the accuracy of recall and the diagnosis may be called into question (Ceci and Bruck 1995; Schacter 2001). However, PTSD may be missed during adolescence because of more disruptive or compelling comorbid disorders such as depression, eating disorders, substance abuse, and conduct disorder, or may remain latent and not express itself fully during adolescence. Modifying factors in adolescence may resolve the effect of earlier trauma, or change the course of development so as to consolidate into personality disorders, i.e., borderline and antisocial personality, or Axis I disorders such as somatization, dissociative disorders, and paraphilias. PTSD

may take the form of a chronic relapsing disorder in some with the possibility of long-term changes in the brain (Beitchman et al. 1992; De Bellis 2001; Sapolsky 2000; Teicher 2002). The prevalence of PTSD among different groups is listed in Table 1.6-1.

ETIOLOGY The role of the stressor and modifying factors Exposure to traumatic events, though an essential criterion in the development of PTSD, does not invariably result in PTSD symptoms even though it may result in a variety of psychiatric sequelae. No threshold exists for the stressor other than it has to be of a life-threatening intensity and must invoke feelings of helplessness, horror, or fear in the subject (March 1993). The range

Table 1.6-1 Post-traumatic stress disorder prevalence in community and subgroups of adolescents Author

Population

Prevalence

Burton et al. (1994) Steiner et al. (1997) Sack et al. (1993)

916 juvenile offenders 85 male incarcerated juvenile offenders 31 Cambodian refugees in the United States studied as a group in 1984, 1987, and 1990.

Savin et al. (1996) Kinze et al. (1989)

99 Cambodian refugee adolescents in Thai refugee camps Cambodian refugees studied in the United States

24% 32% 38% in 1990 48% in 1987 50% in 1984 26% current; 31% lifetime

Weine et al. (1995) Husain (1997)

Bosnian refugees in the United States for one year 79 Bosnian children in adolescence subjected to siege

Hubbard et al. (1995)

59 (29 male, 30 female) young adult (mean age 20 years) Cambodians in the United States 221 Afro-Americans, age 7–18 years, non-random community sample 384 adolescents in community population involved in a long-term study 79 adolescent females studied in inner city medical clinic 218 children in adolescence (mean age 12.1–13.7 years), affected by the Armenian earthquake 179 children in adolescence affected by the Buffalo Creek Dam disaster 156 children (age 8–14 years) referred to the court for maltreatment

Fitzpatick and Boldizar (1993) Giaconia et al. (1995) Horowitz et al. (1995) Goenjian et al. (1995) Green et al. (1991) Fumalaro et al. (1996)

Deykin and Buka (1997) Wolfe et al. (1996) Brent et al. (1995)

299 adolescents (aged 15–19 years) in a substance abuse program 90 children (mean age 12.4 years), sexually abused, in witness preparation program 28 witnesses to suicide of peer

50% at 6 years following trauma, approximately 25% at a 3-year follow-up 25% 18% 40% had subsyndromal 24% current; 59% lifetime 27% 6.3% 67% 54.2% 37% 1/3 showed PTSD at the time of initial examination. 1/3 of these showed PTSD symptoms 2 years later 29.6% for males; 45.5% females 50% 14%

38 Special issues in adolescent psychiatry

of exposures that have resulted in PTSD in adolescents include:

• • • • • •

Community violence. Wars, atrocities, displacement, and the refugee experience. Man-made and natural disasters. Rape, physical, sexual abuse, and the witnessing of domestic violence. Unexpected death of loved ones, especially by violence or suicide. Having to undergo painful procedures and lifethreatening illness.

Some 40 to 85 per cent of the United States population has been exposed to life-threatening violence by late adolescence. One out of four children in some inner cities are described by their mothers as having witnessed a homicide, while 10 to 20 per cent of approximately 80 000 rapes and 24 000 homicides are witnessed by a minor, a third of which involves a family member (Eth 1989; Eth and Pynoos 1985). The majority of runaways, homeless, and juvenile delinquents have experienced a combination of abuse at home and in the community, including in institutions that are meant to protect them. Some 82 per cent of incarcerated juveniles had emergency room visits as a result of violence. The Bureau of Justice Statistics 1991 noted that 20 per cent of injuries among adolescents stemming from violence involve broken bones, loss of consciousness and hospitalizations up to three days (Fitzpatrick and Boldizar 1993). In the face of such massive traumatization that can resemble or exceed that in war zones, most adolescents do not develop PTSD. The absence of a supportive family environment has emerged as the most consistent factor that accounts for the development of PTSD in those exposed to life-threatening community violence. Those who show resilience often trace it back to a single consistent, unambivalently positive figure in their lives. Chronic and multiple exposures have been described both as inoculating towards the development of PTSD (Fitzpatrick and Boldizar 1993) and as predisposing to higher levels of PTSD symptomatology (Horowitz et al. 1995). Being female increases the risk of developing PTSD with respect to community violence, though this is influenced at least in part by the violence of rape, which is directed largely towards female adolescents. Other factors noted in the current literature (Bremner et al. 1995) that influence the development of PTSD in adults include age, parental mental illness, socioeconomic status, history of mental illness in the subject, educational level of subject and peritraumatic dissociation, but these are not seen as significant factors in the development of PTSD in adolescents exposed to violence. PTSD has been described in adolescents exposed to war, concentration camps, and political violence

(Dyregrov et al. 2000; Eth and Pynoos 1985; Kinze et al. 1989; Mollica et al. 1997; Sack et al. 1993, 1999; Savin et al. 1996; Weine et al. 1995; Yehuda and McFarlane 1995). Factors that influence the development of PTSD include the initial adaptation and ongoing level of stressors, the intensity of duration of exposure, parental, peer, and adult support, ongoing reminders and a sense of purpose, i.e., religious, moral, political beliefs and the capacity to fight back as opposed to experiencing total helplessness. Younger age may be a protective factor in that increased parental protection may be perceived, and younger children are cognitively less aware of the impact of the horrors of war. On the other hand, a study of Vietnam veterans (Van Der Kolk 1985) showed more severe and longer-lasting forms of PTSD in those exposed as adolescents. Children as opposed to adolescents experience more of the initial shock-like states and dissociation and are therefore more likely to exhibit PTSD.

Exposure to man-made and natural disasters PTSD has been described in adolescents exposed to earthquakes (Goenjian et al. 1995), hurricanes (Lonigan et al. 1994; Shaw et al. 1996), fires (March 1993; McFarlane 1987), and accidents (Milgram et al. 1988; Tyano et al. 1996). The severity of exposure, including proximity, loss of life, shelter, and community, the extent of life threat, secondary stressors such as parental job loss and lack of shelter increase the risk of developing PTSD. Increased trait anxiety and increased distress at the time of the experience are also seen as factors that increase the risk of PTSD. Age has not been correlated well in some studies (Lonigan et al. 1994), though others (Green et al. 1991) suggest a greater degree of PTSD in adolescents. Females are most likely to develop PTSD when exposed to disaster. Self-efficacy is noted as a protective but less important factor than social support. Parental pathology, including depression and irritability, increases the risk of developing PTSD in these circumstances.

Childhood physical and sexual abuse The role of childhood physical and sexual abuse in the development of adolescent PTSD remains controversial. Chronic maltreatment of childhood and adolescence has been associated with serious psychopathology in up to 40 per cent of cases. Some research suggests that the picture of low self-esteem, self-mutilation, self-endangering behaviors, inappropriate sexualization, chronic states of victimizing and victimization, dissociation, somatization and borderline features represent complex forms of PTSD not addressed by DSM-IV (Herman et al. 1989; Putnam and Trickett 1993).

Post-traumatic stress disorder in adolescents 39

Prior sexual and non-sexual traumatization, being female, the nature, severity, and frequency of the abuse, i.e., whether intercourse occurred or not, and the degree of self-blame are considered important factors in determining the development of PTSD (Giaconia et al. 1995; McLeer et al. 1994; Widom 1999). Factors such as history of anxiety, depression, poor education, family history of anxiety, depression, antisocial personality, and peritraumatic dissociation are significant factors in adult PTSD. However, these are currently not recognized as factors that affect the development of PTSD in adolescents who have been sexually or physically abused. The study by Brent et al. (1995) of adolescents who developed PTSD after witnessing the suicide of a peer indicated that those who did so had problems with substance abuse, agoraphobia, suicide attempts, family history of panic disorder, parent–child disruption, and history of loss compared to those who did not develop PTSD. In almost one-third of adolescents who develop PTSD, the condition stems from the unexpected deaths of loved ones due to violence or suicide.

Neurobiologic factors De Bellis et al. (1994) noted biochemical abnormalities similar to adult PTSD in adolescent girls who had been chronically sexually abused, but only one out of the twenty girls in his sample qualified for the diagnosis of PTSD. Pynoos et al. (1997), using salivary cortisol measurements, noted hypothalamus-pituitary axis (HPA) abnormalities in adolescent survivors of the Armenian earthquake. Diffuse loss of brain size and decrease in superior temporal gyrus volume have been shown in imaging studies of maltreated adolescents with PTSD (De Bellis et al. 2002). Abnormal EEGs, increased soft neurologic signs and mixed handedness have been described more often in juveniles with PTSD (Chemtaub et al. 2001; Teicher et al. 1996). These findings may reflect the effect of adversities in development rather than PTSD per se. In summary, while a growing body of neurobiologic findings has surfaced, their relevance remains uncertain. There are no biologic or imaging tests to diagnose PTSD in adolescents.

MODELS OF PTSD During recent years, several models of PTSD have been developed, including:

• •

The Horowitz (1986) model; this views the denial and intrusive phases of PTSD as necessary components in the gradual resolution of overwhelming psychological stress. Psychosocial models; these explain PTSD symptoms as a trauma-induced psychologic overload that

• •

cannot be handled by the individual’s internal and external coping systems. Learning theory models; these postulate that traumatic events cause a conditioned reflex that generalizes into moods, thoughts, visceral states, and maladaptive avoidance reactions. The Pynoos (1996) model; this provides a developmental model of PTSD. Traumatic events interact with vulnerabilities and strengths in the child and his or her environment, influencing and being influenced by the developmental trajectory (emotional, cognitive, biologic, and interpersonal) that results in an evolving picture of adaptation, symptom formation, and personality development.

DIAGNOSIS OF PTSD PTSD can present as externalizing, internalizing, mood, anxiety, or psychotic disorder, and may be comorbid with these. True comorbidity must be differentiated from the secondary complications of PTSD or unresolved grief including by the way natural history, family history, specific symptomatology, i.e., neurovegetative features, and the tonic/phasic nature of PTSD symptoms. Diagnosis needs to take into account a clear sense of the adolescent’s strengths, weaknesses, defenses, developmental stage, and the extent of family and social support. DSM-IV PTSD diagnosis requires the presence of a traumatic event in which ‘the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others’ and also ‘the person’s response involved intense fear, helplessness, or horror.’ Although DSM-IV restricts the events that qualify for a PTSD diagnosis, many events that may not objectively involve a threat of death, serious injury, or threat to physical integrity of an adolescent, may still be experienced emotionally as such by an adolescent. Past experience or psychodynamic reasons could result in the adolescent feeling subjectively threatened and still lead to a PTSD symptom picture. DSM-IV does not adequately categorize such patients. Since an adjustment disorder diagnosis requires that symptoms not persist for more than six months after the stressor or its consequences have terminated, an appropriate diagnosis would be an Anxiety Disorder Not Otherwise Specified. Some argue that DSM-IV creates too high a bar for those who are traumatized and suffer many (but not the full spectrum of) PTSD symptoms. Nevertheless, DSM-IV does help establish PTSD as a discrete disorder in that traumatic exposures and reactions of lesser severity do not qualify. Adolescents with full spectrum PTSD are more severely traumatized and show higher levels of comorbid pathology and need more intensive treatment than those with ‘partial PTSD’ (Ruchkin et al. 2002).

40 Special issues in adolescent psychiatry

Traumatic events qualifying for DSM-IV PTSD criterion A are more likely to result in psychiatric disorders other than PTSD. Diverse types of traumatic exposure result in a variety of symptoms, even within the categories of re-experiencing, re-enactment, avoidance, numbing, and hyperarousal that are part of the DSM-IV diagnosis (McNally 1993; Pfefferbaum 1997). Cultural factors may account for differences in symptom presentation, i.e., the relative absence of academic failure, disruptive behavior, and substance abuse in the Israeli youth and Cambodian refugees. Intrusive re-experiencing is the most common, most distressing, and most disruptive symptom of PTSD, and varies in intensity depending upon the severity of exposure. Adolescents may be reminded by bodily appearances, mannerisms, clothes, sounds, sights, smells, voice tone, or may spontaneously experience intrusive thoughts, flashbacks, and hallucinatory experiences. They may describe feeling as if they are going ‘crazy’ and may be provoked into violence, headbanging, cutting, or substance abuse in response to or to decrease the agony of these feelings. Chronic adaptations include isolation from family and friends who they feel cannot relate to these feelings; running away from home; sexual fears may lead to not dating or even hanging out with friends; sexual acting-out, promiscuity, prostitution, involvement with other forms of sex work, and involvement with older or abusive men may be forms of re-enactment in those who have been sexually abused. Re-enactment may include involvement with guns, violent gangs, provoking violence, and directing violence towards younger children and animals. Extreme forms of danger-seeking such as playing Russian roulette, balancing off of high places and atrocity types of violence may occur in the primitive adolescent. Adolescents preoccupied with feelings of revenge and guilt may fantasize or occasionally act out. Healthier adolescents may deal with these feelings in books, films, artwork and music that may be repugnant or confusing to adults and even some of their own peers. Adolescents do not show the behavioral regressions such as enuresis, encopresis, hiding under the bed or in closets, tics, increased startle, superhuman fantasies of control and retaliation and the posttraumatic play that are often seen in younger children. Intrusive recall may be accepted by some adolescents as being in the context of their life experiences without necessarily causing disturbances of behavior. Generally, girls are more prone to internalizing, boys to externalizing, and some cultures facilitate somatization as opposed to acting out. In some subcultures, school failure, delinquent behavior and substance abuse may not be apparent but intense guilt, depression, and somatization will emerge instead. Numbing and avoidance are noted in adolescents as decreased involvement in their usual activities, such as socialization, school and play; when severe, basic activities of daily living may be disrupted. Learning and creativity are affected and a picture of withdrawal, confusion, isolation,

and apathy that might resemble depression or schizophrenia may be present. Avoidance of thinking and talking about the traumatic event may prevent involvement in therapy or even informing parents and loved ones of what they may have gone through. Detachment from the outside world increases preoccupation with somatic complaints, more often in women, children, and non-western cultures. The feelings of numbness and deadness may lead to selfmutilation, i.e., cutting, or present as antisocial thrillseeking behaviors such auto theft, breaking and entering, or property destruction. Sex, substance abuse and binge eating may be used to self-medicate this intensely dysphoric state. Behavioral regression including loss of language, and motor skills, thumb-sucking, fear of being alone, affectless clinging, ‘quiet sorrow,’ specific phobic avoidances, memory disturbances, and dissociation are more often seen with younger children as opposed to adolescents. The degree of numbing and avoidance symptoms is believed to correlate with the intensity of negative affect experienced at the time of trauma. In adolescents, hyperarousal is usually noted as suspiciousness, guardedness, paranoia, easy provocation to anger and violence, and early and middle insomnia. The adolescent might show hostility, irritability, and fearfulness. Physical agitation including pacing and inability to sit still in the classroom may be noted even in older adolescents. Adolescents generally do not show sleep-walking, night terrors, bouts of panic at bedtime, tics and school phobia that are noted in younger children.

Differential diagnosis The affective constriction that stems from numbing in PTSD can be differentiated from depression by the intensity and persistence of the depressive mood, hopeless/helpless feelings and neurovegetative features of depression. The adolescent with PTSD may describe isolation as a way of avoiding intrusive reminders. Depression is highly comorbid with PTSD, and traumatic events often involve loss. The depression of unresolved grief and PTSD can complicate and intensify each other, thereby adding to diagnostic and treatment difficulty. Context, triggers and the specificity of intrusive material can help differentiate PTSD from generalized anxiety, phobias, and obsessive– compulsive disorder. Intrusive phenomena of PTSD can elicit rage, helplessness, horror, despair, as opposed to just those of anxiety, fear, or terror. PTSD needs to be differentiated from a substance abuse-induced mental disorder which it can mimic, but with which it can also be highly comorbid. The nature of sleep disturbances may help distinguish dysphoric mania or hypomania from the agitated PTSD state. Hypomania is characterized by a lack of sleep need. In PTSD, sleep tends to be non-restorative, characterized by early and middle insomnia, intense body movements, startle

Post-traumatic stress disorder in adolescents 41

awakenings and nightmares. The physical restlessness of Attention Deficit Hyperactivity Disorder (ADHD), mania/ hypomania (especially dysphoric mania/hypomania), other anxiety disorders and organic brain syndromes may be mistakenly attributed to the arousal symptoms of PTSD by clinicians unfamiliar with these conditions. Intrusive phenomena in PTSD, even when hallucinatory, take place within an otherwise intact reality testing; that is, the adolescent is able to appreciate their unreal nature, even though they are seen as troubling and confusing. The adolescent will experience these quasipsychotic symptoms in some settings, but not in others. These will help to differentiate PTSD from the psychosis that manifests in bipolar disorder, psychotic depression, schizophrenia, or a drug-induced psychosis. Adolescents with PTSD may be mistaken for borderline personalities because of lability, impulsivity and brief psychotic episodes, but will not show neediness, manipulativeness, and interpersonal exploitiveness. Dissociation, depersonalization and derealization seen during the initial shocklike state of acute stress disorder are not noted commonly in adolescents with uncomplicated PTSD. Factitious and malingering PTSD need to be considered in the differential diagnosis, especially in criminal and civil forensic settings (AACAP 1997; Ash and Derdeyn 1997; Kazdin 2000; McCann 1998).

MANAGEMENT OF PTSD The guiding principles of the treatment of PTSD are the re-establishment of a sense of safety and being able to accept the trauma as a part of one’s life. The goal of PTSD treatment is not to attempt to correct early deficits in attachment and trust, but to restore the individual as close as possible to the developmental trajectory that existed prior to the trauma. The desire of adolescents for autonomy, and not sharing with adults, is compounded in those with PTSD, who may avoid treatment because they do not want to be reminded about the trauma. Those who have been abused or feel victimized as a community may be suspicious of mental health providers. Initial therapeutic interventions may benefit from ‘rap groups’ conducted within the community and school settings. Critical incident stress debriefing is popular, but of uncertain benefit in civilian populations. There are no controlled studies that support the use of EMDR (Eye Movement Desensitization and Retraining) in adolescents.

Group therapy Group therapy has been found to be useful especially in single incident traumas and can incorporate aspects of exposure, desensitization, and anxiety/anger management techniques. Cognitive behavioral therapy, though

useful, may be difficult to implement in those severely behaviorally or characterologically disturbed, except in structured and controlled settings. The role of re-enactment in the therapeutic relationship in actions of neediness, manipulativeness, control, rejection, sexual provocation, anger, aggression, and sadism needs to be recognized but should not distract from emphasizing behavioral accountability. Pulsed interventions (Pynoos and Nader 1993) is a form of therapy that is provided for periods of time until the level of functional adjustment is reached, and then discontinued; therapy is restarted at a point in time when situational/developmental interactions bring on a new level of symptoms, modify existing ones, or make existing coping skills ineffective in the new developmental context. Pulsed treatment, in addition to being cost-effective, reinforces positive attributes of adolescents such as wanting to learn, taking on new challenges, gaining mastery, and maintaining autonomy while simultaneously being protective against the dependency and helplessness that long-time psychotherapy sometimes induces in trauma survivors.

Medications Medications should be used for symptomatic relief, though the high degree of depressive comorbidity may warrant the use of antidepressant medications. The selective serotonin re-uptake inhibitors (SSRIs) have been shown to be most helpful in the treatment of adult PTSD. The use of lithium and carbamazepine to control unstable moods, carbamazepine and valproic acid to decrease aggressive outbursts and intrusive phenomena, and clonidine and propranolol to decrease somatic anxiety and hyperarousal have been reported. Antipsychotic medications have only a minor role in the treatment of PTSD, though the behavioral dyscontrol, overwhelming affect, and psychotic-like symptoms of PTSD result in their use in multiple settings all too often. No controlled studies have been reported on the use of any of these medications in adolescents with PTSD (AACAP 1998; Donnelly and Amaya-Jackson 2002; Foa et al. 2000; Perrin et al. 2000).

SUMMARY PTSD may be common in adolescence, and highly comorbid with other serious psychiatric disturbances of that period. The relationship between PTSD and other conditions that are linked to trauma such as borderline personality, dissociative disorders and somatoform disorders remains unclear. The broad range of affective, cognitive, behavioral, anxiety, dissociative, somatic and psychotic-like symptoms that surface in varying intensity at various stages in the course of the illness contributes to the diagnosis

42 Special issues in adolescent psychiatry

often being ignored; advocacy and failure to adhere to the diagnostic criteria may cause it to be assigned inappropriately. Careful and repeated examinations may be necessary to identify the presence of PTSD with information gathered from different settings and sources. The majority of adolescents appear resilient to long-term sequelae of various traumas, and some may grow from it. However, in those that develop PTSD, early identification and intervention are critical. They may help prevent the entrenchment and intensification of traumatic reminders as well as the widening circle of secondary problems and help lead to a more effective resolution of both the effect of the trauma as well as comorbid conditions.

REFERENCES American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with Post-Traumatic Stress Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 37 (suppl.): 4S–26S, 1998. American Academy of Child and Adolescent Psychiatry. Practice parameters for the forensic evaluation of children and adolescents who may have been physically and sexually abused. Journal of the American Academy of Child and Adolescent Psychiatry 36: 423–442, 1997. Ash, P., Derdeyn, A.P. Forensic issues in child and adolescent psychiatry: a review of the past ten years. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1495–1502, 1997. Beitchman, J.H., Zuker, K.J., Hood, J.E., et al. A review of the long-term effects of child abuse. Child Abuse and Neglect 16: 101–118, 1992. Blos, P. The Adolescent Passage. New York International Universities Press, 1979. Bowman, M. Individual Differences in Post-Traumatic Response: Problems with the adversity/distress connection. Mahwah, NJ: Lawrence Erlbaum Associates, Publishers, 1997. Bremner, D.J., Southwick, S.M., Charney, B.S. Etiological factors in the development of Posttraumatic Stress Disorder. In Mazure, C.M. (ed.), Does Stress Cause Psychiatric Illness? Washington, DC: American Psychiatry Press, 1995. Brent, D.A., Perper, J.A., Moritz, G., et al. Posttraumatic Stress Disorder in peers of adolescent suicide victims: predisposing factors and phenomenology. Journal of the American Academy of Child and Adolescent Psychiatry 34: 209–25, 1995. Burton, D., Foy, D., Bwanausic, C., Johnson, J. A relationship between traumatic exposures, family dysfunction, and posttraumatic stress symptoms in male juvenile offenders. Journal of Traumatic Stress 7: 83–93, 1994.

Cauffman, E., Feldman, S.S., Waterman, J. et al. PostTraumatic Stress Disorder among female juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry 37: 1209–1216, 1998. Ceci, S.J., Bruck, M. Jeopardy in the Courtroom: a scientific analysis of children’s testimony. Washington, DC: American Psychologic Association Press, 1995. Chemtaub, C.M., Taylor, K., Woo Liaba, et al. Mixed handedness and trauma symptoms in disaster exposed adolescents. Journal of Nervous and Mental Disease 189: 158–160, 2001. De Bellis, M.D. Developmental traumatology: the psychobiological development of maltreated children and its implications for research, treatment and policy. Developmental Psychopathology 13(3): 539–564, 2001. De Bellis, M.D., Trickett, B.K., Putnam, S.W. Urinary catecholamine excretion in sexually abused girls. Journal of the American Academy of Child and Adolescent Psychiatry 33: 320–327, 1994. De Bellis, M.D., Keshavan, M.S., Frustaci, K., et al. Superior temporal gyrus volumes in maltreated children and adolescents with PTSD. Biological Psychiatry, 51(7): 544–552, 2002. Deykin, E.Y., Buka, S.L. Prevalence and risk factors for posttraumatic stress disorder among chemically dependent adolescents. American Journal of Psychiatry 154: 752–760, 1997. Donnelly, C.L., Amaya-Jackson, L. Post-Traumatic Stress Disorder in children and adolescence. Epidemiology, diagnosis and treatment options. Paediatric Drugs 4(3): 159–170, 2002. Dyregrov, A., Gupta, L., Gjestad, R., et al. Trauma exposure and psychological reactions to genocide among Rowandan children. Journal of Traumatic Stress 13(1): 3–21, 2000. Eth, S. The adolescent witness to homicide. In Benedek, E.P., Cornell, D.G. (eds), Juvenile Homicide. Washington, DC: American Psychiatric Publishing, pp. 87–113, 1989. Eth, S., Pynoos, R.S. Post-Traumatic Stress Disorder in Children. Washington, DC: American Psychiatric Publishing, 1985. Famularo, R., Kinscherff, R., Fenton, T. Psychiatric diagnoses of maltreated children: preliminary findings. Journal of the American Academy of Child and Adolescent Psychiatry 31: 863–867, 1992. Fitzpatrick, K.M., Boldizar, J.P. The prevalence and consequences of exposure to violence among African-American youth. Journal of the American Academy of Child and Adolescent Psychiatry 32: 424–430, 1993. Foa, E.B., Keane, P.M., Friedman, M.J. Effective treatment for PTSD: Practice Guidelines from the International Society for Traumatic Stress Studies. New York: Guilford Press, 2000. Freedy, J.R., Donkervoet, J.C. Traumatic stress: an overview of the field. In Freedy, J.R., Hobfoll, S.E. (eds),

Post-traumatic stress disorder in adolescents 43 Traumatic Stress: From Theory To Practice. New York: Plenum Press, pp. 3–28, 1995. Garbarino, J., Kostelny, K., Dubrow, N. What children can tell us about living in danger. American Psychologist 46: 376–383, 1991. Giaconia, R., Reinherz, H., Silverman, A., et al. Trauma and PTSD in a community population of older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1369–1380, 1995. Giaconia, R., Reinherz, H.Z., Hauf, A.C., et al. Comorbidity of substance abuse and Post-Traumatic Stress Disorders in a community sample of adolescence. American Journal of Orthopsychiatry 70(2): 253–262, 2000. Goenjian, A.K., Pynoos, R.S., Steinberg, A.M., et al. Psychiatric comorbidity in children after the1988 earthquake on Armenia. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1174–1184, 1995. Goodwin, J.M. Sexual Abuse, Incest Victims and their Families, Chicago: Year Book Medical Publishers, 1989. Green, B.L., Korol, M., Grace, M.C., et al. Children and disaster: age, gender, and parental effects on PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry 30: 945–951, 1991. Herman, J.L. Trauma and Recovery. New York: Basic Books, 1992. Herman, J.L., Perry, J.C., van der Kolk, B.A. Childhood trauma in borderline personality disorder. American Journal of Psychiatry 146: 1293–1296, 1989. Horowitz, B.A., Weine, S., Jekel, J. PTSD symptoms in urban adolescent girls: compounded community trauma. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1353–1361, 1995. Horowitz, M.J. Stress Response Syndromes. New York: Jason Aronson, 1986. Hubbard, J., Realmuto, G.M., Northwood, A.K., et al. Comorbidity of psychiatric diagnosis with PTSD in survivors of childhood trauma. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1167–1173, 1995. Husain, S.A. Resiliancy, Vulnerability and Cultural Diversity: Lessons from children exposed to war. Paper presented at the annual meeting of The American Psychiatry Association, San Diego, CA, May 1997. Kazdin, A.E. Development Perspective on Juvenile Justice. In Grisso, N.T., Schwartz, R.D. (eds), Youth on Trial: a development perspective on juvenile justice. Illinois: University of Chicago Press, 2000, pp. 2–93. Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., Nelson, C.B.: Posttraumatic Stress Disorder in the National Comorbidity Survey. Archives of General Psychiatry 52: 1040–1060, 1995. Kilpatrick, D.G., Resnick, H.S., Acierno, R. Health impact of interpersonal violence. 3: Implications for clinical practice and public policy. Behavioral Medicine 23(2): 67–78, 1997.

Kinze, J.D., Sack, W.H., Agnell, R.H., Manson, S., Rath, B. A three years follow-up of Cambodian young people traumatized as children. Journal of the American Academy of Child and Adolescent Psychiatry 28: 501–504, 1989. Koss, M.P., Heise, L., Russo, N.F. The global health burden of rape. Psychology of Women Quarterly 18: 509–537, 1995. Lewis, D.O., Yeager, C.A., Lovely, R., Stein, A., CobhamPortorreal, C.S. A clinical follow-up of delinquent males: Ignored vulnerabilities, in unmet needs and perpetuation of violence. Journal of the American Academy of Child and Adolescent Psychiatry 33: 518–528, 1994. Lonigan, C.J., Shannon, M.P., Taylor, C.M., et al. Children exposed to disaster, II: Risk factors for the development of posttraumatic symptomatology. Journal of the American Academy of Child and Adolescent Psychiatry 33: 94–105, 1994. March, J.S. What constitutes a stressor? The Criterion A issue. In Davidson, J.R.T., Foa, E.B. (eds), Posttraumatic Stress Disorder: DSM-IV and Beyond. Washington, DC: American Psychiatric Press, 1993, pp. 37–54. McCann, J. Malingering and Deception in Adolescents: Assessing credibility in clinical and forensic settings. Washington, DC: American Psychological Association, 1998. McFarlane, A.C. Posttraumatic phenomena in a longitudinal study of children following a natural disaster. Journal of the American Academy of Child and Adolescent Psychiatry 26: 764–769, 1987. Mcleer, S., Deblinger, E., Adkins, M., Foa, E., Ralphe, D. Posttraumatic Stress Disorder in sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry 27: 651–654, 1988. McNally, R.J. Stressors that produce posttraumatic stress disorder in children. In Davidson, J.R.T., Foa, E.B. (eds), Posttraumatic Stress Disorder: DSM-IV and Beyond. Washington, DC: American Psychiatric Press, 1993, pp. 57–74. Milgram, N.A., Toubiana, Y., Klingman, A., et al. Situational exposure and personal loss in children acute and chronic stress reactions to a school disaster. Journal of Traumatic Stress 1: 339–352, 1988. Mollica, R.F., Poole, C., Son, L., et al. Effects of war trauma, on Cambodian refugee adolescents functional health and mental health status. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1098–1111, 1997. Osofsky, J.D. The effects of exposure to violence on young children. American Psychologist 50: 782–788, 1995. Perrin, S., Smith, P., Yule, W. Practitioner review: the assessment and treatment of post-traumatic stress disorder in children and adolescents. Journal of Child Psychology and Psychiatry 41: 277–289, 2000.

44 Special issues in adolescent psychiatry Pfefferbaum, B. Post-Traumatic Stress Disorder in children: the review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1503–1511, 1997. Putnam, F.W., Trickett, P.K. Child sexual abuse: a model of chronic trauma. Psychiatry 56: 82–95, 1993. Pynoos, R.S., Nader, K. Issues in the treatment of posttraumatic stress in children and adolescents. In Wilson, J.P., Raphael, B. (eds), International Handbook of Traumatic Stress Syndromes. New York: Plenum, 1993, pp. 535–549. Pynoos, R.S., Steinberg, A.M., Goenjian, A. Traumatic stress in childhood and adolescents. Recent developments and current controversies. In van der Kolk, B.A., McFarlene, C.E., Weisaeth, L. (eds), Traumatic Stress. New York: Guilford Press, 1996, pp. 331–358. Pynoos, R.S., Steinberg, A.M., Ornitz, E.M., et al. Issues in the developmental neurobiology of traumatic stress. In Yehuda, R., McFarlane, A.C. (eds), Psychobiology of Post-Traumatic Stress Disorder, New York, NY: The New York Academy of Sciences, 1997, pp. 176–193. Rowan, A.B., Fox, D.W., Rodriguez, N., et al. Posttraumatic stress disorders in clinical sample of adults sexually abused as children. Child Abuse and Neglect 18: 51–61, 1994. Ruchkin, V.V., Schwab-Stone, M., Koposov, R., et al. Violence exposure, Post-Traumatic Stress and personality in juvenile delinquents. Journal of the American Academy of Child and Adolescent Psychiatry 41(3): 322–329, 2002. Sack, W.H., Clarke, G.N., Him, C., et al. A 6-year-old follow-up study of Cambodian refugee adolescents traumatized as children. Journal of the American Academy of Child and Adolescent Psychiatry 32: 431–437, 1993. Sack, W.H., Him, C., Dickason, D. 12-year follow-up study of Khmer Youths with separate massive war trauma as children. Journal of the American Academy of Child and Adolescent Psychiatry 38(9): 1173–1179, 1999. Sapolsky, R.M. Glucorticoids and hippocampal atrophy in neuropsychiatric disorders. Archives of General Psychiatry 57: 925–935, 2000. Savin, D., Sack, W.H., Clarke, G.N., et al. The Khmer Adolescent Project III. A study of trauma from Thailand’s site II refugee camp. Journal of the American Academy of Child and Adolescent Psychiatry 35: 384–391, 1996. Schacter, D.L. The Seven Sins of Memory: How the mind forgets and remembers. New York: Houghton Mifflen, 2001. Schetky, D. Child victims. In Applebaum, P., Uyehara, H., Elin, M. (eds), The Legal System. Trauma and

Memory: Clinical and legal controversies. New York: Oxford University Press, 1997, pp. 496–510. Shaw, J.A., Applegate, B.K., Schorr, C. 21-month follow-up study of school-age children exposed to hurricane Andrew. Journal of the American Academy of Child and Adolescent Psychiatry 35: 359–364, 1996. Steiner, H., Garcia, G.H., Matthews, Z. Posttraumatic stress disorder in incarcerated juvenile delinquents. Journal of the American Academy of Child and Adolescent Psychiatry 36: 357–365, 1997. Stone, A.A. Post-Traumatic Stress Disorder and the Law: critical review of the new frontier. Bulletin of the American Academy of Psychiatry and Law 21: 23–26, 1993. Stuber, M.L., Nader, K., Yasuda, P., et al. Stress responses after pediatric bone marrow transplantation: preliminary results of a prospective longitudinal study. Journal of the American Academy of Child and Adolescent Psychiatry 30: 952–957, 1991. Teicher, M.H. Scars that won’t heal: the neurobiology of child abuse. Scientific American 286(3): 68–75, 2002. Teicher, M.H., Itoy, Y., Glod, C.A., et al. Neurophysiological mechanisms have stress response in children. In Pfeffer, C. (ed.), Severe Stress and Mental Disturbance in Children. Washington, DC: American Psychiatric Press, Inc., 1996, pp. 59–84. Tyano, S., Iancu, J., Solomon, S., et al. 7-year follow-up of child survivors of a bus-train collision. Journal of the American Academy of Child and Adolescent Psychiatry 35: 365–373, 1996. van der Kolk, B.A. Adolescent vulnerability to posttraumatic stress disorder. Psychiatry 48: 365–369, 1985. Weine, S., Becker, D.F., McGlashan, T.H. Adolescent survivors of ethnic cleansing: observations on the first year in America. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1153–1159, 1995. Widom, C.S. Post-traumatic stress disorder and abused and neglected children grown up. American Journal of Psychiatry 156(8): 1223–1229, 1999. Wolfe, D.A., Sas, L., Wekerle, C. Factors associated with the development of posttraumatic stress disorder among child victims of sexual abuse. Child Abuse and Neglect, Volume 18, 1994, pp. 35–50. Wooden, K. Weeping in the play time of others: America’s incarcerated children. Columbus, OH: Ohio State University Press, 2000. Yehuda, R. Introduction. In Yehuda, R. (ed.), Risk factors for Post-Traumatic Stress Disorder. Washington, DC: American Psychiatric Press, 1999, pp. xii–xix. Yehuda, R., McFarlane, A.C. Conflict between current knowledge of PTSD and its original conceptual basis. American Journal of Psychiatry 152: 1705–1713, 1995.

1.7 Consultation–liaison psychiatry with adolescents EVERETT P. DULIT

“Art is long; chapters are short”. Virgil/Dulit

•

“A man’s reach should exceed his grasp, or what’s a chapter for?” R. Burns/E. Dulit

• •

This chapter begins with a list of clinical conditions seen on an adolescent medicine inpatient service in order to provide some sense of the breadth of conditions seen, and then zeros in on some of those subtopics in more detail and depth. Each subtopic heading ‘unpacks’ into a vast array of material.

CLINICAL CONDITIONS AND CLINICAL ISSUES SEEN ON AN ADOLESCENT MEDICINE INPATIENT SERVICE

• • • • • • •

The post-suicide-attempter; the depressed adolescent; the serious substance abuser; the conduct disordered adolescent. (Note: all of the foregoing categories have some tendency to ‘go together’). The sickle-cell patient in painful crisis (lifting out for special emphasis common staff problems with providing adequate pain relief). The diabetic and/or asthmatic patient, especially when admitted in an ‘out of control’ crisis, with associated questions that arise regarding past and future compliance/noncompliance. The eating disordered patient with anorexia and/or bulimia. Malignant obesity. Pelvic inflammatory disease. The whole mix of histrionic (‘conversion’) somatoform disorders, and malingering, and psychophysiological conditions, all raising questions about some form of primary psychogenic etiology.

• •

Death and dying issues, for example with cancers or with end-stage renal disease. Trauma and post-traumatic stress disorder (PTSD). Lupus (systemic lupus erythematosus, SLE), often with emergent psychiatric symptoms. Consent and treatment refusal issues, especially highlighting questions around age and maturity/immaturity, sometimes with adolescents ‘living on the street’ without existing or functioning family. What to do in those treatment refusal cases where the clinical judgment of staff is in favor of unilaterally imposing treatment, of over-riding the ‘child’s’ refusal.

And then, stressing some important ‘staff-centered’ issues:

• • • • • • • •

Intra-staff conflicts around demands by patients for pain relief by analgesics and staff reluctance based on ideas about ‘abuse’ and/or overuse and/or alleged ‘recreational’ purposes being served. Staff reactions to death and dying issues, particularly for selected patients (e.g., the especially liked, beloved, respected, admired, endearing patient). Dealing with staff (physicians, nurses, others) who seem particularly nonpsychological minded and/or angry/adversarial with patients (in general, or in any particular case). Approach to clear evidence of denial of illness by a patient. Approach to compliance and noncompliance issues. Use (and overuse and underuse) of one-to-one nursing observation. On the handling of and the expression of anger by staff. On the handling of and the expression of grief by staff.

46 Special issues in adolescent psychiatry

MORE DETAILED DEVELOPMENT ABOUT SOME ISSUES Post-suicide-attempters For more extensive coverage, see the book by Zimmerman and Asnis (1995), including a chapter by the present author on precisely the theme of working with such patients on an Adolescent Medicine service. Some selected points:

• •

A brief hospitalization is almost always desirable (even though many hospitals frequently discharge directly from the emergency room to home when they judge the risk of immediate recurrence to be low). Hospitalizing the patient tends to say to everyone concerned: ‘This is serious!’, which is a good beginning to potentially productive brief therapy at the adolescent–parent interface, which is where the primary trouble is so commonly located.

Among the ‘techniques’ we have come to like is asking if they were really trying to end up dead when they did whatever they did. Quite often the answer is no, but ‘I just had to do SOMETHING!’ That answer makes the attempt seem more like the action equivalent of an explosive communication – something like: ‘G-D Dammit!! This is TERRIBLE!! Somebody NOTICE!!’ Also we like to say to those who say they were indeed trying to and expecting to end up dead: ‘Well, clearly you didn’t die. How do you feel about that? Glad or sorry?’ The overwhelming majority say: ‘Glad’, and then commonly speak about how the attempt precipitated a rush of obvious love and concern from the family and friends. Only very rarely do we hear ‘Sorry – and the next time I’ll get it right.’ That’s obviously a high-risk case. But we urge that you keep alert for the not-too-uncommon shrugged shoulder. That means something like: ‘I’m not sure.’ That’s also a high-risk case and is a clear indication for further Rx. An underlying devitalization is common among suicidal adults but not among adolescents, who more often end up to be angry and irritable in their distress. Although some attempts are preceded by thought and planning, more usually the attempt is an impulsive act, and often with ‘an assist’ from alcohol. Where the notso-common underlying devitalized depression is seen, look for family history of same and consider a serious trial of antidepressants.

The adolescent in pain A very familiar presentation on an adolescent medicine unit is the sickle cell adolescent in painful crisis. Most

commonly, the patient is experienced as a sympathetic figure by staff when first seen, and for some throughout the hospitalization as they recover. But for some of these patients after a while in the hospital, the patient begins to be identified by staff (nursing, housestaff) as ‘exaggerating’ and trying to get the analgesic medicines for recreational purposes (for ‘getting high’ or getting ‘spaced out’) rather than for genuine pain relief. Sometimes that is indeed the truth. However, in our experience, much more usually at the heart of the matter is a kind of conviction that can emerge within staff that they are being ‘manipulated’, being ‘conned’ by the patient. Sometimes that can lead to and be derived from a kind of vicious cycle in which the patient is left to wait too long for his/her next dose, and begins to adapt to that by truly ‘laying it on thick’ just to force reluctant staff to come earlier than they would otherwise. Perception of that deliberate exaggeration by staff can be experienced as confirmation that the patient is ‘faking’ and ‘just jerking us around.’ The consultation–liaison (CL) worker can be a very useful mediator in such situations when they arise.

The psychotic adolescent Every so often a patient is admitted for whom the clinical condition is ‘garden variety’ psychosis, such as would ordinarily be admitted to a psychiatry service. Sometimes those patients are admitted to Adolescent Medicine with the request ‘R/O toxic psychosis.’ Sometimes that is a genuine suspicion, but alas far more commonly in our experience the admission is a disposition solution for embattled emergency room housestaff facing a ‘no psych beds’ situation. Genuine toxic psychosis has been very rare in our experience. Sometimes a psychotic patient is admitted because of a serious suicide attempt, admitted for the necessary health care (for overdose, for self-injury). But almost invariably within hours or within one day the psychosis (especially if florid) comes to dominate. And then one is dealing with a patient for whose clinical condition an Adolescent Medicine ward is not well suited, either as regards physical set-up (no locked doors) and/or staff (expertise, talents, professional self-identification). It behooves the consultant to: a get that patient transferred to a secure psychiatric service as promptly as possible (which is often not easy given overloaded systems, and judgments made by the psychiatric service that ‘at least the patient is in care in the hospital’ compared to a steady demand for beds on behalf of patients in the ER); and b do what he/she can to recommend an antipsychotic medication regimen that can help with management, remembering that pediatric staff tends to lean towards underdosage of neuroleptics, with which they tend not to be familiar.

Consultation–liaison psychiatry with adolescents 47

They need encouragement to go up to and to hold at effective levels, but also they can make good use of reminders re potentially serious side effects to be alert for (notably hypotension and drug incompatibilities).

The patient suspected of psychogenic disease There is a certain steady stream of cases with symptoms that at first generate a series of medical tests (e.g., abdominal pain, pelvic pain, gait disturbance, seizures). However, as medical work-up proceeds and especially as laboratory tests increasingly lead to disconfirmation of hypothesized medical diagnoses, the idea emerges that the symptom may be psychogenic. Possibilities include conversion reactions (symptom picture is symbolic expression of some highly charged psychological conflict), psychosomatic disorders and/or psychophysiological reactions (psychological factors affecting physical condition, e.g., tension headache, painful menstruation, asthma), malingering (straightforward lying for expected gain), more complicated Munchausen’s syndrome (faking illness out of a desire to assume the sick role), and secondary gain (e.g., gaining exemption from unwanted responsibilities or gaining wished-for caretaking). But an important part of the consultant’s response should also be skepticism. Be mindful of a 1965 report by Slater in the British literature showing that roughly 60 per cent of a group of eighty-five patients whose symptoms were diagnosed as ‘hysterical’ in origin after work-up, turned out on long-later-follow up to be suffering from well-defined physical disease underlying the symptom picture, with that disease not yet sufficiently ‘emergent’ at the time of the earlier contact to be discerned (by good and competent workers) but unmistakably discernible and causative later, and almost certainly thus causative earlier even though not detectable. Furthermore, that study also found that the presence of ‘histrionic personality disorder’ was not a reliable ‘marker’ that the symptoms were psychogenic. As a consequence, it is probably best for the CL worker on an adolescent service to urge continued search for ‘organic etiology’ on those cases that are sent as ‘probably psychogenic?,’ primarily because no organic etiology is (yet) ‘establishable,’ while at the same time making an earnest search for positive support for the suspected psychogenicity.

Severe Personality Disorder and/or borderline condition: the impossible patient Patients bearing one or the other or both of the foregoing diagnoses are fairly frequently seen on any adolescent medicine service, for example, in connection with substance

abuse, with recurrent suicide attempts, and/or with severe eating disorder. These patients tend not to be identified by pediatricians by those labels. And they are likely to be approached with persistent sweet reasonability which might work well if they were ‘normal/neurotic.’ The caretaker is trying to invite reasonable response by reasonable approach. For severe character disorder (borderline condition certainly included), that approach (like most others) tends not to work well. And the patient is eventually categorized simply as ‘impossible.’ One important service that a CL worker can provide is to help pediatrics staff to recognize the distinction between the borderline patient and the much more workable young person suffering ‘merely’ from ‘normal-neurotic’ problems (which commonly do respond very well to the best efforts of psychological-minded workers in pediatrics). Failure to make that distinction can discourage precisely those pediatricians (i.e., the psychological-minded ones) we should most want to encourage to develop their psychological skills. Despite the best intentions all around, the ‘impossible patient’ (borderline, severe personality disorder) rarely does respond to the reasonable approach. Sometimes, ‘referral out’ to a psychotherapist adept at work with the borderline patient can lead to some gains.

Consent and refusal It is a ‘tricky’ question at what age is it ethical, reasonable, and/or responsible to give an adolescent authority to consent to and/or to refuse a treatment, especially when there is a parent urging a contrary course. The issues of consent and refusal are discussed elsewhere in this text, but it is customary in discussions of these issues to think of the adolescent as ‘immature’ compared to the adult. There is some validity to that point, of course. However, the author represents a point of view stressing the degree to which a serious conversation with an adolescent by an experienced skilled psychological worker (psychiatrist, other) can elicit a high enough level of response from most adolescents as to justify treating most adolescents (all the way down to young adolescents age twelve, thirteen or fourteen years) as competent to have a decisive say on major consent and refusal issues. Cases differ. The details count. Each one is a ‘judgment call.’ But the reader must remember: the level of judgment on these same matters achieved by the wide range of unselected adult patients seen in any real-life medical practice is no gold standard. Foolish, ‘immature’ and illconsidered judgments and decisions are commonplace in medical work with adults; ask any internist, ask any CL worker on any adult service. As a consequence for the author the mere fact that the patient is ‘under age’ does NOT weigh HEAVILY towards justifying any discounting of the adolescent’s judgment, decisions, or wishes. Where

48 Special issues in adolescent psychiatry

there is a decision made that seems unsound to the health worker, it is best treated as a challenge to the health worker to have yet one more very serious discussion with the patient, with the goal of carrying the level of the discussion to the highest level that patient is capable of. That is exactly what the good internist working with adult patients does, i.e., tries to find a stance that will respect what is sound in what the patient says and 100 per cent honestly trying to persuade the patient of the merits of a different decision where the doctor truly thinks a mistake is being made. There are no rules against trying openly to make a hard sell, where the merits of what you are trying to press seem unmistakable. Of course there are situations where the key issues are all shades of gray, and in such cases one tends to permit the patient to pick the right shade. Only where the judgment seems clearly way off does the doctor have at least an obligation to create a situation in which the patient hears him/her thinking out loud (persuasively!) at his/her best about the relevant issues. What if the adolescent patient refuses a potentially life-saving treatment of which the parent approves? There are cases in which the right judgment for medical staff seems to be to do what one would do with a young child (e.g., age three or six years) – that is, to impose the treatment against the child’s will. There are other cases in which that seems very wrong (particularly where the ‘emotional and physical trauma’ that goes with the treatment is high, e.g., pharmacological treatment of cancer). Furthermore one has to consider: Is the treatment one that requires the patient’s active cooperation, particularly over time? If it is, then ‘imposition’ may simply not be possible. And even when the treatment can be imposed unilaterally, some staff often finds it ‘hard to take’ to find themselves holding down a patient against his/her will for a sedative injection for an anesthesia that can precede and make possible the treatment. Again cases differ, details count, and many of these decisions are ‘judgment calls’ on which decent and able people may differ. What if a parent refuses treatment that the doctor thinks is indicated and to which the adolescent gives an OK? If the probable consequences of non-treatment are significantly life-threatening, there may be grounds for a finding of neglect by the child protection agencies and/or the courts. But, again, cases vary and details count (‘God is in the details’). If the consequences of immediate non-treatment are not life-threatening, often kindly persistence by medical staff (if possible) has the advantage of not creating too intense an adversarial clash between parent and doctor, which can have important advantages in the long run, if only because the parent is much more enduringly in the caretaker role for that child than the doctor is likely ever to be able to become. The parent’s willing acquiescence may well be worth waiting long for and trying hard for.

A weekly conference Multiple useful purposes can be served by a weekly conference attended essentially by ‘everyone’ on the unit and directed by the Chief of the Adolescent Medicine Service and the psychiatric consultant as co-chairs. Typically, in a model we use in a teaching hospital, each conference is organized around one case presentation. The cases are chosen by housestaff and interviewed by the psychiatrist. The interviewer develops an interchange with a minimum of throwing questions at the patient. Adolescents find being ‘put on the spot’ hard to take. The good interview of an adolescent feels more like an interesting conversation – with some fun parts if possible – and with a lot of ‘thinking out loud’ by the interviewer going on (‘I’m sitting here wondering if what you just said means that you’re the kind of person who – or perhaps more like the quite different kind who – ?!’). That approach models honest thinking by the interviewer and invites the adolescent to join in on that thinking process. Those attending commonly get a chance to hear an interchange between interviewer and adolescent where both sides of an honest difference in point of view are clearly articulated – AND THEN LEFT UNRESOLVED! Too often, in conversations between adolescent and ‘official adult’ about something important (e.g., recreational drug use, street behavior, compliance and noncompliance) the adolescent is pressed to give lip service to the adult’s point of view (‘now don’t you agree it would be more sensible to –’) and the adult isn’t even much interested in the adolescent’s contrary point of view. But with the experienced interviewer, at the very least he/she tries to draw out the best possible defense or description from the adolescent of what the adolescent sees and thinks, and sometimes even provides it, for a relatively inarticulate patient. The adolescent may then respond enthusiastically with something like: ‘Yeah – YEAH, Doc – that’s exactly right, man!!.’ But the interviewer may then add something like: ‘But one could also think that maybe – ’ and then articulate a very different point of view (higher level in some critical respect) WITHOUT PRESSING AT ALL for ‘resolution’ of the difference. At first, the adolescent may become a bit confused: ‘But you just said – ??!!’, repeating what the interviewer had said at first, and said well, for the adolescent. The interviewer can then respond with something like: ‘Yes, that’s one way to look at it, and so is the other.’ That leaves unresolved an honest difference, both points of view well articulated and ‘left, shimmering in the air’ for both patient and therapist to look at and think about. That’s not common in conversations between adolescent and professional adult, but it’s a far better point of departure for honest thinking and real change than is the false resolution and/or mere lip service to ‘the proper view.’ And it is more respectful of the adolescent also in a way that can be very good for the working relationship.

Consultation–liaison psychiatry with adolescents 49

Death and dying issues Death and dying issues can hit housestaff and nursing very hard, especially of a patient they like a lot. They commonly turn to the psychiatrist and social work staff to help with ‘talking through’ feelings about the loss, and the feeling of ‘failure.’ Ironically, psychiatrists, social workers, and psychologists have less actual experience with death in their work than do medical and nursing staff. But somehow the identification by others of us as workers on psychological ground creates an expectation to which we have to ‘rise.’ Sometimes the question comes up: Is it appropriate for medical staff to show grief, for example over the slow dying of an especially liked patient? In our experience, moist eyes is usually experienced by family as ‘to the credit’ of the doctor – that he or she is ‘a real person’ and not ‘just a cold professional.’ Really ‘falling apart’ (moaning, deep sobbing) is best not exposed to families who expect the professional to be able to ‘not completely fall apart,’ to be able to have the ‘control’ and ‘strength’ necessary to be able to keep the emotional reaction ‘within bounds.’

a means of introducing an idea about ‘another way’ of working with and/or reacting to a patient that goes best, at first, if received in writing, impersonally, by the intended ‘consumer(s).’ That gives them an opportunity to think about it a bit before the occasion arises to talk about it. It gives them an opportunity to think about it without having at first to acknowledge that the recommended change particularly applies to them. For another, the note has the advantage of being down in black and white to be read by all staff (including night staff, including those ‘off for the day’ at the time the consultation is done). Verbal interchange is, to be sure, often crucial and irreplaceable as a means of achieving ‘a meeting of the minds.’ But if one passes on what one thinks to medical and nursing staff only verbally, that leaves a large number of people who either don’t get the message at all, or only indirectly, such transmitted messages often bearing a very distant relation to the original message.

CONCLUSIONS To conclude with three important general themes:

Expertise on the medical issues It is important to have a good working knowledge of the medical illnesses that come up. But the CL worker who is basically rooted in psychiatry will invariably need to play ‘catch-up’ on some newer approaches to familiar disorders and also on the basics of some relatively unfamiliar disorders. There’s ‘no shame’ in acknowledging on the ward that one needs ‘to do some library work on this one’ when that’s the case, and there’s ‘no shame’ in asking at a conference for ‘some rounded statement, please, by someone who’s more up on the technical details of this disorder than I am, about (for example) the prognosis here’ or ‘about the medical implications of what was just said about the – .’ That is usually much appreciated also by the nonmedical participants in the conference. One half-serious and half-amusing dimension is unfamiliarity with the initials that housestaff use as shorthand: ‘This patient is an AU with a CIP which they attempted to clear with a TF, but it didn’t work,’ to which my response is usually an equally matter-of-fact ‘ETIP.’ Naturally that typically precipitates a puzzled inquiry: ‘What does that mean?!’ to which I cheerfully reply: ‘Explain Those Initials Please.’

The clinical note Although at one level it is a routine matter to be sure to write some brief note each time one sees a case as psychiatric consultant to a medical unit, that note can serve purposes far beyond the routine. For one thing it can be

1 Although it is true at any age that a patient will have the feeling about being ill that: ‘it isn’t fair,’ it is doubly or triply true that adolescents will feel that way. The second decade is in some very serious sense defined as and expected to be a time of thriving good health. It is also a time of super-sensitivity about unfavorable comparisons between oneself and other adolescents. One is supposed to look and feel ‘great’ during adolescence. But for the patients one sees on an Adolescent Medicine Service, they generally do NOT feel great, and for many of them, neither do they look great. Part of the job of the behavioral specialist is to help them to come to some liveable terms with that, compatible with good self-esteem and with as good a life as the illness permits. That isn’t easy. But working on it is essential. And studies of chronic illness in adolescence give real grounds for optimism that it can be done by ‘regular real people’ and not merely by the exceptional youngster. 2 Among those of us – behavioral workers, pediatricians, and nurses – who center our careers on work with adolescents there tends to arise a certain style of relating and speaking with our patients that bears some taking note of. It’s a way of speaking and relating that includes a large component of ‘banter,’ of joking, of saying serious things in a light way. It’s an art form that some people come by naturally and others can learn. It’s a way of talking and thinking that can facilitate communication across the age gap, the social class gap, and the education gap. Part of the responsibility of workers with adolescents is to find a way that works for them (and for their patients) to bridge that gap.

50 Special issues in adolescent psychiatry

3 Finally, one implication of the developmental truth that for some adolescents the teens can be an emotionally tumultuous time and that the twenties are generally an era of coming into calmer waters, is ‘if you can just get them safely through the teens and out the other side, they’ll be home free,’ particularly for those adolescents close to ‘the street life’ and from poverty backgrounds. The foregoing is one overarching generalization worth keeping in mind as one is doing the work.

Suggested reading Friedman, S., Fisher, M., Schonberg, S.K. Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical

Publishing Inc., 1992. See especially: Part One, Section 4 – Treatment Issues; Part One, Section 5 – The Psychomedical Approach; Part Three, Psychosocial Issues, especially Section 5 – Behavioral and Developmental Problems; Part Four, especially Chapters 123 and 124 – Adolescent Pregnancy and Parenting. Fritz, G., Mattison, R., Spirito, A. Child and Adolescent Mental Health Consultation in Hospital, School and Court. Washington, DC: American Psychiatric Association Press, 1993. Slater, E. Diagnosis of Hysteria. British Medical Journal May: 1395–1399, 1964. Zimmerman, J., Asnis, G. Treatment Approaches with Suicidal Adolescents. New York, NY: John Wiley & Sons, 1995. See especially Chapter 5, pp. 91–105.

1.8 Principles of adolescent medicine for psychiatrists MARTIN M. ANDERSON AND ROBERT E. MORRIS

INTRODUCTION This chapter presents aspects of adolescent medical care relevant to psychiatrists. Adolescents who are engaged in therapy with psychiatrists often see them more frequently than their primary care provider. Psychiatrists may also provide medical services to adolescents hospitalized in a psychiatric inpatient setting. Psychiatrists also need to know when to refer their patients to a primary care physician for a potential medical problem. There is a significant interaction between the medical and mental health problems of adolescents, and for these reasons psychiatrists will find it helpful to be familiar with common medical problems that affect adolescents. It follows that there should be significant interaction and cooperation between an adolescent’s psychiatrist and his/her primary care provider. The development of a close working relationship with ongoing communication will improve the healthcare of our shared adolescent patients.

NORMAL PHYSICAL GROWTH AND DEVELOPMENT The emotional, psychosexual, and moral developmental stages of adolescence are reviewed elsewhere. Here, we will briefly outline the physical changes that occur during puberty. Puberty begins in early adolescence and involves the transition from childhood to adult physical and sexual maturity. The development of secondary sexual characteristics during puberty can be rated according to a scale developed by Tanner (Tanner 1962). Sexual maturity ratings (SMR) comprise five stages beginning with SMR1, which is prepubertal, and ending with SMR5 when adult secondary characteristics are achieved. Pubic hair (PH) and genital development (G) are staged in males, while pubic

hair and breast development (BR) are staged in females. Pubic hair is rated in a similar manner for both males and females. During stage PH2, there are a few long, slightly pigmented hairs at the base of the penis or on the labia majora. By stage PH3, there is a moderate amount of curly pubic hair which is pigmented, coarser and extends up to the pubic bone. Stage PH4 resembles adult distribution of pubic hair but does not extend to the medial thigh, which is stage PH5. Some ethnic groups have more body hair and others less, so the final extent of pubic hair varies from person to person. Male genital development is based on changes in the testicles and penis. During stages G1 and G2, the penis remains pre-pubertal and increases in length during stage G3, increasing in length and circumference in stage G4, and achieves adult size in stage G5. Testicular volume also increases, being 1.5 mL at stage G1, 1.6–6 mL at stage G2, 6–12 mL at stage G3, 12–20 mL at stage G4, and >20 mL at stage G5. Breast development during the puberty is rated as follows: no glandular tissue at stage BR1, small volume of glandular tissue and a breast bud in stage BR2, more elevation and glandular tissue beyond the areola with the areola remaining flat in stage BR3, more elevation and larger breast with the areola projecting above the line of the breast in stage BR4, and in step BR5, an adult-sized breast with the areola now in the same plane as the breast with the papilla projecting above the areola. Males begin puberty with the onset of stage G2, usually at age 11.6 years, with a range of 9.5 to 13.5 years. Testicular enlargement is usually the first sign of puberty. Males attain spermarche at G2, ejaculation at G3, and fertility at G4. For males, puberty lasts three years, but can have a range of two to five years. The growth spurt for males begins at G2, but the peak velocity of growth is between G3 and G4 (Tanner and Davies 1985). Puberty usually begins in females with breast development stage BR2 at an average age of 8.87 years for AfricanAmerican girls with a range of 6.0 to 13.4 years and 9.96 years for white girls with a range of 7 to 13.4 years.

52 Special issues in adolescent psychiatry

Puberty usually lasts four years (range 1.5 to 8 years). Menarche usually occurs at BR3 or BR4. The growth spurt begins one year before breast development and the height velocity peaks 1.1 years later, which is about one year before menarche. The ultimate height attainment for teenagers can be estimated using a variety of methods. Some estimates rely solely on parental height, but others require a radiographic evaluation of the teenage bone age (Tanner and Davies 1985). During puberty, alkaline phosphatase activity is elevated above the adult normal level because growing bone produces this enzyme. Males often develop gynecomastia during Tanner stage G3; this is a tender swelling of one or both breasts which may involve only a small breast bud or substantial growth of breast tissue. The degree of development is graded 1 if only a breast bud is present, 2 if a bud plus a small amount of breast tissue develops, while grade 3 approximates the size of a normal female breast. Most gynecomastia which develops during puberty regresses within several years. Some psychotropic drugs, such as phenothiazines, may worsen this condition. Breast enlargement due to obesity should be differentiated from true gynecomastia by the lack of true breast tissue within the breast. Patients with grade 3 gynecomastia, or who develop substantial gynecomastia after puberty, should have luteinizing hormone (LH), testosterone, and human chorionic gonadotropin (HCG) levels measured. Surgical reduction or hormonal therapy is reserved for those boys in whom gynecomastia does not resolve spontaneously, or in whom the gynecomastia presents significant psychological problems.

ABNORMAL GROWTH AND DEVELOPMENT The term ‘abnormal growth’ is used to describe adolescents who are too short or tall, or who are too heavy or light, whereas abnormal development refers to precocious, delayed, or interrupted puberty. Although many adolescents with delayed growth and development may have only constitutional pubertal delay, teens falling two standard deviations outside of the norm should have an evaluation of hypothalamic, pituitary and gonadal function. The presence of a chronic disease should be ruled out. In some cases, extensive testing will be needed and in others, a physical examination may suffice to demonstrate that puberty has occurred. This is especially true in males, where the first signs of puberty – testicular enlargement – may not be apparent to the adolescent. Growth in terms of height and weight should be plotted on growth grids which contain percentiles of normal, from the fifth percentile to the ninety-fifth. The use of growth charts allows the clinician to compare the patient’s height and weight to those of other adolescents of the

same age. It is important that patients with Attention Deficit Hyperactive Disorder (ADHD) who are receiving stimulant medications, and patients with disordered eating, have their growth followed closely. Puberty is delayed in males if Genital Stage 1 (G1) continues beyond age 13.7 years or pubic hair fails to begin development by age 15.1 years, if the patient has not completed pubertal development after five years, or the patient remains in any one stage for over eighteen months to two years. Girls are delayed if breast development (BR2) is delayed beyond 13.4 years or pubic hair fails to begin development (PH2) by 14.1 years. Girls who have not begun to menstruate by age sixteen years are also delayed. Puberty is also delayed if it has not been completed by five years since its onset, or if breast stage (B2) persists for over one year, B3 for over 2.2 years, or B4 over 6.8 years. Likewise, delay is present if pubic hair (PH2) stage 2 persists for over 1.3 years, PH3 persists over 0.9 year, or PH4 persists over 2.4 years (Neinstein and Kaufman 1996). The approach to a teenager with abnormal growth and/or development is based on whether growth or delayed puberty (or both) are involved. Generally, endocrine abnormalities may affect growth and pubertal maturation. Hypothyroidism causes growth delay and both hypo- or hyperthyroidism may impede pubertal development. Excess cortisol secretion may not affect linear growth but can cause truncal obesity with limb wasting and striae on the skin. When pubertal development is delayed and other endocrine hormones are normal, the clinician will test central and gonadal function by measuring serum levels of follicle-stimulating hormone (FSH), LH, and testosterone in both sexes and estrogen and progesterone levels in females. Males with small testicles may suffer from Kleinfelter’s syndrome with a karyotype of 47XXY. Girls with short stature, a webbed neck and ovarian failure may have Turner’s syndrome with a karyotype of 45XO. Patients with these chromosomal abnormalities benefit from hormone replacement and are usually sterile. Some occult organic diseases, such as inflammatory bowel disease, asthma, cystic fibrosis, human immunodeficiency virus (HIV) infection, and renal disease may present with failure to grow or show delayed puberty without any other obvious or overt symptoms. Careful questioning may reveal the presence of mild or forgotten additional symptoms which point toward a diagnosis.

EATING DISORDERS The diagnosis and treatment of disordered eating are presented in Chapter 5.5. The reader is also directed to the American Psychiatric Association (Yager et al. 1993) and Society for Adolescent Medicine’s treatment guideline

Principles of adolescent medicine for psychiatrists 53

and position papers on eating disorders (Fisher et al. 1995; Kreipe et al. 1995). As there are many overlapping behaviors between anorexia nervosa and bulimia nervosa, an overview of medical complications by organ system will be presented, indicating whether the problem arises from starvation, from purging behaviors, or from refeeding (Herzog and Copeland 1985; MacKenzie and Neinstein 1996).

caused by inducing vomiting. Also, edema secondary to increased aldosterone caused by chronic dehydration, especially with increased water intake in face of cessation of purging behaviors.

Endocrine

•

Fluids and electrolytes

• •

•

In starvation: look for elevated blood urea nitrogen (BUN), decreased glomerular filtration rate (GFR), inability to concentrate urine (related to dehydration). In purging/vomiting: look for hypokalemia, hypochloremia, metabolic alkalosis as well as dehydration. – Laxative use: look for hypokalemia, acidosis, dehydration. – Diuretic use; look for hypokalemia, dehydration. Refeeding: look for hypophosphatemia.

•

Hematologic

•

Cardiovascular

• • •

In starvation: look for loss of cardiac muscle mass. Also, bradycardia, hypotension, orthostatic hypotension, mitral valve prolapse, and prolonged QT intervals on the electrocardiogram (EKG). In purging behaviors: look for cardiac dysrhythmias related to hypokalemia. In refeeding: look for congestive heart failure related to excessive water intake in the face of previous chronic dehydration and increased aldosterone levels. Also, dysrhythmias related to hypophostatemia. Ipecac can cause a dose-dependent cardiomyopathy which can be fatal.

Gastrointestinal

• •

In starvation: look for constipation, delayed gastric emptying, fatty infiltration of the liver. Superior mesenteric artery syndrome leading to duodenal obstruction. Gallstones. In purging behaviors: look for decreased peristalsis secondary to hypokalemia. Also, parotid hypertrophy, dental caries, Mallory–Weiss tear of the esophagus, esophagitis related to vomiting of acidic stomach contents. Bloody diarrhea, ‘cathartic colon’ (colonic dysmobility secondary to chronic laxative use).

Skin

• •

In starvation: look for cold, blue hands and feet, brittle hair and nails, hair loss, yellow, dry skin. In purging behaviors: look for facial and scleral petechia secondary to vomiting, calluses over knuckles

In starvation: look for hypoglycemia, growth retardation, pubertal delay, amenorrhea (irregular menses can be associated with bulimia nervosa), decreased vasopressin secretion resulting in partial diabetes insipidus. Increased cortisol. Skeletal changes: look for osteopenia and increased susceptibility to fracturing of bones.

In starvation: look for bone marrow suppression, mild anemia, leukopenia, thrombocytopenia, low erythrocyte sedimentation rate (ESR), possible impaired immune functions.

Neurologic

• •

In starvation: look for cortical atrophy (seen on magnetic resonance imaging, MRI; thought to be reversible) (Katzman et al. 1996; Lambe et al. 1997). In purging behavior: look for seizures related to electrolyte disturbances.

ACNE Acne is a frequent and sometimes unspoken concern of adolescents and their parents. However, when offered treatment for their acne, the majority of adolescents are eager to initiate therapy of this potentially distressing problem. Its presence can be a fortuitous finding for an adolescent’s primary care provider who is searching for a reason to bring the teenager back to further explore a risk behavior or provide confidential services that the patient does not wish to share with his/her parents. Acne is caused by plugged follicles, increased sebum production, and inflammation caused by Proprionobacterium acnes, a bacterium which breaks down sebum into free fatty acids which are inflammatory. This process is mediated by the increase in androgens during puberty. Acne is often worse during periods of stress, but is not worsened by any known dietary factors. Whilst we do not suggest that a psychiatrist should undertake the treatment of acne, a psychiatrist’s recognition of the impact that acne can have on a teenager’s self-esteem should prompt a referral to the patient’s doctor or to a dermatologist.

54 Special issues in adolescent psychiatry

It should also be noted that lithium (Kusumi 1971; Yoder 1975; Ruiz-Maldonado et al. 1973), and possibly also risperidone (Product Information: Risperdal® 1996) and fluoxetine (Wernicke 1985; Product Information: Prozac®, fluoxetine 1996) worsen a patient’s acne.

MENSTRUAL DISORDERS Although most menstrual disorders are not treated by a psychiatrist, there are several areas where knowledge of an adolescent’s menstrual history can be important. An adolescent’s menstrual cycle is controlled through the hypothalamic–pituitary–gonadal axis. There are many things that can affect this axis and cause either irregular bleeding or amenorrhea. The following list is not exhaustive, but contains processes relevant to psychiatrists (Anderson 1991):

• • • • •

Psychological factors: including stress, depression, and anxiety. Nutritional factors: including dieting behaviors, weight loss, and weight gain. Pregnancy. Medications: oral contraceptives, long-acting progesterones, butyrophenones and tricyclic antidepressants, drugs of abuse such as stimulants or opiates. Endocrine factors: hypo- or hyperthyroidism (lithiumrelated hypothyroidism).

The premenstrual syndrome (PMS) does not occur during adolescence, but must be differentiated from exacerbations of underlying psychopathology related to the menstrual cycle (Neinstein 1996, Chapter 51). On occasion, oral contraceptives or depomedroxyprogesterone acetate (DMPA; Depo-Provera®) can be beneficial in either PMS or menstrual cycle exacerbation of other psychopathology.

well as emergency contraceptive methods). Details of the rates of contraception failure for these various methods are listed in Table 1.8-1 (with the exception of the newest methods). Hormonal contraceptives are discussed in greater detail in the following sections, as they are the most likely contraceptive agents to cause mood changes or to cause drug interactions.

Depo-Provera Depo-Provera (DMPA) is an injectable progesterone that has a duration of action of approximately twelve weeks (Hatcher et al. 1994; Nelson and Neinstein 1996). It has the advantage of being highly effective without estrogen side effects, so it can be used in the occasional patient for whom estrogens are contraindicated. Compliance is not a problem, at least during the twelve-week duration of the contraceptive effect. DMPA is particularly useful for patients who either demonstrate or predict that they have difficulty remembering to take pills daily. This includes individuals with cognitive delay who are at risk of becoming pregnant owing to their immaturity and their inability to understand the consequence of sexual intercourse. The ethical and moral considerations of deciding which patients with cognitive delay or altered mental status should receive DMPA are beyond the scope of this section. However, it should be mentioned that, as in all patient interactions, issues of informed consent, potential coercion, parental desires, and the best interests of the patient need to be balanced. The disadvantages of DMPA are complaints of emotional changes such as depression, decreased libido, and physical changes such as weight gain and altered menstrual cycles. The first injection should be given within five days of the onset of a menstrual period in order to avoid pregnancy.

Norplant CONTRACEPTION This brief review of contraceptive methods will highlight salient issues for psychiatrists. Currently available contraceptive methods include abstinence, withdrawal, periodic abstinence (natural family planning, rhythm method), barrier (male condom, female condom, diaphragm, cervical cap), spermicide (vaginal suppositories, vaginal contraceptive film, contraceptive foam jelly, contraceptive creams), the intra-uterine device (IUD), and hormonal methods (DMPA), progesterone-only pills [mini-pills], Norplant, combined oral contraceptive pills, a combined hormonal injectable contraceptive (Lunelle), contraceptive transdermal patch (Ortho Evra), vaginal ring (NuvaRing) as

Norplant is another slow-release form of progesterone. It consists of six silastic rods filled with levonorgestrol (Hatcher et al. 1994; Nelson and Neinstein 1996). These are inserted surgically under the skin of the upper forearm and are effective for a period of five years. The advantages/disadvantages of Norplant are similar to those of Depo-Provera, with the additional disadvantage of requiring an outpatient surgical procedure for insertion and an often more difficult surgery for removal. Norplant’s effectiveness is reduced by agents such as anticonvulsants or rifampin that are metabolized via the cytochrome P450 system. The selective serotonin reuptake inhibitors (SSRIs) do not interact with either progesterone or combined oral contraceptive pills. This method is no longer being marketed in the United States.

Principles of adolescent medicine for psychiatrists 55 Table 1.8-1 Percentage of women experiencing a contraceptive failure during the first year of typical use and the first year of perfect use and the percentage continuing use at the end of the first year, United States Women experiencing accidental pregnancy within first year of use (%) Method

Typical use1

Perfect use2

Chance4 Spermicides5 Periodic abstinence Calendar Ovulation method Sympto-thermal6 Post-ovulation Withdrawal Cap7 Parous women Nulliparous women Sponge Parous women Nulliparous women Diaphragm7 Condom8 Female (reality) Male Pill Progestin only Combined IUD Progesterone T Copper T LNg 20 Depo-Provera Norplant (6 capsules) Female sterilization Male sterilization

85 21 20

85 6

Women continuing use at 1 year (%)3 43 67

19

9 3 2 1 4

36 18

26 9

45 58

36 18 18

20 9 6

45 58 58

21 12

5 3

56 63

0.5 0.1 2.0 0.8 0.1 0.3 0.009 0.4 0.15

1.5 0.6 0.1 0.3 0.09 0.4 0.10

81 78 81 70 85 100 100

Emergency contraceptive pills: Treatment initiated within 72 h after unprotected intercourse reduces the risk of pregnancy by at least 75%.9 Lactational amenorrhea method: LAM is a highly effective, temporary method of contraception.10 1 Among typical couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. 2 Among couples who initiate use of a method (not necessarily for the first time) and who use it perfectly (both consistently and correctly), the percentage who experience an accidental pregnancy during the first year if they do not stop use for any other reason. 3 Among couples attempting to avoid pregnancy, the percentage who continue to use a method for one year. 4 The percentages failing in columns (2) and (3) are based on data from populations where contraception is not used and from women who cease using contraception in order to become pregnant. Among such populations, about 89% become pregnant within one year. This estimate was lowered slightly (to 85%) to represent the percentage who would become pregnant within one year among women now relying on reversible methods of contraception if they abandoned contraception altogether. 5 Foams, creams, gels, vaginal suppositories, and vaginal film. 6 Cervical mucus (ovulation) method supplemented by calendar in the pre-ovulatory and basal body temperature in the post-ovulatory phases. 7 With spermicidal cream or jelly. 8 Without spermicides. 9 The treatment schedule is one dose as soon as possible (but no more than 72 h) after unprotected intercourse, and a second dose 12 h after the first dose. The hormones that have been studied in the clinical trials of postcoital hormone contraception are found in Nordette, Levlen, Lo-ovral (one dose ⫽ four pills), Triphasil, Tri-Levlen (one dose ⫽ four yellow pills), and Ovral (one dose ⫽ two pills). 10 However, to maintain effective protection against pregnancy, another method of contraception must be used as soon as menstruation resumes, the frequency or duration of breastfeeds is reduced, bottle feeds are introduced, or the baby reaches six months of age. From: Hatcher et al. Contraceptive Technology. 16th revised edition. Chapter 5. Irvington Publishers, Inc., New York, 1994.

56 Special issues in adolescent psychiatry

Combined oral contraceptives

Table 1.8-2 Oral contraceptive pill side effects

Combined oral contraceptives (COCs) contain both estrogen and progesterone (Hatcher et al. 1994; Nelson and Neinstein 1996), and include a myriad of different oral contraceptives (OCs). They fall mainly into two categories: (i) monophasic pills, in which the concentrations of estrogen and progesterone are constant throughout the twenty-one days of activity; and (ii) triphasic pills, which have varying ratios of estrogen and progesterone at different times during the twenty-one-day cycle. The newest generation of OC are pills (third-generation pills) that contain progesterones with reduced androgenic effects. The side effects and drug interactions of the OCs are listed in Tables 1.8-2 and 1.8-3.

Estrogenic side effects • Nausea • Increased breast size (ductal and fatty tissue) • Stimulation of breast neoplasia • Fluid retention • Cyclic weight gain due to fluid retention • Leukorrhea • Cervical erosion or ectopia • Thromboembolic complications • Pulmonary emboli • Cerebrovascular accidents • Hepatocellular adenomas • Hepatocellular cancer • Rise in cholesterol concentration in gallbladder bile • Growth of leiomyomata • Telangiectasia

•

•

•

MPA/E2C (Lunelle): A monthly intramuscular injection of medroxyprogesterone acetate (progesterone) and estradiol cyprionate (estrogen). Actions are similar to those of OCPs (suppression of HPA and progestin actions). Currently, the injection must be administered by a healthcare provider. Side effects and drug interactions are similar to those of OCPs (Kaunitz and Garceau 1999; Kaunitz 1998; Shulman et al. 1999; Shulman 2000). Vaginal contraceptive ring (NuvaRing): A thin flexible plastic ring which contains ethinyl estradiol and etonogesterel (a progesterone) which are slowly released. The ring is inserted into the vagina and fits in the posterior vagina. It is left in for twenty-one days and removed for one week for menstruation. Hormones are released continuously into the vaginal mucus and absorbed. Efficacy is similar to that of oral contraceptives. Side effects may be less because serum hormone levels are less than that of OCPs (Timmer and Mulders 2000). Contraceptive patch Ortho Evra: A seven-day patch that provides a steady dose of ethinyl estradiol and 17-diacetyl norgestimate (progesterone). It is about the size of a pack of matches and can be worn on the arm, buttocks, or abdomen. The individual wears three patches for the first three weeks of the cycle and leaves the patch off during the fourth week for menses. Efficacy is similar to that of the oral contraceptive pill (Creasy et al. 2000; Audet et al. 2001; Zieman et al. 2001).

Emergency contraception Emergency contraception has been underused in the United States (Hatcher et al. 1994; Grimes 1997; Nelson and Neinstein 1996). Emergency contraceptives prevent pregnancy after unprotected intercourse. The different currently available hormonal regimens are listed in Table 1.8-4. A ‘hot-line’ (888) NOT-2-LATE is available to answer questions about emergency contraception.

Progestogenic effects • Breast tenderness • Headaches • Hypertension • Myocardial infarction Androgenic effects • Increased appetite and weight gain • Depression, fatigue, tiredness • Decreased libido and enjoyment of intercourse • Acne, oily skin • Increased breast size (alveolar tissue) • Increased LDL cholesterol levels • Decreased HDL cholesterol levels • Diabetogenic effect • Pruritus • Decreased carbohydrate tolerance From: Hatcher et al. Contraceptive Technology. 16th revised edition. Chapter 10. Irvington Publishers, Inc., New York, 1994.

Hormonal contraception and depression The incidence of depression in several studies of depression and hormonal contraception ranged from 16 to 56 per cent (Slap 1981; Anderson et al. 1976; Hatcher et al. 1994; Neinstein 1994; Nelson and Neinstein 1996). Patients with pre-morbid psychological disorders were more likely to have changes in mood. It is believed that depression could be caused by several mechanisms. Progesterone could cause a decrease in vitamin B6, which in turn may cause a decrease in serotonin levels in the brain (Hatcher et al. 1994; Nelson and Neinstein 1996). Both estrogen and progesterone can produce cyclic fluid retention which might contribute to a feeling of bloating and thereby affect mood. However, a prospective study of the mood-altering effects of low-dose contraceptives on a group of 200 women using the Amsterdam Mood Questionnaire and the Sickness Impact Profile prior to treatment and after one and three

Principles of adolescent medicine for psychiatrists 57 Table 1.8-3 Oral contraceptive pill interactions with other drugs Interacting drugs

Adverse effects (probable mechanism)

Comments and recommendations

Acetaminophen (Tylenol and others) Alcohol Anticoagulants (oral) Antidepressants (Elavil, Norpramin, Tofranil and others) SSRIs do not interact Barbiturates (Phenobarbital and others)

Possible decreased pain-relieving effect (increased metabolism) Possible increased effect of alcohol Decreased anticoagulant effect possible increased antidepressant effect

Monitor pain-relieving response

Benzodiazepine Tranquilizers (Ativan, Librium, Serax, Tranxene, Valium, Xanax, and others) Beta-blockers (Corgard, Inderal, Lopressor, Tenormin) Carbamazepine (Tegretol) Corticosteroids (cortisone) Griseofulvin (Fulvicin, Grifulvin V and others) Guanethidine (Esimil, Ismelin)

Possible increased or decreased tranquilizer effects including psychomotor impairment

Hypoglycemics (Tolbutamide, Diabinese, Orinase, Tolinase) Methyldopa (Aldoclor, Aldomet and others) Penicillin Phenytoin (Dilantin) Primidone (Mysoline) Rifampin Tetracycline Theophylline (Bronkotabs, Marax, Primatene, Quibron Tedral, Theor-Dur, and others) Troleandomycin (TAO) Vitamin C

Decreased contraceptive effect

Use with caution Use alternative contraceptive Monitor antidepressant concentration

Possible increased blocker effect

Avoid simultaneous use; use alternative contraceptive for epileptics Use with caution. Greatest impairment during menstrual pause in oral contraceptive dosage Monitor cardiovascular status

Possible decreased contraceptive effect Possible increased corticosteroid toxicity Decreased contraceptive effect

Use alternative contraceptive Clinical significance not established Use alternative contraceptive

Decreased guanethidine effect (mechanism not established) Possible decreased hypoglycemic effect

Avoid simultaneous use

Decreased antihypertensive effect

Avoid simultaneous use

Decreased contraceptive effect with ampicillin Decreased contraceptive effect; possible increased phenytoin effect Decreased contraceptive effect Decreased contraceptive effect Decreased contraceptive effect Increased theophylline effect

Low but unpredictable incidence; use alternative contraceptive Use alternative contraceptive; monitor phenytoin concentration Use alternative contraceptive Use alternative contraceptive Use alternative contraceptive Monitor theophylline concentration

Jaundice (additive) Increased serum concentration and possible increased adverse effects of estrogens with 1g or more per day of vitamin C

Avoid simultaneous use Decrease vitamin C to 100 mg per day

Monitor blood glucose

From: Hatcher et al. Contraceptive Technology. 16th revised edition. Chapter 10. Irvington Publishers, Inc., New York, 1994.

months of treatment found no significant change in mood (Deijen et al. 1992).

SEXUALLY TRANSMISSIBLE INFECTIONS By the end of high school, two-thirds of females and three-fourths of males are sexually active. The incidence of sexually transmissible infections (STI) peaks in females

between the ages of sixteen and nineteen years. Although the peak for STI is in the early twenties for males, teenage males also have high rates of infection. Infection of the urethra and cervix with chlamydia and gonorrhea is increasingly asymptomatic (Brady et al. 1988; CDC 1996). Between 66 and 80 per cent of males and females will be asymptomatically infected. Asymptomatic infections of gonorrhea cause a number of complications, including epididymitis, pelvic inflammatory disease, tenosynovitis, single joint arthritis, and disseminated

58 Special issues in adolescent psychiatry Table 1.8-4 Oral contraceptives used for emergency contraception in the United States Brand

Pills per dose

Ethinyl estradiol per dose (␮g)

Levonorgestrel per dose (mg)a

Ovral Alesse Nordette Levlen Lo/Ovral Triphasil Tri-Levlen Ovfrette

2 white pillsb 5 pink pillsb 4 light-orange pillsb 4 light-orange pillsb 4 white pillsb 4 yellow pillsb 4 yellow pillsb 20 yellow pillsc

100 100 100 120 120 120 120 0

0.50 0.50 0.60 0.60 0.60 0..50 0.50 0.75

a

The progestin in Ovral, Lo/Ovral, and Ovrette is norgestrel, which contains two isomers, only one of which (levonogestrel) is bioactive: the amount of norgestrel in each dose is twice the amount of levonogestrel. b The treatment schedule is one dose within 72 h after unprotected intercourse and another dose 12 h later. c The treatment schedule is one dose within 48 h after unprotected intercourse and another dose 12 h later. From: Trussell, J., Koenig, J., Ellertson, C. and Stewart, F. Preventing unintended pregnancy: the costeffectiveness of three methods of emergency contraception. Am. J. Public Health 87(6): 932–1997.

gonorrhea usually associated with an acral rash of petechia or small necrotic skin lesions. Asymptomatic chlamydia cervicitis in females results in symptomatic and asymptomatic pelvic inflammatory disease with sequelae of infertility or ectopic pregnancy due to tubal scarring (Chow et al. 1990). Chlamydia infections during pregnancy can be associated with obstetric complications. Routine screening of sexually active adolescents at least yearly will reduce the rate of asymptomatic infections and their resulting complications (Scholes et al. 1996; U.S. Department of Health 1993; Martin et al. 1992). Currently, oral medications are used for uncomplicated infections: cefoxime 400 mg once for gonorrhea and azithromycin 1 g once for chlamydia. Sexual partners should also be treated. The addition of ligase chain reaction tests of first-part (initially voided) urine for chlamydia and gonorrhea for both boys and girls has greatly simplified the diagnosis of this infection as no invasive maneuvers are needed. The test amplifies fragments of recognizable DNA and greatly increases the sensitivity of the tests, thus allowing detection of only a few organisms. Pelvic inflammatory disease (PID) is caused by the spread of gonorrhea, chlamydia and/or other organisms from the cervix to the uterus and fallopian tubes. It is most common in female adolescents aged between sixteen and nineteen years. Symptomatic PID is diagnosed and treated in any female who has lower abdominal tenderness with cervical motion tenderness and adnexal tenderness. Patients with severe symptoms presumptively from PID are treated, but should also receive a work-up for other possible pelvic pathologies such as appendicitis, ectopic pregnancy, torsion of an ovary, hemorrhagic ovarian cyst, and simple ovarian cyst. Males develop epididymitis when organisms in the urethra move through the tubes to the epididymus and testicles, causing swelling and pain. Tests of the urethra for organisms will usually reveal the offending bacteria.

Treatment is begun as soon as samples for organism testing have been obtained. The differential diagnosis includes torsion of the testis, torsion of the appendix testis, hernia, and trauma to the testis. There are a number of genital ulcer diseases which may be transmitted during sexual activity. Herpes simplex II causes multiple small vesicles which rapidly break to form painful ulcers during primary infection. The primary infection episode usually includes regional lymphadenopathy and systemic malaise and fever. Up to 20 per cent of primary infections are asymptomatic. Secondary or recurrent attacks of herpes II usually involve fewer lesions, without systemic signs. Primary infections are treated with oral aciclovir in varying doses (Whitley and Gnann 1992). Newer drugs are available with a lower dosing frequency, but with similar clinical results. Secondary attacks are usually not treated, although oral aciclovir may marginally shorten the course. Suppression of frequent secondary attacks may be successful if patients take aciclovir daily for six to twelve months. As patients grow older, the frequency of recurrences decreases and attacks ultimately occur less than yearly. Asymptomatic viral shedding is more frequent close to the time of primary infection and for seven days after a case of secondary lesions, but can take place at any time (Wald et al. 1995; Rolfs and Nakashima 1990). A resurgence of syphilis was associated during the 1980s with the epidemic of crack cocaine use. The number of cases has subsided somewhat, but inner-city ethnic minority residents continue to be affected disproportionately. A painless 1–2-cm diameter ulcer appears at the site or sites of inoculation three weeks after the infection (range three weeks to three months). Regional lymphadenopathy is prominent. Early diagnosis depends on dark-field microscopic examination of the exudate, because only two-thirds of people with chancres will be serologically reactive. After the chancre heals, the lymphadenopathy persists for months. The latent phase is

Principles of adolescent medicine for psychiatrists 59

asymptomatic and lasts for a variable length of time (from days to years) before the appearance of various rashes which herald the onset of secondary syphilis. The rashes often mimic dermatoses with other etiologies. Therefore, condyloma lata may superficially resemble condyloma acuminata or molluscum contagiosum. Syphilis may look like a viral exanthem, although in syphilis the palms and soles usually have flat brownish red circular lesions that are several millimeters to centimeters in diameter. Psoriatic syphilis looks like psoriasis, and syphilis can also mimic pityriasis rosea. The skin lesions are full of spirochetes which are infectious. Tertiary syphilis which affects internal organs is usually seen in older adults. Syphilis present for less than a year is treated with a single dose of benzathine penicillin (1.5 million units). Syphilis which is present for over one year is treated with three injections of benzathine penicillin at the above dose, each one week apart (US Department of Health 1993). Persons infected with the human immunodeficiency virus (HIV) may not clear syphilis normally and require much more intensive treatment (Gordon et al. 1994; Lukehart et al. 1988; Musher 1988; Musher and Baughn 1994). The minor genital ulcer diseases are chancroid, lymphogranuloma venereum, and granuloma inguinale. Chancroid can be treated with either azithromycin (1 g orally) or ceftriaxone (250 mg intramuscular). In areas of the country where chancroid is common, it is suggested that the patients with a single genital ulcer and regional adenopathy be treated for both syphilis and chancroid. Lymphogranuloma venereum is caused by chlamydia and should be treated with doxycycline 100 mg b.i.d. for 21days. Granuloma inguinale is quite rare, and treatment and diagnosis should be carried out in conjunction with an infectious disease specialist. Human papilloma viruses cause common warts as well as condyloma acuminata. The viruses are identified by number, and some are more prone to cause or be related to the onset of cervical neoplasia. The actual warty growths can be destroyed using podophyllin, trichloroacetic acid (TCA), freezing, or electro-cautery. Anal, perianal, and urethral condylomata can be treated with liquid nitrogen, TCA, or topical 5% fluorouracil, though the latter drug is not universally accepted for treatment. Destruction of the condyloma does not rid the patient of the virus, which is latent and can cause recurrence of condylomata at any time. The patient need not have condylomata present to be infectious for the virus. It should be noted that although traditional penetrative sexual intercourse (either vaginally or anally) transmits these infections, many teenagers engage in non-penetrative sexual behavior which could allow infection to take place despite technically remaining virginal. Therefore, a sexual history-taking should include all sexual behaviors (Schuster 1996). The incidence of HIV infection varies across the USA and the world. A number of young adults developing

acquired immunodeficiency disease (AIDS) were infected as teenagers but were not diagnosed until they became symptomatic years later. With the availability of triple antiretroviral therapy, the possibility of substantially slowing the disease progression or perhaps eliminating it has become a reality. Patients with symptomatic primary disease may especially benefit from treatment during the primary infection episode because the progression may be slowed and the virus eventually eliminated (Carpenter et al. 1997). When primary disease is symptomatic it resembles mononucleosis, with malaise, a short-lived rash and lymphadenopathy. An ulcer similar to a chancre may also form at the site of inoculation. Some patients develop more serious disease with a time-limited mini-AIDS syndrome. Neuropathy may also be seen (Quinn 1997). Teen patients, especially those at high risk for HIV infection, should be evaluated for primary HIV infection using virus-identifying tests rather than serologic tests if they develop compatible symptoms. The current therapy for HIV infection usually includes triple drug therapy (two nucleoside reverse transcriptase inhibitors and a protease inhibitor) and appropriate prophylaxis for opportunistic infections (OI). It is very important to take all antiretroviral drugs on schedule without missing doses. Intermittent use of these drugs will allow viral resistance to develop and negate their usefulness. Therefore, patients should not begin taking these drugs unless they are committed to perfect compliance. Many drug interactions occur between antiretroviral drugs, opportunistic infections prophylactic drugs and psychotropic drugs, causing either toxicity or loss of drug effectiveness. The course of HIV infection and the effect of antiretroviral drugs is determined by following viral load and CD4 lymphocyte counts (Ho 1996; Mellors et al. 1996). Effective therapy will suppress viral counts in the blood to ‘undetectable’ and lead to a substantial increase in CD4 counts in all but the most immunocompromised patients (Carpenter et al. 1997). The appropriate time to start or suspend treatment has varied as the appreciation of the natural history of HIV infection has improved.

HEADACHES Headaches are a common symptom in adolescents (see Table 1.8-5 for a differential diagnosis) (Neinstein 1996). Headaches can be divided into extracranial or intracranial categories. The causes of extracranial headaches include processes such as dental abscesses, sinus infection, and temporomandibular joint arthritis (TMJ dysfunction). Intracranial headaches are further divided into traction, tension, and migraine headaches. Traction headaches are due to space-occupying lesions such as brain tumors or other causes of increased intracranial pressure. Tension

Table 1.8-5 Headache presentations Precipitating factors

Type of headache

Onset

Location

Pain quality

Duration

Associated symptoms

Prodromata

Common migraine

Gradual

Uni- or bilateral

Throbbing, pulsating

Hours to days

Nausea, vomiting, chills, fever, photophobia, weakness, fatigue

Paresthesias, dizziness, mood disturbance, minutes to hours before pain

Alcohol, chocolate, cheese, red wine, glare

Classic migraine

Gradual

Unilateral

Throbbing, pulsating

4–8 h or longer

As in common migraine

Scotomata, sensory paresis, weakness, 10–20 min before pain

As in common migraine

Muscle contraction

Variable, usually afternoon

Occipital, bilateral, frontal, bandlike

Steady pressure, dull

Hours to day

Weakness, fatigue

None

Stress

Cluster

02:00–03:00, abrupt

Unilateral, orbital or temporal

Burning, boring, excruciating

Minutes to hours; usually 30–40 min.

Unilateral, lacrimation, conjunctival infection, rhinorrhea, ptosis, sweating, miosis

None

Alcohol

Mass lesions

Gradual or sudden, but usually recent

Focal or general

Varied, often dull ache

Varied

Neurological signs

None

Cough, bending, exercise

Pseudotumor (benign increased intracranial pressure)

Variable

Vertex or diffuse

Dull

Variable; may occur during sleep or early morning

Visual obscurations and papilledema

None

Vitamin A or D overdose, steroid treatment or withdrawal, obesity, endocrine abnormalities, tetracycline

Depressive

Prolonged, constant

Generalized

Dull, unvarying

Days to months

Depression may be masked; anorexia; sleep disturbances; anhedonia; school phobia

None

Factors causing depression; family history of affective disorders common

From: Neinstein, L.S. Adolescent Health Care. A Practical Guide. 3rd edition. Section VI, Neurological Disorders. 1996.

Principles of adolescent medicine for psychiatrists 61

headaches are very common in adolescents, and are generally described by the patient as band-like and associated with a tight or pressure-like sensation. Migraine headaches are classified as either classic, common, or atypical. The classic migraine has an aura such as flashing lights, wavy lines or blind spots. The headache is characterized as pounding and is often associated with nausea or vomiting; it might be described as a ‘sick headache.’ The common migraine is similar to the classic except that it lacks the aura. Atypical migraines have associated neurological symptoms such as ophthalmoplegia or hemiplegia. Depressive headaches typically last all day, though the patient may not exhibit classic symptoms of depression. The headaches are frequently associated with school absenteeism and a positive family history of affective disorder. Depressive headaches, tension headaches and migraines can benefit from psychotherapy as well as stress reduction and relaxation techniques, and show good response to antidepressant medications. They may have a diurnal variation; worse at 04:00 to 08:00 and from 16:00 to 20:00. A headache diary is often helpful in diagnosing the headache type and identifying potential triggers (Blau 1990; Mitchell and Neinstein 1996; McGregor 1997). Nonsteroidal anti-inflammatory drugs (NSAIDs) are useful for mild to moderate migraine headaches, while sumatriptan 20mg intranasally has demonstrated efficacy in adolescents (Ueberall 1999; Winner 1999).

CHEST PAIN Chest pain is a common symptom in adolescents. Most chest pain is idiopathic or is muscular or cartilaginous in origin (costochondritis). The physical examination reveals a normal chest except for tenderness of intracostal muscles or costochondral junctions. This type of pain responds to seven to fourteen days’ treatment with an NSAID. A study of adolescents presenting to a pediatric emergency room with chest pain found that in all cases the need for further diagnostic tests such as electrocardiogram or radiography was guided by the history and physical examination. The need to rule out serious pathology was obvious after completing the history and physical examination (Selbst et al. 1988). At times, the presence of intermittent chest wall pain will trigger a hyperventilation spell in which the adolescent experiences anxiety, dizziness, and paraesthesis of the extremities. Conversely, hyperventilation can be the cause of the chest pain. Patients may become quite upset and occasionally experience loss of consciousness due to the resulting decrease in blood perfusion of the brain. These patients may appear to be having seizures or other serious medical or psychiatric disorders. Recovery from hyperventilation spells is quick and complete.

In early pubertal girls, and in boys with gynecomastia, the breast buds are tender and may be the cause of alarm to the teenager or their parents. Patients who have chest pain, loss of consciousness, seizures, or pallor during exercise should be evaluated for cardiac and other pathology. If a patient has any of the following: a family history of sudden death, syncope, dysrhythmia, mitral valve prolapse, prolonged QT syndrome, or hypertrophic cardiomyopathy, then a cardiology consultation should be obtained (Risser et al. 1995).

ORTHOPEDICS/SPORTS MEDICINE Adolescents are prone to a variety of musculoskeletal disorders and injuries because of growth and highly active lifestyles. They may complain of these aches and pains during sessions with their psychiatrist. Thus, the psychiatrist needs to be able to discern which complaints should prompt further evaluation. The condition of slipped capital femoral epiphysis is associated with the onset of puberty. It can occur in one or both hips (25% bilateral). The teenager complains of hip or knee pain (referred from the hip) either spontaneously or after an injury. There may be limping and decreased internal rotation of the affected hip. Radiographs of the hip show the femoral head slipping posteriorly. Because the head will have to be pinned in the place to which it has become displaced, it is important to diagnose this disorder before serious slippage has occurred. When the diagnosis is suspected, the patient should remain non-weight-bearing until radiographs have ruled out the disorder (Skinner 1996). Less serious is Osgood–Schlatter’s disease, which appears as an apophysitis of the tibial tubercle just below the knee joint. The constant pulling of the infra-patellar tendon on the tubercle leads to pain and cartilaginous overgrowth of the junction of the apophysis and the tibia. Activities involving jumping lead to aching of the area. Rest and NSAID treatment alleviates the pain. When growth ceases, so does the disease because the bone fuses to the tibia. Night cramps, especially in the legs, are due to an over flaccid state of the muscles during sleep and may be associated with an increase in muscle activity such as ‘going out’ for a sport. The cramp often begins when the muscle is maximally shortened, and the cramp can be alleviated by stretching the muscle, for example, by dorsiflexing the foot for a cramp in the calf (Weiner and Weiner 1980). Sports can cause many injuries to bones, muscles, and the ligaments or surfaces of active joints. Each sport has specific active and overuse injuries associated with it. For most sports injuries, muscle rehabilitation is the keystone of a successful return to the sport. Injury causes muscle atrophy and subsequent further injury. Muscle

62 Special issues in adolescent psychiatry

rehabilitation allows proper functioning and stabilization of the joints. The goal of sports medicine physicians is to return the athlete to the sport he/she wishes to play.

•

•

Knees are particularly prone to injury during football and other activities in which the lower leg is stabilized and the upper leg continues to move, causing damage to ligaments or cartilage in the knee. Repair of some ligaments and cartilage may be successful. However, cruciate ligament repairs may fail. Ankle injuries are often due to lack of proprioception in the ankle. Rehabilitation includes work on a tilt board to improve this type of sensation.

NSAIDs are commonly prescribed for athletes but should not be taken by patients on lithium because of increased plasma lithium levels caused by decreased renal lithium clearance (Price and Henninger 1994). Overuse syndromes usually involve new shoes, new exercises, a return too quickly to full activity after a gap in the activity, a change in running terrain or exercise pattern, or rapid growth. The use of rest, ice, compression and elevation, and NSAIDS usually allows healing of the injury. Slowly increasing the work load allows a painless return to the sport.

Foot problems Teenagers’ feet are subject to many problems. The skin may suffer from tinea pedis, dyshydrosis, and contact dermatitis. Antifungal creams for tinea, and steroid cream for dyshydrosis and contact dermatitis will eliminate these problems. Feet with structural problems may not become symptomatic until the teenager’s size, weight and athletic pursuits combine to cause pain in the abnormal foot. Foot pain should be evaluated by an orthopedist who is familiar with foot problems, or a podiatrist.

FATIGUE Adolescents and/or their parents frequently complain of the adolescent being overly ‘tired’ (Belzer and Neinstein 1996; Kulig 1991; McGregor 1997). It is important to differentiate between sleepiness and muscular weakness. The former is common, and the latter rare. The differential diagnosis includes, among others, sleep deprivation, pregnancy, various infections, depression and chronic fatigue syndrome (CFS). A detailed list of potential causes of fatigue is provided in Table 1.8-6. Sleep laboratory studies have shown that adolescents require 91⁄2 to 10 hours of sleep to feel rested, and the time of spontaneous awakening occurs later in the morning as teenagers age and go through puberty (Carskadon 1990; Carskadon et al. 1993). Unfortunately, most secondary schools do not accommodate this developmental shift in

sleep behavior. Sleep-deprived teenagers will usually have energy to do things that are fun or interesting, and they will feel rested if allowed to sleep until they awaken spontaneously. A detailed sleep history is the most important aspect of the evaluation of this complaint. Several acute illnesses can cause fatigue, such as hepatitis A, B, or C, infectious mononucleosis, and influenza. Malignancies such as acute leukemia or Hodgkin’s lymphoma can also cause fatigue. Endocrinological causes of fatigue are hypo/hyperthyroidism, diabetes, and Addison’s disease. Anemia, allergies, pregnancy and of course, prescription/non-prescription drug use or abuse are potential causes. Since complaints of fatigue are common and significant pathological causes are rare, it is important to approach the evaluation of fatigue in a stepwise fashion. First, a psychosocial and medical history as well as a complete physical examination should be performed. It should be determined if the teenager has sufficient energy to do fun things such as go to a late movie, play sports, go out with friends, or stay up late watching TV, play video/computer games, or talk on the phone. A detailed sleep and medication/drug history is essential. If the etiology is unclear after this initial evaluation, then screening laboratory examinations such as a complete blood count, ESR, renal function tests, liver enzyme tests, and thyroid function tests can be performed. Removal of a television from the adolescent’s bedroom can be curative in many cases. It is rare that any further evaluation is needed, but if the complaint is chronic then chronic fatigue syndrome might be considered. Diagnostic criteria for fatigue are listed in Table 1.8-7.

GENETIC/DEGENERATIVE DISEASES As the management of many chronic diseases improves, an increasing number of chronically ill children will live into, and through, adolescence. These complex conditions often require case management and multispecialty involvement. The usual concerns of adolescents can be forgotten in such a formidable setting. Issues of education, vocation choices, sexual functioning and illicit drug use should be addressed for all adolescents. Assistance in adhering to difficult and complex treatment regimens may be necessary to the survival of these chronically ill adolescents (Anderson 1991).

PSYCHOSOMATIC SYMPTOMS All healthcare providers have had patients whose symptoms, after an appropriate medical evaluation, cannot be explained by any disease process. When are these symptoms psychosomatic? A psychosomatic symptom is one

Principles of adolescent medicine for psychiatrists 63 Table 1.8-6 Expanded differential diagnosis for fatigue in adolescents Common causes

Uncommon causes

Rare causes

Psychosocial Excessive physical exertion Depression School avoidance Grief Stress – prolonged Eating disorders, including dieting Sedentary lifestyle Infectious Mononucleosis syndromes (Epstein–Barr virus, cytomegalovirus) Hematologic–oncologic Anemia Gynecologic Pregnancy Allergic Chronic atopy Sleep-related Insomnia REM sleep deprivation Pulmonary Poorly controlled or unrecognized Asthma Neurologic Central nervous system-acting drugs or toxins

Psychosocial Hyperventilation Drug abuse Infectious Mononucleosis, syndromes (toxoplasmosis, human, immunodeficiency virus) Chronic infections Tuberculosis Brucellosis Histoplasmosis Occult osteomyelitis Hepatitis Sinusitis parasites Subacute bacterial endocarditis Endocrinologic Diabetes mellitus Diabetes insipidus Addison’s disease Cushing’s syndrome Hyper- or hypopituitarism Hyper- or hypothyroidism Collagen vascular Fibromyalgia Gastroiontestinal Inflammatory bowel disease Hepatitis Sleep-related Sleep apnea Pickwickian syndrome Cardiovascular Pulmonary hypertension Hypertrophic obstructive cardiomyopathy Cardiomyopathy Myocarditis Pericarditis Neuro-mediated hypotension Pulmonary Cystic fibrosis Renal Renal tubular acidosis Uremia Neurologic Neuro-mediated hypotension

Hematologic–oncologic Leukemia Lymphoma Pheochromocytoma Endocrinologic Hypoglycemia Collagen vascular Dermatomyositis Systemic lupus erythematosus Rheumatoid arthritis Scleroderma Mixed connective tissue disease Allergic Allergic tension–fatigue syndrome Cardiovascular Takayasu’s arthritis Pulmonary Sarcoidosis Metabolic Hypokalemia Hyponatremia Hyper- or hypomagnesemia Neurologic Myasthenia gravis Heavy metal poisoning Insecticide poisoning Carbon monoxide inhalation

Adapted from Dietz, H.C. and Oski, F.A. Presenting signs and symptoms. In Oski, F.A. (ed.), Principles and Practice of Pediatrics, Philadelphia, J.B. Lippincott, 1990; and Green, M. (ed.), Green and Richmond Pediatric Diagnosis, 4th edition, Philadelphia, W.B. Saunders, 1986. From: Braverman, P.K. and Strasburger, V.C. (eds), Adolescent medicine. State of the Art Reviews 8(1): February 1997.

whose presence, frequency of occurrence, severity or duration is not explainable on the basis of a pathological process or a disease state and of which psychological factors are believed to influence the symptoms (Anderson 1991). Familiar psychosomatic symptoms are headaches,

nausea, abdominal pain, chest pain, fatigue, and dizziness. However, any system can be involved, including symptoms such as recurrent sore throats, muscle aches, cough, diarrhea, itchy skin, vaginal discharge, dyspnea, or difficulty swallowing (Smith 1990).

64 Special issues in adolescent psychiatry Table 1.8-7 Chronic fatigue (1994 Revised case definition of chronic fatigue syndrome) Persistent or relapsing fatigue for ⭓6 months, with a clearly defined time of onset that is: 1

Unexplained by previous evaluation with a thorough medical and psychological history, physical examination (including mental status), and laboratory screens, including complete blood count, erythrocyte sedimentation rate, serum aspartate aminotransferase, T protein, albumin, globulin, alkaline phosphatase, calcium, phosphorus, electrolytes, glucose, blood urea nitrogen, creatinine, thyroid-stimulating hormone, and urinalysis. • Resulting in significant reduction in previous levels of activity with respect to occupational, educational, social, or personal function • Not significantly alleviated by rest • Not resulting from continued exertion • Not explained by unresolved previous or active medical conditions (e.g., sleep apnea, untreated hypothyroidism) and 2 Concurrent with ⭓4 of the following symptoms (which have persisted or recurred during ⭓6 consecutive months of the illness and must not have predated the fatigue) • Self-reported impairment in short-term memory or concentration • Sore throat • Tender cervical or axillary lymph nodes • Muscle pain • Multiple joint pains without objective findings • Headaches of new type, pattern, or severity • Unrefreshing sleep • Post-exertional malaise lasting >24 hours

Adapted from Fukuda, K., Straus, S.E., Hickie, I., et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann. Intern. Med. 121: 953, 1994. From: Braverman, P.K. and Strasburger, V.C. (eds), Adolescent medicine. State of the Art Reviews 8(1): February 1997.

The diagnosis of psychosomatic symptoms should not be made without a thoughtful and thorough medical as well as psychological evaluation. The diagnosis should not be made only on the basis of the absence of a demonstrable medical cause for the symptom. There should also be a search for psychological factors that could be active in creating or influencing the symptoms. This is where the primary care physician and the psychiatrist can work together. The patient’s symptoms need to be legitimized and the mental health practitioner involved early to assist the patient with the frustration of living with a chronic complaint and to investigate potential psychological mediating factors. Unfortunately, most psychiatrists have little control over when they become involved in these cases. If consulted after a ‘complete medical evaluation is done,’ the psychiatrist will need to assure the patient that he/she will remain alert to any change in symptoms that the referring doctor may find useful in further investigating the symptom. Frequently it is useful to explain the symptom as a physiologic response to stress or that the patient has a physiologic hyper-responsiveness to somatic stimuli. An explanation such as tight neck muscles secondary to working at a computer, or abdominal pain/diarrhea secondary to a hypersensitive colon give the patient a way of legitimizing the symptoms yet acknowledging the benefit of psychological treatment in helping them cope with their pain. The psychiatrist and primary care provider should assure the patient that all the necessary

medical work-up has been done and, when appropriate, additional investigations will be ordered. The patient’s understandable tendency to shop around seeing multiple providers while seeking answers should be discussed openly and discouraged. The balance between an excessive evaluation and an appropriate one is often hard to achieve and the judicial use of subspecialty referral and second opinions can be useful.

DRUG INTERACTIONS There may be interactions with many of the drugs commonly used by teenagers. Erythromycin, cimetidine, and seizure medications are some of the most common. Others are mentioned elsewhere in this chapter. Oral contraceptives (OCs) interact with many drugs with a range of effects including decreased efficacy of the OC, increased or decreased plasma levels of other drugs. Antidepressants, beta-blockers, carbamazepine, phenytoin, primidine, and tetracycline comprise a partial list of drugs which interact with OCs. Lithium interacts with a number of drugs, the most important of which are NSAIDs such as ibuprofen. A complete listing of all drug interactions is beyond the scope of this chapter. However, the clinician should be familiar with the drug interactions of any psychotropic agent which is being prescribed to the patient.

Principles of adolescent medicine for psychiatrists 65

COMPLIANCE ISSUES Although adolescents are frequently assumed to be noncompliant, age alone is not an adequate predictor of compliance. Physicians fare little better than chance when predicting patient compliance. To put this issue into perspective, readers should ask themselves if in the past they have successfully completed a course of medication without missing any doses, or are they following the current health recommendations regarding diet and exercise, wearing seat belts, bike helmets, or using sunscreen. The following suggestions can potentially improve compliance (Anderson 1991): 1 Simplify the regimen and tailor it to the adolescent’s life style as much as possible. Provide written instructions. Outline clearly how a dose should be increased if the medicine is given with instructions to gradually increase the dose. 2 Discuss potential side effects of the medication and encourage the patient to contact you to ask questions before stopping the medication. (Have a mechanism to be available to your patients when they call.) 3 Educate the patient as to the purpose and consequences of complying or not complying with the treatment regimen. 4 Do not assume that an intelligent, well-educated patient will comply, or that a poorly educated patient will not. 5 Enlist the adolescent’s cooperation in the treatment plan. Work with them on ways to remember to take the medicine, i.e., alarms, associating the medication with daily activities such as brushing teeth, taking a shower, or eating dinner. A pill box with spaces for each day’s medication can assist a patient in remembering to take the medication correctly. 6 Trying to instill in a patient fear of long-term consequences of non-compliance is rarely successful. Fear is a poor long-term motivating factor. 7 Make the patient responsible for the treatment as much as possible. Self-management techniques such as a medication log or a symptom diary can assist to promote the patient’s feeling of self-efficacy. 8 Share with the patient that you are aware of how difficult it is to comply with a medication regimen. Assure them that you will not be angry with them if they admit to difficulties adhering to the treatment plan. Encourage discussion of difficulties so that together you can try to make taking the medicine less difficult. 9 If you need to involve the parents in the supervision of treatment, do this in cooperation with the teenager and emphasize how they can work together. Discourage parents from taking complete control, yet keep safety in mind with medications having an abuse potential, i.e., Ritalin, and a narrow safety margin, i.e., tricyclic antidepressants or lithium.

10 The longer the treatment regimen, the more often you need to reinforce the importance of the medication. Since most psychiatric medications are given long term, this is particularly important. Use praise liberally when the patient complies. Use every opportunity to bolster the patient’s self-esteem and sense of self-efficacy. Avoid criticism or arguments/confrontations over non-compliance. Showing empathy for the patient’s difficulty in compliance will ultimately be more effective than trying to ‘force compliance.’ 11 Be aware that there may be cultural, religious, or financial reasons for non-compliance. A parent or patient may be embarrassed to admit that they cannot afford a medication or patient visit. 12 Believe adolescents when they say they will not be able to comply, and recognize that past compliant behavior is useful in predicting future compliance.

CONCLUSION Herein, we have briefly presented areas of the medical care of adolescents that we feel will be of use to psychiatrists caring for adolescents. Communication among all the members of the healthcare team will ultimately allow appropriate medical and psychiatric services to be provided to adolescents.

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66 Special issues in adolescent psychiatry Carskadon, M.A. Patterns of sleep and sleepiness in adolescents. Pediatrician 17: 17, 1990. Carskadon, M.A., Vieira, C., Acebo, C. Association between puberty and delayed phase preference. Sleep 16(3): 258, 1993. Carpenter, C.C.J., Fischl, M.A., Hammer, S.M., et al. Antiretroviral therapy for HIV infection in 1997. Updated recommendations of the International AIDS Society – USA Panel. Journal of the American Medical Association 277(24): 1962–1969, 1997. CDC. Ten leading nationally notifiable infectious diseases – United States, 1995. Morbidity and Mortality Weekly Report 45: 883–884, 1996. Chow, J.M., Yonekura, L., Richwald, G.A., et al. The association between Chlamydia trachomatis and ectopic pregnancy. A matched-pair, case-control study. Journal of the American Medical Association 263(23): 3164–3167, 1990. Creasy, G., Hall, N., Shangold, G. Patient adherence with the contraceptive patch dosing schedule versus oral contraceptives. Obstetrics and Gynecology 95(4 Suppl.1): S60, 2000. Deijen, J.B., Duyn, K.J., Jansen, W.A., et al. Use of a monophasic, low dose oral contraceptive in relation to mental functioning. Contraception 46: 359–367, 1992. Fisher, M., Golden, N.H., Katzman, D.K., et al. Eating disorders in adolescents: a background paper. Journal of Adolescent Health 16(6): 420–437, 1995. Gordon, S.M., Eaton, M.E., George, R., et al. The response of symptomatic neurosyphilis to high-dose intravenous penicillin G in patients with human immunodeficiency virus infection. New England Journal of Medicine 331(22): 1469–1473, 1994. Grimes, D.A. Emergency contraception options. The Contraception Report 8(2): 4–16. 1997. Hatcher, R.A., Trussell, J., Stewart, F., et al. Contraceptive Technology. 16th revised edition. New York: Irvington Publishers, Inc., 1994. Herzog, C.B., Copeland, P.M. Eating disorders. New England Journal of Medicine 313: 295–303, 1985. Ho, D.D. Viral counts count in HIV infection. Science 272: 1124–1125, 1996. Katzman, D.K., Lambe, E.K., Mikulis, D.J., et al. Cerebral gray matter and white matter volume deficits in adolescent girls with anorexia nervosa. Journal of Pediatrics 129(6): 794–803, 1996. Kaufman, F.R., Neinstein, L.W. Normal physical growth and development. In Neinstein, L.W. (ed.), Adolescent Health Care. A Practical Guide. 3rd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 3–39. Kaunitz, A.M., Garceau, A.J., Cromie, M.A. Comparative safety, efficacy, and cycle control of Lunelle monthly contraceptive injection (medroxyprogesterone acetate and estradiol cyprionate injectable suspension) and Ortho-Novum 7/7/7 oral contraceptive

(norethindrone/ethinyl estradiol triphasic). Lunelle Study Group. Contraception 60: 179–187, 1999. Kaunitz, A.M. Injectable contraception: new and existing options. Obstetric and Gynecologic Clinics of North America 27: 741–780, 2000. Kreipe, R.E., Golden, N.H., Katzman, D.K., et al. Eating disorders in adolescents. A position paper of the Society for Adolescent Medicine. Journal of Adolescent Health 16(6): 476–479, 1995. Kulig, J.W. Chronic fatigue syndrome and fibromyalgia in adolescence. State of the Art Reviews 2(3): 473–484, 1991. Kusumi, Y. A cutaneous side effect of lithium: report of 2 cases. Diseases of the Nervous System 32: 853, 1971. Lambe, E.K., Katzman, D.K., Mikulis, D.J., et al. Cerebral gray matter volume deficits after weight recovery from anorexia nervosa. Archives of General Psychiatry 54(6): 537–542, 1997. Lukehart, S.A., Hook, E.W., Baker-Zander, S.A., et al. Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment. Annals of Internal Medicine 109: 855–862, 1988. MacKenzie, R., Neinstein, L.S. Anorexia nervosa and bulimia. In Neinstein, L.W. (ed.), Adolescent Health Care. A Practical Guide. 3rd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 564–586. Martin, D.H., Mroczkowski, T.F., Dalu, A.Z., et al. A controlled trial of a single dose of azithromycin for the treatment of chlamydial urethritis and cervicitis. New England Journal of Medicine 327(13): 921–925, 1992. McGregor, R.S. Chronic complaints in adolescence: chest pain, chronic fatigue, headaches, abdominal pain. State of the Art Reviews 8(1): 15–32, 1997. Mellors, J.W., Rinaldo, C.R., Gupta, P., et al. Prognosis in HIV-1 infection predicted by the quantity of virus in plasma. Science 272: 1167–1170, 1996. Mitchell, W.G., Neinstein, L.S. Headaches. In Neinstein, L.S. (ed.), Adolescent Health Care. A Practical Guide. 3rd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 400–411. Musher, D.M. How much penicillin cures early syphilis? Annals of Internal Medicine 109(11): 849–851, 1988. Musher, D.M., Baughn, R.E. Neurosyphilis in HIV-infected persons. New England Journal of Medicine 331(22): 1516–1517, 1994. Neinstein, L.S. Issues in Reproductive Management. Stuttgart, NY: George Thieme Verlag, 1994. Neinstein, L.S. Dysmenorrhea and premenstrual syndrome. In Neinstein, L.S. (ed.), Adolescent Health Care. A Practical Guide. 3rd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 766–775. Nelson, A., Neinstein, L.S. Oral contraceptives. In Neinstein, L.S. (ed.), Adolescent Health Care. A Practical Guide. 3rd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 695–712.

Principles of adolescent medicine for psychiatrists 67 Position paper, Society for Adolescent Medicine: Eating disorders in adolescents. Journal of Adolescent Health 16: 475–479, 1995. Price, L.H., Heninger, G.R. Lithium in the treatment of mood disorders. New England Journal of Medicine 331(9): 591–598, 1994. Product Information: Prozac®, fluoxetine. Dista Products Company, Indianapolis, IN, 1996. Product Information: Risperdal®, risperidone. Janssen Pharmaceutica, Titusville, NY, 1996. Quinn, T.C. Acute primary HIV infection. Journal of the American Medical Association 278(1): 58–62, 1997. Risser, W.L., Anderson, S.J., Bolduc, S.P., et al. Cardiac dysrhythmias and sports. Pediatrics 95(5): 786–787, 1995. Rolfs, R.T., Nakashima, A.K. Epidemiology of primary and secondary syphilis in the United States, 1981 through 1989. Journal of the American Medical Association 264(11): 1432–1437, 1990. Ruiz-Maldonado, R., Perez de Francisco, O., Tamayo, L. Lithium dermatitis (letter). Journal of the American Medical Association 224: 1534, 1973. Scholes, D., Stergachis, A., Heidrich, F.E., et al. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. New England Journal of Medicine 334: 1362–1366, 1996. Schuster, M.A., Bell, R.M., Kanouse, D.E. The sexual practices of adolescent virgins: Genital sexual activities of high school students who have never had vaginal intercourse. American Journal of Public Health 86(11): 1570–1576, 1996. Selbst, S.M., Ruddy, R.M., Clark, B.J., et al. Pediatric chest pain: a prospective study. Pediatrics 82(2): 319–323, 1988. Shulman, L.P. Clinical trial results with MPA/E2C. Journal of Reproductive Medicine 45: 873–877, 2000. Shulman, L.P., Oleen-Burkey, M., Willke, R.J. Patient acceptability and satisfaction with Lunelle monthly contraceptive injection (medroxyprogesterone acetate and estradiol cyprionate injectable suspension). Contraception 60: 215–222, 1999. Skinner, S.R. Orthopedic problems in childhood. In Rudolph, A.M., Hoffman, J.I.E., Rudolph, C.D. (eds), Rudolph’s Pediatrics. Stamford, Connecticut: Appleton & Lange, 1996, pp. 2145–2146. Slap, G.B. Oral contraceptives and depression; impact, prevalence and cause. Journal of Adolescent Health Care 2: 53–64, 1981.

Smith, M.S. Psychosomatic symptoms in adolescence. Medical Clinics of North America 74: 1121, 1990. Tanner, J.M. Growth at Adolescence, 2nd edition. Springfield: Charles C. Thomas, 1962. Tanner, J.M., Davies, P.W. Clinical longitudinal standards for height and height velocity for North American children. Journal of Pediatrics 107: 317, 1985. Timmer, C.J., Mulders, T.M. Pharmacokinetics of etonorgestrel and ethinylestradiol released from a combined contraceptive vaginal ring. Clinical Pharmacokinetics 39: 232–242, 2000. Trussell, J., Koenig, J., Ellertson, C., Stewart, F. Preventing unintended pregnancy: the cost-effectiveness of three methods of emergency contraception. American Journal of Public Health 87(6): 932–937, 1997. Ueberall, M.A., Wenzel, D. Intranasal sumatriptan for the acute treatment of migraine in children. Neurology 52(7): 1507–1510, 1999. U.S. Department of Health and Human Services, CDC. 1993 Sexually Transmitted Diseases Treatment Guidelines. CDC-MMWR Recommendations and Reports 42(RR-14), September 24, 1993. Wald, A., Zeh, J., Selke, S., et al. Virologic characteristics of subclinical and symptomatic genital herpes infections. New England Journal of Medicine 333(12): 770–775, 1995. Weiner, I.H., Weiner, H.L. Nocturnal leg muscle cramps. Journal of the American Medical Association 244(20): 2332–2333, 1980. Wernicke, J.F. The side effect profile and safety of fluoxetine. Journal of Clinical Psychiatry 46(3 Pt 2): 59–67, 1985. Whitley, R.J., Gnann, J.W. Acyclovir: a decade later. New England Journal of Medicine 327(11): 782–789, 1992. Winner, P., Saper, J.R., Nett, R., et al. Sumatriptan nasal spray in the acute treatment of migraine in adolescent migraineurs [abstract]. Pediatrics 104 (Suppl.): 694–695, 1999. Yager, J., Andreson, A., Devlin, M., et al. American Psychiatric Association practice guidelines for eating disorders. American Journal of Psychiatry 150: 207–228, 1993. Yoder, F.W. Acneiform eruption due to lithium carbonate. Archives of Dermatology 111: 396, 1975. Zieman, M., Guillebaud, J., Weisberg, G., et al. Integrated summary of contraceptive efficacy with the Ortho Evra/Evra transdermal system [abstract O-48]. Fertility and Sterility 76: S19, 2001.

1.9 The history of adolescent psychiatry in the United States BERTRAM SLAFF

In Act III, Scene 3 of Shakespeare’s The Winter’s Tale, an old shepherd speaks: ‘I would there were no age between ten and three and twenty, or that youth would sleep out the rest, for there is nothing in the between but getting wenches with child, wronging the ancientry, stealing, fighting.’ Philippe Aries (1962), in his Centuries of Childhood, reports that during the Middle Ages, childhood as we know it did not exist. The state of infancy, lasting until about age seven years, was acknowledged, but thereafter these individuals were dressed similarly to adults, and were simply assimilated into the adult world. The concept of childhood as a separate stage of life emerged slowly during the seventeenth and eighteenth centuries. Adolescence as a concept is of even more recent origin. Stone and Church (1957) state that, ‘In primitive societies, there is no equivalent for our concept of adolescence. In some primitive societies, the transition from childhood to adulthood is so smooth that it goes unrecognized. More frequently, we find that the young person on the threshold of maturity goes through a ceremonial adolescence. Such ceremonial observances are called puberty rites, since they are usually timed to the onset of sexual maturity … . At the conclusion of the puberty rite, the young person is granted full adult status and assumes it without any sense of strain or conflict.’ Keniston (1971) writes that while puberty as a biological state has been recognized, adolescence, as we think of it today, was discovered only during the nineteenth and twentieth centuries. He observes that three changes occurred during the twentieth century: ‘First, adolescence as a stage of life has been socially recognized and acknowledged. Second, society has begun to sanction and support adolescence, increasingly buttressing it with educational, familial, institutional and economic resources. Third ... these new resources, coupled with other changes in society, have opened up to an even larger proportion of

the 13 to 18 year old age group the possibility of continuing psychological growth during the adolescent years. A further protection from adult responsibilities has been granted, educational institutions have been created to fill this moratorium, and a positive image of a postchildhood, preadult stage of life, adolescence, is now almost universally held.’ (p. 165). Increasing industrialization has freed post-pubertal youngsters from the requirements of farm and factory labor. The rising standards of economic productivity make the adolescent, especially the uneducated adolescent, a burden on the labor market. Growing affluence enables families and society as a whole to support economically unproductive adolescents in school. G. Stanley Hall’s two-volume work Adolescence was published in 1904, and was the first scholarly contribution to focus on adolescent development. Weiner (1970) states that Hall, heavily influenced by Darwin’s theory of biological evolution, had formulated an essentially evolutionary theory of psychological development based on a ‘law of recapitulation.’ Individuals were thought to develop through predetermined stages from primitiveness to civilized behavior in a manner that re-creates the development of the human race. Delinquency was a major focus in the early years of the twentieth century. A group of philanthropically minded individuals in Chicago had proposed a five-year study of Illinois delinquents that would, according to Jane Addams, one of the sponsors, ‘get at the root of the exact causes that make children go wrong.’ It can be assumed that most of the children referred to here were adolescents. In 1909, on the recommendation of Adolf Meyer and William James, William Healy (1869–1963) was hired to head this study. Healy was charged to work with the Juvenile Court of Chicago to provide the court with a detailed scientific record on each subject, to collect data about the medical, psychological and social background

The history of adolescent psychiatry in the United States 69

of frequent offenders in an effort to determine the causes of juvenile delinquency. Freud’s work was beginning to be known at this time, and in his 1915 book The Individual Delinquent, Healy included psychoanalysis among his ‘working methods.’ He made use of a psychologist and a social worker in a collaborative effort and used Southard’s term ‘clinic team’ to describe this activity. Subsequently, Healy and his principal collaborator Dr Augusta Bronner (a psychologist) moved to Boston and founded the clinic known as the Judge Baker Foundation (later the Judge Baker Guidance Center). Healy continued to be active in the Boston area until his death at the age of 94. In 1909, Clifford Beers founded the National Committee for Mental Hygiene, the slogan of which was ‘the prevention of insanity and delinquency.’ In 1918, the Commonwealth Fund was established with the goal of furthering medical knowledge; its interests came to include delinquency. During the 1920s, ‘child guidance’ clinics made their appearance, and the ‘team approach’ prevailed. Generally, the psychiatrist treated the child, the social worker took a history and worked with the parents, and the psychologist did the testing. In 1923, responding to Karl Menninger’s alerting that there was ‘no centralizing organization of the representatives of the neuropsychiatric or medical view of crime,’ the American Orthopsychiatric Association (‘Ortho’) was founded. The 1926 program included the statement: ‘The American Orthopsychiatric Association has as its purpose the centralizing of the techniques, objectives and aspirations of psychiatrists, psychologists and social workers, whose primary interests lie in the problems of human behavior, particularly conduct disorders of the antisocial types, providing a common meeting ground for students of these problems, and fostering scientific research in this field.’ (Lowrey 1948, p. 198). In 1926, Piaget published The Language and Thought of the Child. In this and many succeeding works, Piaget was able to show the development of cognitive structures in an orderly and predictable developmental sequence. He described the sensorimotor stage until the age of about eighteen months, the preoperational stage until five to six years, the stage of concrete operations until about eleven years, and finally the potential for abstract operational thought of the adolescent. The influence of Freud and his followers has been outstanding in the development of adolescent psychiatry. Ernest Jones (1948) propounded ‘the general law ... that adolescence recapitulates infancy, and that the precise way in which a given person will pass through the necessary stages of development in adolescence is to a very great extent determined by the form of his infantile development.’ (p. 399). In 1937, an adolescent psychiatry ward was opened at Bellevue Hospital in New York City under Frank Curran. The 1940s saw an interesting development in the realm of delinquency whereby an early concept emerged that was to make psychiatry especially

cognizant of the power of family factors in the genesis of emotional disorders. Articles appeared describing the unconscious fostering by parents of child acting-out behavior – formulations later to be couched in Adelaide Johnson’s (1949) term of parental ‘superego lacunae.’ In 1946, the Group for the Advancement of Psychiatry (GAP) was formed, with William Menninger as a guiding figure. This was intended to be a progressive force in contrast to the American Psychiatric Association, which some considered to be overly conservative. The GAP’s membership of close to 200 psychiatrists was organized in the form of a number of working committees, including a Committee on Adolescence. Here, mention will be made of the contributions of some major students of adolescence. First, Freud’s classic case of eighteen-year-old Dora should be cited, although he did not comment on her as an adolescent. In 1948, Maxwell Gitelson commented on the ‘ego weakness’ of adolescents: ‘Psychoanalysts have tended to be cautious about analyzing adolescents. Some have felt it should not be attempted and the fact is that very few adolescents have been analyzed... The therapeutic task is not one of psychic analysis but rather of character synthesis.’ Erik Erikson, in his 1950 volume Childhood and Society, has described crucial stages in personality development as ‘normative crises’ – critical points that determine the outcome of subsequent developmental stages. Adolescence is an example of such a normative crisis. Erikson’s concepts of identity formation and the experiences of adolescence in promoting the sense of personal identity have been widely accepted, as well as his formulation of a basic conflict of this period as ‘identity versus identity diffusion.’ In 1958, Anna Freud wrote: ‘I take it that it is normal for an adolescent to behave for a considerable length of time in an inconsistent and unpredictable manner; to fight his impulses and to accept them; to ward them off successfully and to be overrun by them; to love his parents and to hate them; to revolt against them and to be dependent on them; to be deeply ashamed to acknowledge his mother before others and, unexpectedly, to desire heart-to-heart talks with her; to thrive on imitation of and identification with others while searching unceasingly for his own identity; to be more idealistic, artistic, generous and unselfish than he will ever be again, but also the opposite, self-centered, egoistic, calculating. Such fluctuations between extreme opposites would be deemed highly abnormal at any other time of life. At this time they may signify no more than that an adult structure of personality takes a long time to emerge, that the ego of the individual in question does not cease to experiment and is in no hurry to close down on possibilities.’ Masterson (1968) questioned the ubiquity of adolescent turmoil. In his view, turmoil is not normative: when the adolescent appears to be disturbed, he or she is

70 Special issues in adolescent psychiatry

indeed disturbed and treatment is indicated. Offer (1969) too has challenged Anna Freud’s view of adolescence as a period of disturbance. He states: ‘Studies of normal populations that exhibit little behavioral disequilibrium might eventually lead to the concept that adolescence as a period of growth can be undergone without serious disruptions between the generations or between the adolescent and his former identity. The transition to adulthood may be accomplished gradually but accomplished all the same.’

PROFESSIONAL ORGANIZATIONS IN THE CHILD–ADOLESCENT PSYCHIATRY WORLD Three major conflict areas should be noted: medical versus not necessarily medical (team) approach; strong credentialism versus openness; and adolescence as a later stage of child development versus adolescence as an identifiably separate stage of growth. In 1948, many child guidance clinics came together and created the American Association of Psychiatric Clinics for Children (AAPCC) under Frederick Allen’s leadership. This was to be the first standard-setting body for child psychiatric services and for the training of child psychiatrists. These clinics manifested the multidisciplinary team approach (psychiatrists, psychologists, social workers) and were not necessarily under medical supervision. The question arose: why should non-psychiatrists be involved in setting standards for child psychiatrists? At an Ortho meeting a group of child psychiatrists led by George Gardner began work which led to the formation of the American Academy of Child Psychiatry in 1953. Membership was to be by invitation only. To be eligible for fellow membership, an individual had to have satisfied numerous criteria and to have made an ‘outstandingly significant’ contribution to any of several activities within child psychiatry. It was an organization made up of the recognized leaders in the field who proclaimed the goal of setting and maintaining the highest standards. At that time, the AACP did not have the goal of being an organization that included the rank-and-file of child psychiatrists in the nation. In 1957, the Council of the APA, after nine years of resisting this action, finally accepted that child psychiatrists be certified after a specialized training curriculum, and in 1959 the American Board of Psychiatry and Neurology set up a Committee on Certification in Child Psychiatry. The subspecialty of child psychiatry had been established. The AAPCC was thus relieved of the responsibility of setting standards for child psychiatry training. In 1958, James Masterson, when noting how little attention was being paid to older children (i.e., adolescents), called a meeting of psychiatrists with an interest in this age group. This led to the formation in New York

of the Society for Adolescent Psychiatry. When it was pointed out that the acronym was SAP, the late Ed Hornick responded that adolescent psychiatrists should not take themselves too seriously, and the name stayed. SAP welcomed individuals coming from child psychiatry and from adult psychiatry perspectives, if they had an interest in adolescents. Some time later, Masterson and Slaff journeyed to Philadelphia where a similar society was formed. Subsequently this happened in Chicago and in Southern California. Underlying this development was the point of view that adolescence is an identifiably unique stage of growth as well as being a later stage of child development. In 1967, representatives of the New York, Philadelphia, Chicago and Southern California Societies for Adolescent Psychiatry met in Detroit and coalesced to form the American Society for Adolescent Psychiatry (ASAP). William Schonfeld was elected as the first president, and ASAP welcomed individuals from child psychiatry and adult psychiatry who shared an interest in adolescents. Apart from membership in the APA, there were no additional credentialing requirements. To the question, ‘Another Society! Why?’, Feinstein and Slaff (1971) responded: ‘The essential function of an adolescent psychiatry society is to provide a forum for the encouragement and discussion of the psychiatric needs of youth. Teenagers are treated by child psychiatrists and adult psychiatrists, as well as by those who limit their work to this age group. Therapists’ conceptualizations and approaches vary greatly depending on their training opportunities and experiences. The forum approach encourages communication in a specific area among psychiatrists of diverse backgrounds.’

In 1969, the AACP underwent a major transformation. As Sidney Berman (1970) has written: ‘Council faced this critical question, asking how the Academy could meet the needs of young child psychiatrists, colleagues whom we have trained and with whom we practice, and yet justify, by its membership roll call, the concept of an Academy. (This) culminated in the decision by the members to make the Academy truly the representative voice for child psychiatry nationally. This included admission by application.’ Training in child psychiatry was a requirement for those applying for membership. The contrast should be noted between ASAP, which had an open policy on psychiatrists seeking membership, and the AACP with its strict training requirements. In a 1970 article ‘The Manpower Emergency in Adolescent Psychiatry,’ Slaff stated that, since child psychiatry training programs, though admirably planned, could not meet the needs in trained manpower, relief must be sought through training the general psychiatry resident to work with this age group.

The history of adolescent psychiatry in the United States 71

The psychiatrist who works with adolescents should be fairly well in touch with his own adolescence. He should be prepared to offer help to troubled individuals negotiating the perils of this stage of growth. This approach must avoid authoritarianism and must respect the autonomy and growth potential of the teenager. The spirit is one of inquiry in the shared endeavor of increasing understanding. Not every adolescent psychiatrist can work optimally with every teenager. There has to be a good ‘fit’ between the two, if progress is to occur. If the ‘fit’ is unsatisfactory, the youth is likely to withdraw from the treatment situation. Early child psychiatry had evolved in the freestanding community service unit, the child guidance clinic. Now many were growing as subunits of departments of general psychiatry. There was considerable growth in psychiatric units attached to general hospitals. Even where a child psychiatry unit existed, in many centers the adolescent patients were housed on the adult units and treated by general psychiatry residents under the supervision of adolescent preceptors. Family therapy became a major development. Noshpitz (1979) remarks: ‘System theory was applied and the concept of the family system, or the family as a system, became commonplace. All this presently moved in the direction of a view of family therapy, which regarded the child as a function of family interaction. The child’s psychopathology was accordingly viewed as a product or an expression of intrafamilial forces.’ Group therapy became another helpful resource. Sugar and Berkovitz (1975) have stated: ‘A prime advantage of group therapy to many teenagers is the feeling of protection vis-à-vis the adult therapist. The opportunity to rap with peers seems less associated with being ill (at first) and safer from possible adult domination.’ Cognitive– behavioral therapy became another fast-growing treatment modality. In 1971, the first ASAP-sponsored annual volume Adolescent Psychiatry Developmental and Clinical Studies was published under the editorship of Sherman Feinstein, Peter Giovacchini, and Arthur Miller. In 1986, the International Society for Adolescent Psychiatry was established under the leadership of Serge Lebovici of Paris and Sherman Feinstein of the United States. Meetings have since been held in Paris, Geneva, Chicago, and Athens. In 1987, the American Academy of Child Psychiatry changed its name to the American Academy of Child and Adolescent Psychiatry. Within the American Board of Psychiatry and Neurology, the Committee on Certification in Child Psychiatry became the Committee on Certification in Child and Adolescent Psychiatry. Many of the members of ASAP have certification in child and adolescent psychiatry. Nevertheless, a significant number have come from adult psychiatry, drawn by their interest in adolescence. Many of these have specialized training in working with adolescents but lack experience in working with younger children. ASAP took the position that this

group should have the opportunity to be credentialed specifically in adolescent psychiatry, and developed its own certifying examination, which was given by the American Board of Adolescent Psychiatry for the first time in 1992. Indeed, by 2002, a total of 519 candidates had so been certified.

THE DIVERGENT PATHS OF ASAP AND THE ACADEMY As president of ASAP in 1970, Slaff was sounded out by a leading child psychiatrist as to the possibility of merging the two organizations. However, the Executive Committee was unwilling to give up ASAP’s membership policy of openness to psychiatrists interested in adolescence without elaborate credentialing requirements including training in child psychiatry and did not follow up on this suggestion. The Academy has grown appreciably: currently (2002) it has 7100 members, includes 57 local organizations, has its own building in Washington, DC, it has welcomed child–adolescent psychiatry groups into its Assembly of Regional Organizations, and in 1991 made it a condition of individuals belonging to the local groups that they concurrently maintain membership in the AACAP. It publishes a very successful journal, convenes each fall in a well-attended, scientifically grounded meeting, and operates on a budget of 5 million dollars. In short, it is a very successful, highly respected organization. The ASAP membership has decreased over recent years, however; it now includes 684 members, many of whom are strongly devoted and loyal to the organization for the excellent clinical quality of its meetings, for the unusual friendliness and camaraderie of this more intimate group compared with the APA and the Academy, for the professional bonding that takes place among the participants and for the general ‘gemütlichkeit’ of working together in the study and practice of adolescent psychiatry. Many factors are thought to be contributory to the fall-off in ASAP membership. One component is economic; the practice of adolescent psychiatry is no longer a growth industry. Income levels in psychiatry, indeed in most of medicine, have fallen. Scandals relating to the matter of the over-hospitalization of adolescent patients some years ago have not helped. Other organizations, including the American Orthopsychiatric Association, also report decreasing memberships. The era of reinvigorated biologic psychiatry began in 1953 when it was reported that chlorpromazine affected the symptoms of psychosis. In the years following, effective drugs for treating schizophrenia, manic–depressive illness, major depression, panic reaction, and Tourette syndrome have been introduced with manifold benefits

72 Special issues in adolescent psychiatry

to those afflicted. For many years, psychiatrists have been aware of two powerful currents within the profession, represented by the terms biologic psychiatry and psychotherapeutic psychiatry. In clinical work it is important to see these not as opposing constructs but rather as complementary concepts. Should depressed individuals be offered an opportunity to obtain relief through medication? Should manic persons be offered lithium? Should schizophrenics be placed on neuroleptics? Of course the answer must be yes. A crucial development in the past decade has been the extraordinary growth of the phenomenon known as Managed Care (Campbell and Golash, 1995), (the) ‘organized system of health care providers whose goal is to deliver services in a manner that would keep costs down. This definition reflects a view of the health system as a business … . Managed care systems consist of networks of providers, such as doctors, hospitals, clinics and day programs, who often share the financial risks of providing care to those enrolled in the managed care plan … . In most managed care systems, a generalist (a primary care physician or gatekeeper) is responsible for a longitudinal approach to patient care, integrating, controlling and limiting the clinical and psychosocial aspects, as well as subspecialty care, health promotion, and disease prevention. The gatekeeper controls referrals to the specialists and referral and procedures prescribed by the specialists must usually be approved by the gatekeeper.’ In the pursuit of cutting costs, and in the pursuit of profit, managed care personnel have taken strong stands in favor of psychopharmacological treatment and have resisted support for psychotherapeutic interventions. Hospital stays have been severely curtailed. Since most adolescents require treatment for causes other than an Axis I diagnosis, this has resulted in major limitation on the help that can be offered to troubled youth.

REFERENCES Aries, P. Centuries of Childhood. New York: W.W. Norton, 1962. Berman, S. Epilogue and a new beginning. Journal of the American Academy of Child Psychiatry 9: 193–201, 1970. Campbell, R.J., Golash, T. How to Manage with Managed Care. New York: New York County District Branch of the American Psychiatric Association, 1995. Erikson, E. Childhood and Society. New York: W.W. Norton, 1950.

Feinstein, S., Slaff, B. Another society! Why? Newsletter, American Society for Adolescent Psychiatry, April, 1971. Freud, A. Adolescence. The Psychoanalytic Study of the Child, Volume 13. New York: International Universities Press, 1958, pp. 255–278. Gitelson, M. Character synthesis: the psychotherapeutic problem of adolescence. American Journal of Orthopsychiatry 18: 422–431, 1948. Hall, G. Adolescence. New York: Appleton, 1904. Healy, W. The Individual Delinquent. Boston: Little Brown, 1915. Johnson, A. Sanctions for superego lacunae of adolescents. In Eissler, K. (ed.), Searchlights on Delinquency. New York: International Universities Press, 1949, pp. 225–245. Jones, E. Some problems of adolescence. Papers on Psychoanalysis. London: Baillière, Tindall & Cox, 1948. Keniston, K. Youth as a stage of life. In Feinstein, S.C., Giovacchini, P.L., Miller, A.A. (eds), Adolescent Psychiatry: Developmental and Clinical Studies, Volume 1. New York: Basic Books, 1971. Lowrey, L. The birth of orthopsychiatry. In Lowrey, L. (ed.), Orthopsychiatry, 1923–1948 Retrospect and Prospect. Menasha, WI: George Banta Publishing, 1948. Masterson, J. The psychiatric significance of adolescent turmoil. American Journal of Psychiatry 124: 1549–1554, 1968. Noshpitz, J. History of Childhood and Child Psychiatry in the Twentieth Century. Washington, DC: George Washington University, Typescript, 1979. Offer, D. The Psychological World of the Teenager. New York: Basic Books, 1969. Piaget, J. The Language and Thought of the Child. New York: Harcourt Brace, 1926. Slaff, B. The manpower emergency in adolescent psychiatry. Psychiatric Opinion 7: 25–28, 1970. Slaff, B. History of child and adolescent psychiatry ideas and organizations in the United States: a twentieth century review. Adolescent Psychiatry 16: 31–52, 1989. Stone, L., Church, J. Childhood and Adolescence – A Psychology of the Growing Person. New York: Random House, 1957. Sugar, M., Berkovitz, I. Indications and contraindications for adolescent group therapy. In Sugar, M. (ed.), The Adolescent in Group and Family Therapy. New York: Brunner/Mazel, 1975, pp. 3–26. Weiner, I. Psychological Disturbance in Adolescence. New York: John Wiley & Sons, 1970.

1.10 Adolescent psychiatry as a psychiatric subspecialty SIDNEY WEISSMAN, SHARON WEISSMAN, AND KATHRYN WEISSMAN

Before adolescent psychiatry can be spoken of as a psychiatric subspecialty, we must first explore what is meant by the term ‘medical subspecialty.’ The history of medicine has seen the constant development of new medical specialties and eventually subspecialties. Indeed, both specialties and subspecialties evolve and are themselves further subdivided. Until the twentieth century, when physicians’ knowledge and skills were limited, there existed two classes of doctor. One group was surgeons who treated patients with surgery or blood-letting, and the other was physicians who treated their patients with medication. The Columbia University Medical School recognizes this tradition in its name College of Physicians and Surgeons. In England, all medical degrees refer to being both a physician and a surgeon. In the United States, in the early twentieth century, almost all doctors were generalists utilizing surgical and medical skills as needed. Yet, issues of specialization were already arising. The development of modern anesthesia and enhanced diagnostic abilities coupled with the development of new complex instrumentation led to physicians initially informally organizing themselves around their special interests and skills. These groups were organized around interests in certain disease states or treatments, and/or around the use of specific technical equipment. In this climate, the first formal modern American medical specialty was born – ophthalmology. Its birth was triggered by the invention of the ophthalmoscope and a desire both to control its use and to ensure its appropriate use. After establishing an initial professional organization, the ophthalmologists established a ‘Board’ to designate who was and was not a qualified specialist to use these new instruments. The American Board of Ophthalmology was formed in 1917 and preceded the formation of the American Board of Medical Specialties (ABMS), formed in 1933, by sixteen years. The American Board of Psychiatry

and Neurology (ABPN) which certifies specialists in psychiatry was founded in 1935 (ABMS 1992). In the United States, the ABMS has assumed responsibility to oversee the development of specialty boards and developed criteria for what is a specialty or subspecialty. The ABMS itself does not serve as a Specialty Board. For many physicians and organizations, an area of interest or ability in United States medicine is only a formally recognized specialty or subspecialty when the ABMS has approved of an examination and certificate being offered in it. The 1930s saw an explosion in the formation of medical specialties. At that time, the criteria for becoming a medical specialty appeared relatively clear. First, there was a distinct body of knowledge to be mastered by the practitioner. Second, there existed journals and other research publications in the particular area. Third, an extensive period of time was needed to master the subject matter and obtain competence in its practice. Fourth, the newly trained specialist had significantly enhanced attributes in treating and diagnosing disorders in their specialty; and, fifth, professional societies existed of practitioners in the special areas. It was only a short time after the formation of medical specialties that medical subspecialties were developed. Many, if not all, of the same criteria were used to argue for their development. In 1941, the first medical subspecialties were approved, and these required three years of general training in internal medicine. The field of internal medicine controlled the subspecialties generated, and subspecialists were all initially general internists. A similar model was followed by pediatrics. The surgeons, unlike the internists, established whole new surgical specialties and medical school departments. For example, a medical school will have a Department of Orthopedics, but a section in the Department of Medicine in rheumatology. Orthopedic surgeons are not initially general surgeons, whereas rheumatologists are initially general internists. Whether new surgical specialists or internal

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medicine subspecialists, for example, members of each group are usually known by their area of specialization. For example, internists specializing in cardiology are known as cardiologists, while surgeons who treat urological disorders are called urologists. It should be noted that the original clearer boundaries between varied specialists and who they treat has never existed in the same degree between specialists and subspecialists. In gastroenterology, general internists and gastroenterologists, for example, may compete for the same patients. These distinctions of what specialists and subspecialists are about and do does not include how advances in therapeutics change, how we treat disorders, and which specialists provide the treatment. Patients with a specific disorder can be seemingly passed for treatment by one specialty to another over time. Two quite different disorders make this point. The first of these is syphilis. In 1900, this disease resulted in a majority of what we today would call hospitalization in state mental institutions for tertiary syphilis. Indeed, a psychiatrist – Wagner von Jauregg – was a Nobel Prize winner for the fever treatment of this disorder. With medical advances, treatment and diagnosis of this disorder in the middle of the twentieth century was moved to the dermatologist, and today syphilis is treated by the internist specializing in infectious diseases. The disease has not changed, but our medical competencies have, resulting in changes in its course and the roles of medical specialists and subspecialists in the diagnosis and treatment. Another example of this change is seen in the treatment of renal stones. For many years, if medical management did not succeed, then surgical intervention by a urologist was required. Today, through the use of radiographic equipment and sound-wave lithotripsy, nonsurgical routes to remove stones have developed. Yet, just because the stones relate to the urological system, should they be treated by urologists? Since the equipment used and the technical capacity to crush the stones nonsurgically is closest to that used by radiologists, should they perform the treatment? This detour in our discussion of the boundaries of specialties is to make the point that, independent of economics or political concerns, the boundaries between specialties are necessarily and constantly shifting as our knowledge expands and new technologies evolve (Weissman and Bashook 1989). During the 1980s in the United States, two issues focused on the expansion of medical subspecialties. The first was the growth of our knowledge and technical skills. Second was the economic advantages to practitioners of being called specialists or subspecialists. The subspecialties in existence prior to 1980 required further training, generally of two or more years’ duration. In internal medicine, cardiology would be the model, whereas in psychiatry, child psychiatry would be the model. Many of the new subspecialties created during the 1980s required only one year of post-residency training, and individuals received

certificates of added qualification, not as in the earlier subspecialties’ special qualification (eighteen new subspecialties were approved between 1980 and 1989). It was further assumed that the overwhelming number of patients treated by the subspecialist could be effectively treated by ‘general’ specialists in the field without this training. Strikingly, these new ‘subspecialists’ did not necessarily take on the name of their subspecialties. They did require that specific bodies of knowledge with journals addressing this knowledge and specific skills existed, as well as ‘subspecialty’ professional societies. This new model led to the acceptance by the ABMS of added qualification subspecialties in internal medicine of geriatric medicine and adolescent medicine, in family practice of geriatrics and sport medicine, and in psychiatry of geriatric, addiction, and forensics. To head off pressure on the American Board of Psychiatry and Neurology (ABPN) for approval of added qualifications in adolescent psychiatry, the ABPN, without organized input from the field, changed the name of its certificate in Child Psychiatry to read Child and Adolescent Psychiatry. In a related earlier action, the American Academy of Child Psychiatry changed its name to the American Academy of Child and Adolescent Psychiatry (AACAP). The question arises as to why, at a time when American medicine was establishing numerous new subspecialties, was adolescent psychiatry, which on its own met the criteria for the evolving ABMS added qualifications requirement, side-tracked? Depending on one’s perspective, varied explanations are offered. From the perspective of child psychiatry the view is that only child psychiatrists, with their grounding in development, have the appropriate foundation to become experts in adolescent psychiatry, whereas the general psychiatrist without formal training in child psychiatry cannot make up the deficiencies in training to treat adolescents adequately. Concurrent with the dispute between general psychiatrists and child psychiatrists regarding competency to treat adolescents and how to certify expertise was a dispute between pediatricians and internists regarding adolescent medicine. The solution they have established differs significantly from the one established by the ABPN and supported by the AACAP. General internists and pediatricians, through the actions of the American Board of Pediatrics and the American Board of Internal Medicine, agreed that both can undertake training to obtain certification through their respective board in adolescent medicine (subspecialty status) with the approval of the ABMS. In essence, internists and pediatricians concede that expertise in treating this complex patient group can be obtained from either the unique training of pediatrics or internal medicine. This is, in fact, the same position taken by the American Board of Adolescent Psychiatry (ABAP) at its formation prior to the establishment of its own added qualification examination. The ABAP has maintained

Adolescent psychiatry as a psychiatric subspecialty 75

there are two separate routes to the practice of adolescent psychiatry just as in adolescent medicine at this time. Evidence does not exist to support the superiority of one model of training versus the other. In the absence of a certificate of added qualifications in adolescent psychiatry by the ABPN, the American Board of Adolescent Psychiatry, utilizing the certificate criteria of the ABMS, established a certification program in adolescent psychiatry. It is the stated long-term intention of the ABAP to work for the same resolution for adolescent psychiatry as has developed in adolescent medicine. In light of internal medicine and pediatrics’ resolution of the adolescent medicine issue, one can speculate as to why psychiatry has acted as it has and not resolved the conflict. One can suspect that economics and political influence have been more critical in the outcome than data. At present, for a five-year period after a new subspecialty is established, practitioners in the field who devote 25 per cent of their time to that subspecialty can take a certifying examination. The ABMS requires that after five years, new trainees wanting added qualifications must obtain a certification in the parent specialty and a fellowship in the subspecialty in order to sit for the examination. This model of training requires a subspecialty career choice to be made immediately after general training. This requirement runs counter to how practitioners frequently grow and develop subspecialty interests. Historically, many practitioners make these choices years after general training and at times in their careers when they cannot take fellowships. In order to maintain the relevance of added qualification certification, new models of training which will not last one to two years will need to be developed. Indeed, the pace of change in medical technology

and knowledge will require ongoing methodologies to assure that practicing physicians maintain their current competencies and learn new ones. Our current examination system of certification will require major overhaul. Indeed aware of these rapidly moving changes in the United States, the American Board of Medical Specialties and the Accreditation Council for Graduate Medical Education – the two bodies that govern graduate medical education – are developing methods to assess the performance of specialists based on their demonstrating that they have mastered the core competencies of their respective fields. Furthermore, that to maintain certification in the specialty, they must demonstrate that they have learned the new competencies in their field and maintained one already present. The techniques to accomplish this are currently being developed. In conclusion, the past two decades have seen the consolidation of research, scholarship and practice supporting adolescent psychiatry as a formal subspecialty in the United States. We would hope that the model used to develop the subspecialty of adolescent medicine becomes the model for the future growth of adolescent psychiatry.

REFERENCES American Board of Medical Specialties Annual Report 1992. Evanston, Illinois. Weissman, S., Bashook, P. The Future Psychiatrist as a Generalist: Arguments Against Credentials for Subspecialists. In The Future of Psychiatry as a Medical Specialty. American Psychiatric Press, 1989, pp. 23–31.

1.11 Education and training in adolescent psychiatry RICHARD ROSNER

The 1995 report of the Carnegie Council on Adolescent Development, Great Transitions: Preparing Adolescents for a New Century, states in its Executive Summary that: ‘Since 1960, the burden of adolescent illness has shifted from the traditional causes of disease to the more behavior-related problems, such as sexually transmitted disease, teenage pregnancy, motor vehicle accidents, gun-related homicides and accidents, depression leading to suicide and abuse of drugs (alcohol and cigarettes as well as illegal drugs). Instilling in adolescents the knowledge, skills, and values that foster physical and mental health will require substantial changes in the way health professionals work and the way they connect with families, schools, and community organizations. At least three measures are needed to meet these goals. The first is the training and availability of health providers with a deep and sensitive understanding of the developmental needs and behavior-related problems of adolescents.’ (Carnegie Council on Adolescent Development 1995).

One response of the American Society for Adolescent Psychiatry to the challenge of meeting the mental health needs of adolescents is, among other actions, to encourage education and training in the specialty of adolescent psychiatry. There are four approaches currently to education and training in adolescent psychiatry: 1 Through a residency in general psychiatry with an extended elective in adolescent psychiatry. 2 Through a residency in general psychiatry with subsequent self-directed study and experience. 3 Through a residency in child and adolescent psychiatry. 4 Through a residency in adolescent psychiatry. There are advantages and disadvantages to each of these routes.

RESIDENCY IN ADULT PSYCHIATRY WITH AN EXTENDED ELECTIVE IN ADOLESCENT PSYCHIATRY The Accreditation Council for Graduate Medical Education (ACGME) requires that all residency programs in general psychiatry include initial education and training in adolescent psychiatry. Some residents in adult psychiatry are sufficiently interested in adolescent psychiatry that they participate in an extended elective in adolescent psychiatry in their fourth post-graduate year (PGY-4). The advantage of this route into the practice of adolescent psychiatry is that it can be accommodated within the customary four years of a residency in general psychiatry. One of the disadvantages of this route is that the exact contents of such elective experiences vary widely, so that persons who have taken PGY-4 electives in adolescent psychiatry differ greatly in their didactic and clinical training. In an effort to foster quality in PGY-4 electives in adolescent psychiatry, the Accreditation Council on Fellowships in Adolescent Psychiatry (ACFAP) of the American Society for Adolescent Psychiatry (ASAP) has recommended that its Standards, as set forth in its Special Requirements for Programs in Adolescent Psychiatry (Rosner 1997), should serve as a model for PGY-4 electives in adolescent psychiatry; the more closely the PGY-4 elective in adolescent psychiatry conforms to the ACFAP’s Standards, the better the training provided. Another disadvantage of this route into the practice of adolescent psychiatry is that it does not automatically establish eligibility for either the examination of The American Board of Adolescent Psychiatry (ABAP) or the examination of The American Board of Psychiatry and Neurology (ABPN) in the specialty of child and adolescent psychiatry. Such Board certification may be

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important, for example to establish peer-recognition of expertise, for academic advancement, or for reimbursement. Persons interested in such certifications should contact the appropriate Boards for detailed information about eligibility requirements.

RESIDENCY IN GENERAL PSYCHIATRY WITH SUBSEQUENT INDEPENDENT STUDY AND EXPERIENCE This is a fairly frequent route into the practice of adolescent psychiatry. Practitioners may indicate to their colleagues in general psychiatry a willingness to accept adolescent patients; they may subsequently find themselves receiving referrals of adolescents from colleagues who do not feel comfortable working with teenagers. Necessity being the mother of invention, such de facto specialists in adolescent psychiatry find themselves obliged to develop their clinical skills and increase their knowledge base to treat their teenaged patients. Self-directed education and training in adolescent psychiatry has three components: formal didactic reading/lectures/seminars/demonstrations; clinical experience; and competent supervision. The most convenient learning experience is provided by reading. Most general psychiatry textbooks, and certainly all child and adolescent psychiatry textbooks, will devote part of their contents to the assessment and treatment of teenagers. Among books focussed exclusively on adolescent psychiatry are two for which members of the American Society for Adolescent Psychiatry have played a major role: (1) Textbook on Adolescent Psychiatry (Rosner 2003); and (2) Adolescence: Development and Syndromes (Flaherty and Sarles 1997). In addition to such fundamental texts, the American Society for Adolescent Psychiatry publishes Adolescent Psychiatry: The Annals of the American Society for Adolescent Psychiatry and previously sponsored The Journal of Youth and Adolescence, both of which present current articles on issues and research. The library catalogue of any medical school will provide a list of further readings. The annual conventions of the American Psychiatric Association offer Continuing Medical Education (CME) courses, workshops, panels and research presentations that often include adolescent psychiatry. All of the conventions of the American Society for Adolescent Psychiatry and part of the conventions of the American Academy of Child and Adolescent Psychiatry (AACAP) provide opportunities for formal learning of adolescent psychiatry. For those who cannot physically attend these conventions, audiotapes (and sometimes video-tapes) are often available. Supervision may be purchased, usually in increments of one hour, from clinicians experienced in working with adolescents. Such supervisors can be found by contacting

the local medical school and asking for the senior faculty specializing in adolescent psychiatry. One can also contact the American Society for Adolescent Psychiatry’s national office for the names of persons certified by the American Board of Adolescent Psychiatry. Alternatively, one can contact the American Board of Psychiatry and Neurology to obtain the names of persons certified in child and adolescent psychiatry. Supervision may be more readily available for those practitioners who work in organizations where adolescents form a significant portion of the patient case-load. In such settings, there are usually senior clinicians who can provide on-the-job training and supervision in the assessment and treatment of adolescents. However, a problem with such on-the-job training is that the supervisors may have a narrow focus and may not be competent to address matters different from those the organization customarily encounters. For example, a hospital’s adolescent psychiatry outpatient clinic may: (i) have no supervisor who is experienced in adolescent forensic psychiatry; or (ii) restrict its patients to middle and late adolescents and have no supervisor experienced with early adolescents. It may be necessary for the wouldbe adolescent psychiatrist to obtain different supervisors for different kinds of cases. What has been said here about physicians who seek to acquire skills in adolescent psychiatry without any prior special experience with teenagers is also relevant to the ongoing post-residency education and training of psychiatrists who have taken an extended elective in adolescent psychiatry during their general psychiatry residency. Again, a disadvantage of this form of self-directed study is that is does not automatically render one eligible for the examination of the American Board of Adolescent Psychiatry or the child and adolescent psychiatry specialty examination of the American Board of Psychiatry and Neurology.

RESIDENCY IN CHILD AND ADOLESCENT PSYCHIATRY The Accreditation Council on Fellowships in Adolescent Psychiatry has accepted that residencies in child and adolescent psychiatry approved by the Accreditation Council on Graduate Medical Education (ACGME) meet the standards of competence expected of specialty programs in adolescent psychiatry. It is likely that graduates of such ACGME-accredited child and adolescent psychiatry residencies automatically will be eligible for the examination of the American Board of Adolescent Psychiatry, but potential applicants for that Board should check the most current eligibility requirements. Graduation from a residency program in child and adolescent psychiatry that has been accredited by the ACGME automatically

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provides eligibility for the child and adolescent psychiatry specialty examination of the American Board of Psychiatry and Neurology. For those psychiatrists who are interested in working with adolescents, but are not interested in working with children, a residency in child and adolescent psychiatry may not be desirable. Because the child and adolescent residency usually occurs in the third and fourth postgraduate years (PGY-4 and PGY-5) of residency training, the child and adolescent resident usually misses out on the training provided in the PGY-4 year of the general psychiatry residency, for example electives in forensic psychiatry, public psychiatry, administrative psychiatry, geriatrics, addictions, or research. The time spent in training is extended by an additional year, which may be a matter of concern to trainees burdened by student loans from college or medical school.

RESIDENCY IN ADOLESCENT PSYCHIATRY Some general psychiatry residency programs that offer an extended elective in adolescent psychiatry in the fourth postgraduate year (PGY-4) may refer to that training as a residency in adolescent psychiatry: caveat emptor! The Accreditation Council on Fellowships in Adolescent Psychiatry does not accredit PGY-4 programs. Graduation from a PGY-4 program, even one that is modeled closely on the ACFAP Standards (Special Requirements for Programs in Adolescent Psychiatry), will not automatically provide eligibility for the ABAP examination. The American Board of Adolescent Psychiatry does not accept graduation from a PGY-4 adolescent program as equivalent to a PGY-5 adolescent psychiatry program. In principle, there are two types of accreditable PGY-5 residency in adolescent psychiatry. The first type may be offered by ACGME-accredited child and adolescent psychiatry programs that make an accommodation to physicians who do not want to learn about child psychiatry; these may be PGY-5 budget lines that would otherwise go unfilled due to a shortage of acceptable candidates for combined child and adolescent psychiatry training. Graduates of such programs would be eligible to take the examination of the American Board of Adolescent Psychiatry, but would not be eligible to take the ABPN examination in child and adolescent psychiatry. At the time of writing, only nine ACGME-accredited residencies in child and adolescent psychiatry have indicated a willingness, depending on funding, to consider providing a residency in adolescent psychiatry per se. The Accreditation Council on Fellowships in Adolescent Psychiatry has twice surveyed all ACGME-accredited child and adolescent psychiatry residencies to determine which of them would consider providing a residency in adolescent psychiatry per se and plans periodically to re-survey and update its list of such

programs; potential candidates for training in adolescent psychiatry are encouraged to contact the American Society for Adolescent Psychiatry to obtain the latest list of this first type of adolescent psychiatry residency. The second type of adolescent psychiatry residency may be offered by ACGME-accredited general psychiatry programs that do not have the resources or inclination to develop a combined child and adolescent psychiatry residency. Such programs may be approved by the Accreditation Council on Fellowships in Adolescent Psychiatry. Graduates of ACFAP-accredited programs would be eligible to take the examination of the American Board of Adolescent Psychiatry, but would not be eligible to take the ABPN examination in child and adolescent psychiatry. Graduates of adolescent psychiatry residency programs neither approved by the ACFAP nor derived from combined child and adolescent residency programs approved by the ACGME would have to contact the American Board of Adolescent Psychiatry to determine whether they meet eligibility criteria to take the ABAP examination; they would not be eligible to take the ABPN examination in child and adolescent psychiatry. At the time of writing, only one ACGMEaccredited residency in general psychiatry has expressed interest in developing a residency in adolescent psychiatry per se, although several such programs have existed in the past. The advantages of a residency in adolescent psychiatry in the fifth postgraduate year (PGY-5) include that it permits the psychiatrist to take the full range of educational opportunities ordinarily provided in the PGY-4 year of a general psychiatry residency, it focuses exclusively on the age period in which the psychiatrist wishes to specialize, it is eligible for review and approval by the Accreditation Council on Fellowships in Adolescent Psychiatry, and graduates from ACFAP-approved residencies are automatically eligible for the examination of the American Board of Adolescent Psychiatry. The disadvantages of a PGY-5 residency in adolescent psychiatry include that it is hard to find such a program, that neither the American Psychiatric Association nor the American Board of Medical Specialties has yet recognized adolescent psychiatry per se as a specialty (apart from the combined specialty of child and adolescent psychiatry), and that academic recognition and advancement may be more difficult for graduates of an adolescent psychiatry residency than for graduates of a combined child and adolescent psychiatry residency. The Accreditation Council on Fellowships in Forensic Psychiatry’s Standards (Special Requirements for Programs in Adolescent Psychiatry) are set forth here. They are presented to: (1) encourage the creation of PGY-5 residencies in adolescent psychiatry per se; and (2) be used as a model in creating PGY-4 extended electives in adolescent psychiatry (the more closely the PGY-4 program matches the Standards, the better the training).

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STANDARDS (SPECIAL REQUIREMENTS FOR PROGRAMS IN ADOLESCENT PSYCHIATRY) These are as follows:

•

•

•

•

Academic affiliation: the Fellowship Program in Adolescent Psychiatry should be associated with a residency program in psychiatry that has been accredited by the Accreditation Council for Graduate Medical Education. Director of the Program: the Director of the Program should be an experienced adolescent psychiatrist. The Director should be certified by the American Board of Adolescent Psychiatry, or be certified by the American Board of Psychiatry and Neurology in child and adolescent psychiatry. Faculty of the Program: it is important that the Fellow has exposure to more than one practitioner of adolescent psychiatry, so that at least one additional member of the faculty, i.e., in addition to the Director, should be an experienced adolescent psychiatrist. It is not necessary, although it is highly desirable, that the additional faculty person be certified either by the American Board of Adolescent Psychiatry, or by the American Board of Psychiatry and Neurology in child and adolescent psychiatry. Supervised Clinical Experiences: emphasis should be placed on meeting the educational needs of the Fellow, rather than on the service needs of the clinical components of the Fellowship Program. Regularly scheduled, frequent, individual case supervision of the Fellow’s clinical experiences is essential to effective clinical education.

the Fellow by means of lectures, seminars, demonstrations and other formal teaching.

BASIC COMPONENTS OF THE DIDACTIC PROGRAM

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SPECIALTY CONTENT OF ADOLESCENT PSYCHIATRY

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Basic components of the clinical experiences

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A. Inpatient experience. B. Outpatient (clinic) experience. C. Consultation-liaison experience. D. Additional clinical experiences: 1 Juvenile delinquency and criminality. 2 Adolescent risk-taking behaviors, for example: a. sexual contact b. alcohol and drug abuse 3 Transition to young adulthood. 4 School-related problems, i.e., grades 7 through college. 5 Adolescent medicine.

•

Didactic Core Curriculum The Didactic Core Curriculum presents that body of information and skills which is to be communicated to

A. Diagnostic case conferences. B. Continuous case seminar. C. Reading seminar – covering all of the topics listed below under the category of Specialty Content of Adolescent Psychiatry.

•

A. Normal development. 1 Developmental tasks of childhood, adolescence and young adulthood. 2 Psychosocial development. 3 Interpersonal relations. 4 Moral development. 5 Cognitive development. 6 Social and cultural influences on development. B. Assessment. 1 Psychiatric interview of the adolescent. 2 Family interviewing. 3 Psychological testing. 4 Psychosocial assessment, for example, school, peer-relations, work. 5 Biological. 6 Medical. C. Psychiatric disorders in childhood, adolescence and young adulthood. D. Sexuality. 1 Normal sexual development. 2 Sexual problems. 3 Sexual abuse. 4 Pregnancy and parenthood during adolescence. 5 Sexually transmitted diseases, contraception and abortion. E. Legal and ethical issues. 1 Emancipated minors. 2 Confidentiality. 3 Informed consent for treatment and hospitalization. 4 Rights to refuse treatment and hospitalization. 5 Juvenile delinquency, the juvenile justice system, and adolescents in the adult criminal justice system. 6 Custody determination and visitation rights. 7 Status offenses. 8 Abuse and neglect. 9 Special ethical considerations in working with adolescents. F. Psychiatric aspects of physical illness. 1 Acute illness and trauma. 2 Chronic illness.

80 Special issues in adolescent psychiatry

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3 Death and dying. 4 Non-compliance with medical treatment. G. Psychiatric treatments. 1 The therapeutic alliance. 2 Communication with parents. 3 Communication with schools. 4 Termination. 5 Family therapy. 6 Group therapy. 7 Psychoanalysis and psychodynamic psychotherapy. 8 Behavioral and cognitive therapies. 9 Psychopharmacological treatment (special considerations with adolescents).

Training in research The Program should provide the Fellow with basic skills in research in adolescent psychiatry, so that the Fellow can critically evaluate published research findings in the subspecialty and is equipped to make some contribution to the scholarly or scientific development of adolescent psychiatry. The Program should include a research requirement for completion of its course. Suitable research projects include a scholarly review or clinical study suitable for presentation at a scientific program or publication in a refereed journal, participation in ongoing externally funded research at a level of effort equivalent to at least two months of full-time work, production of a videotape or film suitable for presentation at a scientific program, production of a practice manual in some specific area of adolescent psychiatry or preparation of an annotated bibliography on a selected topic in the subspecialty. The Program must include the resources that would make such research possible. These include, as a minimum, access to a major medical library and to at least one behavioral science research resource (e.g., computer processing, a programmable calculator, a one-way mirror observation room, video-tape equipment, endocrine assays, psychotropic drug assays, electroencephalography, or computed tomography).

Training in teaching The Program should provide opportunities to foster the Fellow’s development as a teacher of adolescent psychiatry. Such opportunities should be consistent with the Fellow’s acquisition of the essential knowledge and skills of the subspecialty, so that the bulk of the Fellow’s teaching should be scheduled after the Fellow has received basic training in adolescent psychiatry. It is recommended that the Fellow have exposure to senior teachers in the field, who can provide effective role models.

Among the suitable teaching opportunities are: teaching medical students and residents in general psychiatry; and teaching relevant topics to non-psychiatric physicians.

CHOOSING THE BEST ROUTE INTO ADOLESCENT PSYCHIATRY Psychiatrists who have already completed their residency training in general psychiatry should choose the route of independent self-directed study and experience as the most feasible. Psychiatrists who are still in their residency training in general psychiatry, and who are certain that they do not wish to work with children, will find that an extended elective in adolescent psychiatry will provide both: (1) an opportunity to determine if a career in adolescent psychiatry will be stimulating and satisfying; and (2) a foundation for subsequent self-directed study. An accredited PGY-5 residency in adolescent psychiatry per se would be a better choice for psychiatrists still in residency programs, who know that they do not wish to work with children, if only such programs were more readily available. Psychiatrists who wish to work both with children and adolescents are well-advised to take two years of formal training in child and adolescent psychiatry in an ACGME-accredited residency.

REFERENCES Carnegie Council on Adolescent Development: Great Transitions: Preparing Adolescents for a New Century: Executive Summary. New York: Carnegie Corporation, October 1995, p. 10. Flaherty, L., Sarles, R. Adolescence: development and syndromes. In Noshpitz, J. (ed.), Basic Handbook of Child and Adolescent Psychiatry. New York: John Wiley & Sons, 1997, Volume 3. Rosner, R. Report of the Accreditation Council on Fellowships in Adolescent Psychiatry. Adolescent Psychiatry, 21: 389–407, 1997. The Analytic Press, Hillsdale, N.J, 1997. Rosner, R. (ed.) Textbook on Adolescent Psychiatry. London, England: Edward Arnold Publishers, 2003.

Suggested reading Flaherty, L. A model curriculum for teaching adolescent psychiatry. Adolescent Psychiatry 16: 491–520, 1989. Hendren, R., Armentano, M., Grater, S., Mikkelsen, E., Sarles, R., Sondheimer, A. Adolescent Psychiatry

Education and training in adolescent psychiatry 81 Training: Guidelines for Child and Adolescent Psychiatry Residents, General Psychiatry Residents, and Medical Students. Adolescent Psychiatry, 21: 409–435, The Analytic Press, Hillsdale, N.J, 1997. This is a hardcover, annual book published for the American Society of Adolescent Psychiatry.

Looney, J., Ellis, W., Benedek, E., Schowalter, J. Training in adolescent psychiatry for general psychiatry residents: elements of a model curriculum. Adolescent Psychiatry, 12: 94–103, University of Chicago Press, Chicago, 1985. This is a hard-cover, annual book published for the American Society of Adolescent Psychiatry.

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SECTION

2

Risk behavior, risk-taking, and sexuality EDITED BY LYNN E. PONTON

2.1 Normal sexual development Alayne Yates

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2.2 Adolescent risk-taking and risk behavior Lynn E. Ponton and Ralph J. DiClemente

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2.3 Alcohol and substance abuse among adolescents: prevention and intervention Donald A. Paoletti, Katharine E. Stewart, and Ralph J. DiClemente

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2.4 Adolescent violence: implications for intervention Arlene Rubin Stiffman, Jennifer A. Abeloff, Ester B. Kaggwa, Donald E. Meissner, Michael G. Regier, and Catherine A. Winn

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2.5 The effects of sexual abuse on adolescent development and adaptation Graeme Hanson

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2.6 Pregnancy and parenthood during adolescence Larry K. Brown and Kevin J. Lourie

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2.7 High-risk sexual behavior associated with sexually transmitted diseases and human immunodeficiency virus infections among adolescents Ralph J. DiClemente 2.8 Adolescent homosexuality William M. Womack

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2.1 Normal sexual development ALAYNE YATES

INTRODUCTION

BEFORE ADOLESCENCE

In the year 2003, adolescent sexuality is recognized as a significant problem with medical, social, and economic consequences. Early intercourse is viewed as one of several high-risk behaviors such as substance abuse, dropping out of school, and breaking the law (Koyle et al. 1989). Yet adolescent sexuality, and the way in which adolescents handle sexuality, is an important marker for healthy development and the formation of a positive identity. The study of healthy sexuality is often neglected because of the emphasis on the associated risks. For instance, we know nothing about the 14 per cent of adolescents who come of their own accord to a family planning clinic before having sex. Why is adolescent sexual activity seen as more of a problem now than it was earlier this century? There are a number of reasons, including the greater value placed on women’s education and achievement, the swing back from the sexual permissiveness of the 1960s and 1970s, and the climate of social criticism. A factor less often considered is that adolescent pregnancy is more visible now. In the first half of the twentieth century, single adolescent girls did become pregnant and many obtained illicit abortions, though abortions in general were less available then. Those who remained pregnant were dropped from school when their condition became apparent. They were severely criticized and often ostracized by the community. Because of the shame experienced by all members of the family, pregnant teenagers were often sent away to stay with members of the extended family, or to a home for unwed mothers. Yet by far the most frequent solution was the ‘honorable choice’ of a hasty marriage. For these and other reasons, unwed pregnant teenagers were rarely seen, and therefore thought not to be a problem.

For the past century, the prevailing cultural bias has been that children are sexually innocent and that they need to be protected from sexual information and experience (Yates 2002). Parents and teachers assumed the responsibility of guarding children: limiting their access to movies or books and screening friends for morality. An additional bias was added in the early 1980s when society became more aware of sexual abuse and the fact that adults can harm children instead of protecting them. Children were taught about the dangers associated with sex in the hope that they would better be able to protect themselves. Sex abuse prevention programs are now part of the curriculum in virtually every school in the United States. Dramatized sex abuse prevention programs are presented by concerned citizen groups as early as kindergarten. The goal is to increase children’s anxiety about certain aspects of sexuality by presenting scenes of potential danger so that the children will recognize the threat and react by saying ‘no,’ informing others, or running away. Scenes are vague (to preserve children’s innocence) and are subject to the child’s interpretation. Programs are also initiated without preliminary study about the effect on normal sexual development (Yates 2002). In middle school and high school, older children and adolescents continue to be told about risks associated with sexual activity. Sex abuse prevention programs are followed by AIDS prevention programs. Sex-negative information on sexually transmitted disease could be balanced by sex-positive information on creative, constructive, and pleasurable aspects of sexuality, but it is not – mainly because of concern that such information would foster inappropriate sexual behavior. Yet outside of the literature on abuse, there is no evidence that sexual

86 Risk behavior, risk-taking, and sexuality

experience hurts most children. In fact, a recent eighteenyear outcome study that looked at children who had been exposed to parental nudity or who had witnessed parents’ sexual activity did not demonstrate any harmful effects (Okami et al. 1998).

FAMILY INFLUENCE Most adolescents do not think that their parents influence their sexuality. They expect that they know more about sex than their parents do, perhaps reflecting the fact that sex is often discussed in the schoolyard, but rarely at home. Most adolescents regard their parents as out of step with the times and as overly moralistic (Sanders and Mullis 1988). Yet research indicates that parents exert a powerful and pervasive influence on adolescent sexual behavior. Adolescents are less likely to become sexually active or pregnant and more likely to use contraceptives when they are satisfied with the relationship to mother (Dittus and Jaccard 2000). Adolescent girls reared by parents who are close, who express reasonable values, and who are moderately strict are less likely to initiate sex early (Jessor and Jessor 1975; Fox 1981; Zelnik and Shah 1983). Too many rules and too much control in the family predict early sexual experience, as does an absence of parental control (Miller et al. 1986). Parental control of dating is also a deterrent (Hogan and Kitigawa 1985); this is not surprising as early and frequent dating precipitates early sexual experience (Thorton 1990). When parents who hold traditional values do discuss sex, their adolescent girl offspring are less likely to initiate sex early (Moore et al. 1986) and they are more likely to feel good about themselves (Bates and Joubert 1993). However, most parents do not influence children’s attitudes toward sexuality by providing information about sex, but rather through role modeling and style of parenting. Parents may furnish guidelines that the schools do not, covering topics such as ground rules, degree of commitment, confidentiality of disclosure, and the limits of one’s responsibility toward the other person. These topics are rarely included in sex education curriculae (Shaughnessy and Shakesby 1992). In the wake of divorce or other family disruption, adolescents are more likely to become sexually active at an early age (Flewelling and Bauman 1990). This may be because of social disadvantage, diminished control, emotional upset, or because the parent in residence is engaging in romantic or sexual relationships. When the family is already on welfare, adolescents are more likely to be involved in early, unprotected sex. A stressful life with parental marital disruption predicts early sexual experience (Moore et al. 1995), which may be both voluntary and unwanted and is less likely to involve contraceptives (Abma et al. 1998).

As might be expected, youth with sexually active older siblings are more likely to become sexually active at an early age (Rodgers and Rowe 1988). This may be due to one child directly influencing another, but could also be due to their having been reared in the same environment.

NORMAL DEVELOPMENT: PUBERTY In both genders, pubertal changes begin earlier than commonly thought. Adrenal androgen secretion begins to increase between ages six and eight years (Nottelman et al. 1990), while between the ages of nine and thirteen years there is an equally impressive rise in gonadotropin-induced hormones (Fitschen and Clayton 1965; McCandless 1960). In boys, these hormones are generated by the adrenal glands and testes, and in girls by the adrenal glands and ovaries. It is important to remember that the adrenal glands contribute some testosterone in girls and some estrogen in boys. About 80 per cent of boys experience temporary growth of breast tissue in early adolescence, and this can be a source of intense embarrassment and gender identity concerns.

Sexual maturation in boys Sexual maturation is marked by semenarche (ejaculation) in boys. Although semenarche has not been well studied, recent investigations (Stein and Reiser 1994) have indicated that it might occur at around age twelve years instead of thirteen–fourteen years as was once thought. Youth who are poorly prepared for semenarche can react with anxiety or depression. Poor preparation is the norm for boys, as few parents discuss ejaculation and it is not usually presented in sex education classes until after boys have experienced it. When the first ejaculation occurs as a nocturnal emission or ‘wet dream,’ boys are likely to confuse the event with bedwetting. They are unaware of pleasure and feel as if they have lost control. Some 75 per cent of them report feeling surprised, confused, embarrassed, and afraid. Those who first ejaculate while masturbating are more likely to experience pleasure and to report happiness, but some are intensely embarrassed. The testosterone level of boys is eight-fold higher than that reached by girls (Udry et al. 1986). Testosterone increases boys’ muscle mass dramatically and it precipitates the growth spurt. Although there is individual variation, on the average, growth acceleration peaks at age fourteen years in boys and drops off sharply at sixteen years. Testosterone is a powerful erotogenic force, and the free testosterone index becomes the single strongest predictor of sexual motivation and behavior (Udry et al. 1985; Udry and Billy 1987). Some boys masturbate several times each day and, in spite of this, experience erections at inopportune moments.

Normal sexual development 87

Boys who mature relatively late tend to be less popular, less assertive, and less confident. They are also described as eager, talkative, and attention-seeking (McCandless 1960; Sorensen 1973). They are apt to have problems with self-esteem because of associated deficiencies in muscle mass, athletic prowess, and sexual success – all of which are highly regarded for males in this culture. This places them at risk for emotional disturbance. However, they also demonstrate at least a temporary increase in IQ compared to their peers, together with greater intellectual curiosity, social initiative, and creativity (Ehrhardt and Meyer-Bahlburg 1994; Livson and Peskin 1980). If the increase in intelligence persists, as long-term studies should demonstrate, this could balance out the emotional difficulties attendant upon late maturation. Cognitive ability can exert a far-reaching, positive effect on other areas of functioning, such as emotional and behavioral domains.

Sexual maturation in girls Girls enter puberty approximately two years earlier than boys and they complete their changes sooner, though individual variation is considerable. The earlier growth spurt in girls causes them to be, on the average, slightly taller than boys at age twelve–thirteen years. Breast buds appear between ages of eight and thirteen years, followed by hair growth on the inner borders of the labia, an increase in vaginal secretion, and menstruation (Tanner 1971). An increase in estradiol serum level brings about menarche; estradiol continues to increase, reaching adult levels by age nineteen years. Because there is a lag in progesterone secretion, anovulatory cycles are common in the first year or two after menarche. Menstrual bleeding may be irregular or excessive and missed menses, often several in a row, can occur. In Western cultures and, for the most part, crossculturally, girls do not present a strong increase in erotic behavior at puberty. Instead, they attend to how they look and how they present themselves to boys. This suggests that pubertal hormones influence sexual motivation in girls more than sexual activity (Smith et al. 1985). Sex differences in animal behavior are similar, with males approaching and females presenting. Exceptions to the rule exist in animals and in humans, with a few females becoming sexually aggressive. Higher testosterone levels or a different hormonal mix could influence behavioral variations. Breast development, menstruation, and weight powerfully affect girls’ self-concept. Studies of youth in grades seven and eight found a precipitous drop in girls’ selfevaluation of appearance and competence. The greater the actual weight, the lower the sense of self-worth (O’Dea 1999a). Girls have high self-expectations of how they should look, measuring themselves against the

Western ideal of thinness as seen in magazine pictures of models and actresses. Boys often handle their sexual anxiety by reacting to girls’ emerging sexual characteristics with extreme approval or derision. Girls base part of their self-evaluation on this feedback. More importantly, girls check one another out for signs of maturation. Some early-maturing girls are embarrassed by breast enlargement, while others are proud to be one step ahead (McCandless 1960). Some subgroups such as gymnasts fear maturation and may diet to delay the onset of menses. Relatively few adolescent girls have masturbated by the time they reach adolescence. Many have not examined themselves and remain unaware that the genitals are separate from the organs of elimination. Queasiness about the body and sexual function is brought into focus when girls consider whether or not to use tampons. Girls talk to one another about this, and the more experienced encourage the less experienced. Occasionally a girl will consult her mother. The first insertion of a tampon is similar to a rite of passage and, if successful, it promotes a sense of competence and control over sexual aspects of the body. Many girls have not touched or been aware of the inside of the vagina until they first insert a tampon (Whisnant et al. 1979). Menstruation can solidify a girl’s identification with her mother, but it can also trigger a reaction against the closeness of that relationship. Girls who have had a highly gratifying relationship with mother may become disobedient and employ more extreme measures such as running away. Although these reactions are of considerable concern and can place girls at risk for harm, they also are healthy in that they represent a struggle for individuation.

ADOLESCENT EROTICISM Literature on adolescent sexuality looks at facts and figures on subjects such as initiation of intercourse, but shies away from investigating the erotic experience itself. The omission is related to sanctions against talking to young people about sex and, in particular, the pleasurable aspects of sex.‘Have you done it?’ is an easier question to ask than ‘How does it feel when you do it?’ Yet pleasure is the primary reason listed for having sex (Donovan and Ross 2000). In an era that stresses the dangerousness of sex, masturbation might be expected to assume considerable importance as a ‘good,’ or less risky, alternative to intercourse. Masturbation is, however, rarely mentioned in the scientific literature or in sex education curriculae. Many parents and educators think that any sexual activity is dangerous because it inevitably leads to more sexual activity. This is not the case for masturbation. One study (Leitenberg et al. 1993) shows that men and women who

88 Risk behavior, risk-taking, and sexuality

begin masturbating before or during early adolescence adjust just as well and behave sexually the same as those who do not. Masturbation is not considered an acceptable or manly activity among males reared in a lower socioeconomic (SES) environment, and they try to refrain from doing it. When they do masturbate, they do so quickly and with little enjoyment (Gagnon and Simon 1973). Masturbation is somewhat more acceptable for upper SES males and they are more open in discussing it (Kinsey et al. 1948). Boys are twice as likely to masturbate as girls, and they do so three times more frequently. Biologic variables are a likely cause for this discrepancy as it exists across cultures and within species of other primates and subprimates (Ford and Beach 1951). Some 80 per cent of males have masturbated by age fourteen years, and more than 90 per cent have masturbated by age eighteen to twentyfive years (Diepold and Young 1979; Atwood and Gagnon 1987). Less than 50 per cent of adolescent girls masturbate, but girls and women are more likely to masturbate now than in years past (Hunt 1974). In any case, many more adolescents are masturbating than are having intercourse (Coles and Stokes 1985). Girls keep their masturbation practices secret, even from best friends. Guilt fosters secrecy, and it affects twothirds of adolescent boys and girls who masturbate. Although some boys masturbate with friends, most do so in private and doubt that their friends masturbate. Many are ashamed and actively trying to stop, thinking that the practice is bad, dirty, or a sign of weakness. When adolescents masturbate, they engage in fantasy at the same time. Fantasies commonly include romantic, affectionate, and pregenital exhibitionistic, sadomasochistic, and narcissistic elements. Boys focus on the genital experience and are likely to picture themselves engaged in intercourse. Girls are more likely to imagine an idealized self or some other person engaged in a romantic encounter, which may not involve intercourse. Sometimes the fantasy is unconscious and expressed in daydreams, games, or patterns of relatedness (Freud 1965). For instance, adolescent girls may focus all of their romantic attention on a horse. One girl emphasizes nurturance, grooming, and feeding the animal, another emphasizes control and can intentionally hurt the horse in order to train it, and another is chiefly interested in being applauded in dressage events. An understanding of adolescent erotic fantasy can enable an understanding of the developing personality, the nature of sexual impulses and the defenses against them. In both sexes, fantasies become more realistic and explicit with age and experience. Adolescent girls often have not developed genital primacy (Lamb 1980). Many are ashamed of the genitals and associate them with dirt and odor (Yates 1978). The experience of orgasm does not necessarily change this. Girls who experience orgasm without having established

genital primacy describe the event as something that happened to them, ‘down there’ (Gagnon and Simon 1973). The negative perception of the genitals, together with lower levels of the erotogenic hormone testosterone, and greater learned inhibition, places girls at risk for sexual dysfunction, especially impaired orgasm and deficits in desire (Yates 1993). Although relatively more adolescents were sexually active during the 1980s, this trend has leveled off and may even be beginning to decline (Singh and Darroch 1999; Yates 1993) What has remained constant is the level of initiation of sexual activity during adolescence. This indicates that sexual experience has become part of the process of growing up in the United States. Definitions of ‘intercourse’ or ‘having sex’ have changed dramatically in recent years, with only 40 per cent of adolescents defining oral sex as intercourse. As no researcher has asked about this issue, surveys may not reflect what is actually occurring.

SEX EDUCATION Controversy exists over the value of sex education, which appears to be more effective in children and younger adolescents, and may affect attitudes about sex even after the factual material is forgotten. Numerous studies have shown that adolescents accumulate much misinformation from peers and soon forget the more accurate information that they learn in sex education classes and from books (Stewart 1987). There is a large discrepancy between what adolescents think they know and what they actually do know. The knowledge they retain is colored by gender-specific bias. For instance, young women choose to describe male sexual organs using cute diminutives like ‘penie,’‘dickie,’ and ‘baby-maker.’ Young men employ a different bias, referring to their genitals as ‘rod,’ ‘unit,’ or ‘stick.’ Young women describe their genitals using vague terms such as ‘mine,’ ‘down there,’ and ‘you know,’ while young men refer to female genitalia as ‘the hole,’ ‘furburger,’ and ‘lovenest’ (Sanders and Robinson 1979).

CHANGES IN MALE DEVELOPMENT The advent of puberty provides an enormous boost to male self-esteem, and boys continue to receive strong positive affirmation of sexuality from peers. This counterbalances the sense of genital inferiority (penis size) that early adolescent boys experience. Compared to girls, early adolescent males feel most in control of their lives and have the highest self-esteem (O’Dea and Abraham 1999b). However, in the 21st century, young males are not feeling as good about themselves as they did in the

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past. More males are anxious about appearance and trying to change the body to conform with an idealized image (Pope et al. 2000). The age at which this begins is not known, but college students in their 20s harbor a significantly greater dislike of body and self than do males in their 40s (Yates et al. 1999).

VARIATION IN FEMALE DEVELOPMENT Theory on women’s development (Gilligan 1982; Rosenblatt 1995) suggests that girls develop in the context of important relationships and that they never become as autonomous as do boys. They see themselves as ‘helpers and nurturers’ rather than ‘movers and shakers.’ In adolescence, girls face intense pressure to conform to gender-specific ideals of beauty, neatness, politeness, and obedience. This generates a ‘critical paradox’ in which girls remain intensely involved in relationships but suppress a large part of the self so that they can present a favorable appearance. Because of the need to please, they can be drawn into one-sided relationships with adolescent males, who are conditioned ‘to score’ with as many girls as possible. These relationships are often brief and superficial, leaving girls feeling depressed, inadequate, distrustful, and less likely to pursue a close relationship. The need of adolescent girls to present a favorable appearance is reflected in the fact that 70 per cent of young college women in the United States are preoccupied with appearance and dissatisfied with their body (Heatherton et al. 1995). Half of them report that they are prettier in their fantasies than in real life, and 23 per cent imagine themselves thinner (Kirkendall and McBride 1990). Dissatisfaction with the body fosters spartan dieting, compulsive exercise, and the binge/purge cycle. High achieving, anxious girls are at greatest risk for eating disturbances (O’Dea and Abraham 1999b). From a slightly different perspective, girls often use the focus on body control and appearance to defend against erotic longing and the need to be close (Yates 1991). When they become sexually active, their sexual response is hampered by their concern about physical appearance. The need to defend may be due to a series of disappointments in past relationships and the expectation of more misery in the future, as Gilligan suggests, and/or it may be due to cultural overemphasis on autonomy with young children experiencing many brief separations from their parents. This could yield a deep-seated fear of intimacy (Yates 1991). In either scenario, anorexic adolescents are extreme examples of this complex of pathology: over-riding concern with appearance; need for absolute autonomy and control of the body; negation of intimacy; and sexual unresponsiveness. That emotional autonomy may have a down-side is underscored by a recent study showing that

it predicts higher levels of internal distress (Beyers and Goossens 1999).

SEXUAL DYSFUNCTION Given the forces described above, and the pervasive embarrassment and guilt that teenagers experience, sexual dysfunction should be a common occurrence (Yates 1993; Darling and Davidson 1986). Indeed, among sexually active adolescent girls, inhibited orgasm is the norm. Only 42 per cent have achieved orgasm, 33 per cent are not sure, and 25 per cent are certain that they are anorgasmic. In the early college years, 81 per cent of sexually active males claim they are sexually satisfied, but only 28 per cent of females say they are (Darling and Davidson 1986). Although male college students function better, overall, than females, 11 per cent report erectile dysfunction and 20 per cent premature ejaculation (Miller and Cirone 1978). Women students are troubled by guilt and afraid of consequences such as social criticism or disease. Male students are more concerned about disease than social criticism. Male and female college students have many sexual concerns, but they rarely ask questions or seek help. College-age women are described as rigid and reserved when it comes to talking about sex (Sanders and Robinson 1979). Concern about AIDS, disseminated in sex education classes, may have made talking about sex even more difficult. Some 55 per cent of students are afraid of engaging in sexual intercourse; 44 per cent doubt if there is such a thing as safe sex; 11 per cent think that they have an abnormal fear of sex; and 10 per cent want help for a sexual problem (Katz et al. 1989). Women worry more about the social consequences of sexual behavior, and they handle the fear by avoiding compromising situations. Men are more frustrated sexually, and they worry about catching a sexually transmitted disease. In recent years, erotic thoughts and acts have been openly displayed and discussed in the media. Families watch sexual scenes on television together, yet parents are unable to talk to children about sex. Today’s children may note that an unmarried teenage neighbor is about to have a baby, that famous movie stars are not married but living together, or that Mommy has a good friend who regularly stays for the night. Yet they cannot expect to discuss this material with parents who are too anxious and embarrassed to sex educate children. The system teaches children that it is OK to look, but not to talk about or touch. A general awareness of sex is allowed – even fostered – but the awareness is oddly dissociated from everyday life. Children may have difficulty in owning the genitals or in integrating sexual feelings into the sense of self. No one knows where this trajectory will take our children.

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Individuals have difficulty growing up in cultures in which there is discontinuity between what is expected of children (sexual innocence) and what is expected of adults (sexual responsiveness). In recent years, erotic development has become even more problematic due to the fear of AIDS and distress about sexual abuse. These concerns are systematically instilled in children through the media and through prevention programs in the schools, without knowledge of the long-range consequences. Children are taught that they may, at any time, encounter potentially devastating sexual circumstances. Young children are poorly equipped to process such emotionally charged material. Because they have a limited knowledge base, they are not able to evaluate critically what is being presented. They tend to trust implicitly what is said by authority figures and they often generalize concepts to other areas of life. Thus, well-intentioned prevention programs such as ‘Stranger Danger’ could generate negative attitudes toward the body, sexual feelings, and males in general. The consequences may just now be becoming apparent with the increased sexual anxiety and decreased sexual satisfaction reported by young adults. We must have accurate information if we are to promote healthy aspects of something as basic as sexuality. A large-scale, longitudinal study of sexual development, beginning in infancy and extending through adolescence into young adulthood, is desperately needed. A study such as this would provide correlates and predictors of adult sexual function and dysfunction. It would allow us to move toward the primary prevention of adult sexual dysfunction.

REFERENCES Abma, J., Driscoll, A., Moore, K. Young women’s degree of control over first intercourse: an exploratory analysis. Family Planning Perspectives 30: 12–18, 1998. Atwood, J.D., Gagnon, J. Masturbatory behavior in college youth. Journal of Sex Education and Therapy 13: 35–42, 1987. Bates, L.W., Joubert, C.E. Source of sex education in relation to self-esteem and attitudes toward AIDS precautions among college students. Psychological Reports 72: 603–606, 1993. Beyers, W., Goossens, L. Emotional autonomy, psychosocial adjustment and parenting: interactions, moderating and mediating effects. Journal of Adolescence 22: 753–769, 1999. Coles, R., Stokes, G. Sex and the American Teenager. New York, Harper and Row, 1985. Darling, C.A., Davidson, J.K. Coitally active university students: sexual behaviors, concerns, and challenges. Adolescence 21: 403–419, 1986.

Dittus, P.J., Jaccard, J. Adolescents’ perceptions of maternal disapproval of sex: relationship to sexual outcomes. Journal of Adolescent Health 26: 268–278, 2000. Donovan, B., Ross, M.W. Preventing HIV: determinants of sexual behavior. Lancet 355: 1897–1901, 2000. Ehrhardt, A.A., Meyer-Bahlburg, H.F. Psychosocial aspects of precocious puberty. Hormone Research 41 (Suppl. 2P): 30–35, 1994. Fitschen, W., Clayton, B.E. Urinary excretion of gonadotrophins with particular reference to children. Archives of Disease in Childhood 40: 16–26, 1965. Flewelling, R.L., Bauman, K.E. Family structure as a predictor of initial substance use and sexual intercourse in early adolescence. Journal of Marriage and Family Health 52: 171–180, 1990. Ford, C., Beach, F. Patterns of Sexual Behavior. New York: Harper and Row, 1951. Fox, G.L. The family’s role in adolescent sexual behavior. In Ooms, T. (ed.), Teenage Pregnancy in a Family Context. Philadelphia: Temple University Press, 1981. Freud, A. Normality and pathology in childhood. In The Writings of Anna Freud. New York: International Universities Press, 1965. Gagnon, J.H., Simon, W. Sexual Conduct. Chicago: Aldine Publishing, 1973. Gilligan, C. In a Different Voice: Psychological Theory and Women’s Development. Cambridge: Harvard University Press, 1982. Heatherton, T.F., Nichols, P., Mahamedi, F., Keel, P. Body weight, dieting, and eating disorder symptoms among college students, 1982–1992. American Journal of Psychiatry 152: 1623–1629, 1995. Hogan, D.P., Kitagawa, E.M. The impact of social status, family structure, and neighborhood on the fertility of black adolescents. American Journal of Sociology 90: 825–855, 1985. Hunt, M. Sexual Behavior in the 70’s. Chicago: Playboy Press, 1974. Jessor, S.L., Jessor, R. Transition from virginity to nonvirginity among youth: a social-psychological study over time. Developmental Psychology 11: 473–484, 1975. Katz, R.C., Gipson, M.T., Kearl, A., et al. Assessing sexual aversion in college students: the sexual aversion scale. Journal of Sex and Marital Therapy 15: 135–140, 1989. Kinsey, A.C., Pomeroy, W.G., Martin, C.E. Sexual Behavior in the Human Male. Philadelphia: W.B. Saunders, 1948. Kirkendall, L.A., McBride, L.G. Preadolescent and adolescent imagery fantasies; beliefs and experiences. In Perry, M.E. (ed.), Handbook of Sexology. Volume 7: Childhood and Adolescent Sexology. Amsterdam: Elsevier Science Publishers, 1990.

Normal sexual development 91 Koyle, P., Jensen, L., Olsen, J., Cundick, B. Comparison of sexual behaviors among adolescents having an early, middle, and late first intercourse experience. Youth and Society 20: 461–475, 1989. Lamb, M.E. The development of parent–infant attachments in the first two years of life. In Pedersen, F.A. (ed.), The Father–Infant Relationship. New York: Praeger, 1980. Leitenberg, H., Detzer, M.J., Srebnik, D. Gender differences in masturbation and the relation of masturbation experience in preadolescence and/or early adolescence to sexual behavior and sexual adjustment in young adulthood. Archives of Sexual Behavior 22: 87–98, 1993. Livson and Peskin, 1980. Cited in Ehrhardt, A.A., Meyer-Bahlburg, H.F. (1994). McCandless, B.R. Rate of development, body build and personality. In Shagass, C., Pasamanick, B. (eds), Child Development and Child Psychiatry. Volume 88. Washington, DC: American Psychiatric Association Press, 1960. Miller, G.D., Cirone, J. Sexual dysfunction in college sexuality course attenders and course treatment benefits. Journal of the American College Health Association 27: 107–108, 1978. Miller, B., McCoy, J., Olsen, T., Wallace, C. Parental discipline and control attempts in relation to adolescent sexual attitudes and behaviors. Journal of Marital and Family Therapy 48: 503–512, 1986. Moore, K., Morrison, D.R., Glei, D.A. Welfare and adolescent sex: the effects of family history, benefit levels, and community context. Journal of Family Economic Issues 16: 207–237, 1995. Moore, K., Peterson, J., Furstenberg, F. Parental attitudes and the occurrence of early sexual activity. Journal of Marital and Family Therapy 48: 777–782, 1986. Nottelman, E.D., Inoff-Germain, G., Sussman, E.J., et al. Hormones and behavior at puberty. In Bancroft, J., Reinsich, J.M. (eds), Adolescence and Puberty. New York: Oxford University Press, 1990. O’Dea, J.A., Abraham, S. Association between self-concept and body weight, gender, and pubertal development among male and female adolescents. Adolescence 34: 69–79, 1999a. O’Dea, J.A., Abraham, S. Onset of disordered eating attitudes and behaviors in early adolescence: interplay of pubertal status, gender, weight, and age. Adolescence 34: 671–679, 1999b. Okami, P., Olmstead, R., Abramson, P.R., Pendleton, L. Early childhood exposure to parental nudity and scenes of parental sexuality (‘primal scenes’): an 18-year longitudinal study of outcome. Archives of Sexual Behavior 27: 361–384, 1998. Pope, H.G., Phillips, K.A., Olivardia, R. The Adonis Complex: The Secret Crisis of Male Body Obsession. New York: Free Press, 2000.

Rodgers, J., Rowe, D. Influence of siblings on adolescent sexual behavior. Developmental Psychology 24: 722–728, 1988. Rosenblatt, E.A. Emerging concepts of women’s development. Psychiatric Clinics of North America 18: 95–106, 1995. Sanders, G., Mullis, R. Family influences on sexual attitudes and knowledge as reported by college students. Adolescence 23: 837–845, 1988. Sanders, J.S., Robinson, W.L. Talking and not talking about sex: male and female vocabularies. Journal of Communication 29: 22–30, 1979. Shaughnessy, M.F., Shakesby, P. Adolescent sexual and emotional intimacy. Adolescence 27: 475–480, 1992. Singh, S., Darroch, J.E. Trends in sexual activity among adolescent American women: 1982–1995. Family Planning Perspectives 31: 212–219, 1999. Smith, E.A., Udry, J.R., Morris, N.M. Pubertal development and friends: a biosocial explanation of adolescent sexual behavior. Journal of Health and Social Behavior 26: 183–192, 1985. Sorensen, R.C. Adolescent Sexuality in Contemporary America. Mountain View, CA: World Publications, 1973. Stein, J.H., Reiser, L.W. A study of white middle-class adolescent boys’ responses to ‘semenarche’ (the first ejaculation). Journal of Youth and Adolescence 23: 373–384, 1994. Stewart, D.C. Sexuality and the adolescent: issues for the clinician. Adolescent Medicine 14: 83–99, 1987. Tanner, J.M. Sequence, tempo and individual variation in growth and development in boys and girls aged twelve to sixteen. Daedalus 100: 907–930, 1971. Thorton, A. The courtship process and adolescent sexuality. Journal of Family Issues 11: 239–273, 1990. Trad, P.V. Mental health of adolescent mothers. Journal of the American Academy of Child and Adolescent Psychiatry 34: 130–142, 1995. Udry, J.R., Billy, J.O.G., Morris, N.M., et al. Serum androgenic hormones motivate sexual behavior in adolescent boys. Fertility and Sterility 43: 90–94, 1985. Udry, J.R., Billy, J.O.G. Initiation of coitus in early adolescence. American Sociological Review 52: 841–855, 1987. Udry, J.R., Talbert, L.M., Morris, N.M. Biosocial foundations for adolescent female sexuality. Demography 23: 217–230, 1986. Whisnant, L., Brett, E., Zegans, L. Adolescent girls and menstruation. Adolescent Psychiatry 7: 157–171, 1979. Yates, A. Sex Without Shame: Encouraging the child’s healthy sexual development. New York: Wm. Morrow, 1978. Yates, A. Compulsive Exercise and the Eating Disorders: Toward an integrated theory of activity. New York: Brunner/Mazel, 1991. Yates, A. Sexually inhibited children. In Yates, A. (ed.), Sexual and Gender Identity Disorders. Child and

92 Risk behavior, risk-taking, and sexuality Adolescent Psychiatric Clinics of North America. Philadelphia: W.B. Saunders, 1993. Yates, A., Edman, J.D., Crago, M., Crowell, D., Zimmerman, R. Measurement of exercise orientation in normal subjects: gender and age differences. Journal of Personality and Individual Differences 27: 199–209, 1999.

Yates, A. Childhood sexuality. In Lewis, M. (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook, 3rd edition., Baltimore: Lippincott, Williams & Wilkins, 2002. Zelnik, M., Shah, F.K. First intercourse among young Americans. Family Planning Perspectives 15: 64–70, 1983.

2.2 Adolescent risk-taking and risk behavior LYNN E. PONTON AND RALPH J. DICLEMENTE

INTRODUCTION

DEFINITIONS

Adolescence is a developmental period of rapid physical, psychological, sociocultural, and cognitive changes characterized by efforts to confront and surmount challenges and simultaneously to establish a sense of identity and autonomy (DiClemente et al. 1996a). Adolescents take risks as a way of developing and defining themselves, often taking on challenges in areas that they understand very little about, and in this process, engaging in a whole range of behaviors with results that range from devastation to extremely positive. In a sense, risk-taking is the major tool that adolescents use to shape their identities. Both directly and indirectly, risk-taking affects all aspects of development during this important period of life – physical, social, psychological, sexual, and cultural (Ponton 1997). For the purposes of this chapter, dangerous risk-taking – a process which takes place when normal adolescent testing goes awry and an adolescent becomes locked into a pattern with largely negative consequences – will be termed ‘risk behavior’ (Ponton 1997). During the past fifty years, there has been a marked change in the causes of morbidity and mortality among adolescents. Adolescents today are increasingly at risk for adverse health outcomes, even death, that are not primarily biomedical in origin and are the result of risk behaviors. These social morbidities include a broad spectrum of behaviors and related outcomes such as substance use and abuse; reckless driving of motor vehicles; reckless participation in sports activities such as diving and boating; participation in sexual activities without protection from pregnancy or sexually transmitted diseases, including HIV; withdrawal from school; eating disorders; mutilation of one’s body in various ways, including cutting and piercing; violence; suicide; and placing themselves in positions where they can be victimized, including running away from home.

Irwin (1989) describes risk-taking as a normal developmental process, noting that it is characterized by young people with limited experience engaging in a whole range of behaviors, many if not all of which are potentially destructive with only a limited understanding of the consequences of their actions. Even keeping in mind the possibility of danger, it is important to remember that most young people negotiate their adolescence without undergoing the turmoil that was once considered characteristic by G. Stanley Hall (1904), Ernest Jones (1922/1948), and Anna Freud (1958). Anna Freud (1958) described the adolescent period as one whose ‘very nature is an interruption of peaceful growth,’ noting that ‘a steady equilibrium during the adolescent process is in itself abnormal.’ Daniel Offer and his collaborators (1992) refuted the idea that adolescence is by its very nature turbulent, finding that 80 per cent of adolescents do not experience adolescent turmoil and negotiate the period without significant difficulty. As mentioned earlier, what begins as an adolescent engaged in healthy risk-taking may change rapidly or gradually evolve into an unhealthy dangerous pattern defined as risk behavior. Many factors play a role in the evaluation of this process, among them mental illness, highlighting how important it is for psychiatrists to be aware of the connection between risk behavior and psychopathology. Adolescents who fall within psychiatric populations present unique and challenging patterns of risk behavior. The inter-relationship of risk behavior and psychopathology has important implications for treatment. There is a great deal of evidence that shows that mental disorders or distress are often present at or near the time an adolescent engages in risk behavior. Whether psychopathology is preexistent, develops along with risk behaviors, or is one of its consequences is a complex and currently unanswerable

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question. Examples of the close association between risk behaviors and psychological problems are easily found. For example, depression, a major cause of psychiatric morbidity in adolescents, commonly follows unplanned pregnancy. Substance abuse often pre-dates a suicide attempt. We do not know to what extent psychological problems pre-date risk behavior in adolescents. Several studies have attempted to quantify risk behaviors in adolescents with psychiatric disorders. DiClemente and colleagues (1989) found that known risk behaviors were prevalent among their hospitalized sample: intravenous drug use (15%), sharing intravenous drug needles (15%), partners of intravenous drug users (15.8%), having sexual intercourse with someone whose sexual history is unknown, self-mutilation (60%), and sharing of cutting instruments with peers (25%). Similarly, Baker and Mossman (1991) in a small sample of hospitalized girls found high levels of drug abuse (17% reported daily use of drugs), high-risk sexual activities (57%), and histories of sexually transmitted diseases (STDs) (17%). In a comparison study of psychiatrically hospitalized adolescents and school-based adolescents (DiClemente and Ponton 1993), the hospitalized adolescents were found to be almost twice as likely to be sexually active, almost twice as likely to report intercourse without condoms, and more than twice as likely to use intravenous drugs.

THEORETICAL MODELS FOR UNDERSTANDING ADOLESCENT RISK-TAKING Theoretical frameworks of risk-taking behavior are helpful both to researchers interpreting empirical findings and to clinicians trying to understand the behaviors of their patients. One of the key models conceptualizes adolescent risk-taking as interrelated domains of risk and protective factors affecting both individual adolescents and groups of adolescents (Jessor 1990). This model effectively countered the early proclivity in the field to attach global meaning to a single variable, exemplified by the noteworthy ‘Just Say No’ public awareness campaign against drugs, which was single-focused and failed to take into account the complexity of behavioral patterns and the multiplicity of influences on behavior. Jessor’s model divides the factors that contribute to adolescent risk behaviors into five areas:

• • • •

biological or genetic contributions; the social environment, which includes factors such as poverty and quality of schools; an area called perceived environment, which is defined as how the adolescent sees his or her own environmental models for both abnormal and conventional behavior; individual personality factors, which include self-esteem, the way a teenager visualizes or fails to visualize his or

•

her own future, his or her propensity for risk-taking, and his or her values related to achievement and health; and, finally behavioral factors, such as school attendance and drinking.

Also emphasized are the importance of protective factors, which are those factors that protect or buffer an adolescent against participation in risk behavior. A second model underscores the importance of lifestyles in adolescent risk-taking, and emphasizes the interrelated nature of behavior. Using this approach, specific behaviors are understood to be embedded in general styles of adaptation which are maintained by complex networks of social and cultural reinforcement (Nutbeam et al. 1989). This model has obvious clinical applications indicating that individual, clinical, and larger-scale prevention programs should attempt to influence the lifestyle in which a particular behavior is embedded versus focusing on specific forms of behavior. Igra and Irwin (1996) underscore the important of utilizing a biopsychosocial perspective when explaining adolescent risk behavior. They characterize contributors to risk-taking behavior from the biological sphere as genetic predispositions, direct hormonal influences, and the interplay of hormones and the developmental period of puberty. Psychological contributors include an adolescent’s cognitive ability and dispositional personality traits. Social or environmental aspects of risk-taking include the roles of peers, parents, family structure, and social institutions. All of these components are woven into the biopsychosocial model, including an evaluation of cultural factors (Lightfoot 1997). As stated elsewhere (Ponton 1997): ‘Risk-taking must be placed in a developmental framework in order to see it for the vital tool that it is. The many complex developmental tasks of adolescence include: separation and individuation, developing a sense of oneself as a distinct person, separate from family members and others; identity formation; exploration of the biological, sexual, psychological, social, and cultural aspects of identity; learning how to develop close relationships with others; gaining control of one’s impulses; and learning how to take responsibility for one’s actions. Risk-taking is one of the primary tools that adolescents use to accomplish these developmental tasks, which serve, in turn, to improve adolescents’ risk-taking skills.’ (Ponton 1997, p. 275).

EPIDEMIOLOGY While risk-taking has always been a part of adolescence, teenagers growing up in America today face the opportunity

Adolescent risk-taking and risk behavior 95

for increasingly inventive and challenging risk behaviors. They have easier access to cars, sex, and drugs than earlier generations of teenagers (Gelman 1990). For example, over the past thirty years, there have been dramatic shifts in the leading causes of death for adolescents from natural to violent etiologies. Marked reductions in communicable diseases have been mostly offset by large increases in violent deaths (unintentional injuries, homicide, and suicide) (Sells and Blum 1996). While there have been increases in homicides in all ages, the largest percentage increases were noted in youth of ages ten to fourteen years (US Department of Health and Human Services 1993). A major concern is the easy availability of firearms to children and youth. Surveys suggest that a one-quarter of all United States homes contain a handgun (American Academy of Pediatrics and Center to Prevent Handgun Violence 1994), and almost half have some type of gun (Children’s Defense Fund 1994). A 1990 survey of gun owners found that over half reported that they keep their guns unlocked, and nearly one in four always kept it loaded (Yankelovich et al. 1990). In a national survey of 6th through 12th grade students, 59 per cent reported knowing where they could get a gun, and one in three reported they could acquire a gun in less than an hour (American Academy of Pediatrics and Center to Prevent Handgun Violence 1994). Related to this, since 1960, suicide has increased more than 150 per cent to the current level of 13.1 per 100 000 among 15- to 24-year-olds in 1991 (National Center for Health Statistics 1993; Rosen et al. 1990). Between 1979 and 1988, the national suicide rates increased by 7.9 per cent. While there were significant reductions in youth aged twenty to twenty-four years (8.5%), there were marked increased in both youth aged ten to fourteen (75%) and fifteen to nineteen years (34.5%) (US Department of Health and Human Services 1993). Firearms are the most common method of suicide for both young men and women (National Institute of Mental Health 1993). US youth between the ages of ten and nineteen years commit suicide with a handgun an average every six hours (Fingerhut 1993). While the availability and accessibility of firearms may be related to increases in intentional morbidity and mortality attributable to homicide and suicide among adolescents, another concern is the recent increases in reported use of illicit substances in addition to changes in attitudes and beliefs associated with drug use. The 1993 annual survey of US high school students reported a sharp rise in marijuana use in 8th, 10th, and 12th grade students. In addition, there were significant increases in stimulant, LSD, and inhalant use at all three grades (Hansen and O’Malley 1996). Moreover, primarily attributable to the advent of the HIV epidemic, closer monitoring of adolescent sexual risk behavior indicates that the proportion of adolescents who are sexually active may be increasing over time

(DiClemente 1990). Depending on the survey, anywhere from 50 to 70 per cent of adolescents report being sexually active by nineteen years of age. Of sexually active adolescents, only 47 per cent of females and 25 per cent of males report using condoms as a primary contraceptive method. More alarming, it is believed that one-third to one-quarter of sexually active adolescents never use any form of contraception. Longitudinal data collected at three time points (1971, 1976, and 1979) have suggested that the proportion of adolescents who are sexually active is increasing for all ages from fifteen to nineteen years, with the greatest increase observed for sixteen-year-old White females. In 1971, for example, approximately 15 per cent of this group were sexually active, but by 1979 this figure had more than doubled, increasing to 32 per cent. Evidence has suggested that this trend toward earlier initiation of sexual intercourse is continuing, with greater numbers of adolescents projected to engage in sexual activity at increasingly younger ages. Two emerging trends have been identified which increase the likelihood of risk for HIV infection in this population. First, data have indicated that adolescents below the age of fourteen years show the greatest increase in the rate of initiation of sexual activity relative to other ages, and second, data have indicated a growing trend toward increased numbers of sexual partners among adolescents. Directly related to adolescent sexual risk behavior is, of course, the adverse health outcomes of STDs, including HIV infection (D’Angelo and DiClemente 1996). While data from public clinics specifically established to treat STDs are more reliable than data from other sources, they are heavily biased towards racial, ethnic, and socioeconomic groups that are forced to use these health services for care. Despite these limitations, existing data about STDs in adolescents are both informative and disturbing. For instance, while the overall total number of cases of gonorrhea reported nationally between 1981 and 1991 decreased from 990 864 to 620 478 cases, with an accompanying decrease in the overall rate of cases to 249.5 cases per 100 000 population, the rates of gonorrhea in 15- to 19-year-old males actually increased from 868.4 per 100 000 population in 1981 to 882.6 per 100 000 population in 1991 (Webster et al. 1993). During this same time period, while the rate in 15- to 19-yearold females fell from 1253.7 per 100 000 population in 1981 to 1043.6 per 100 000 population in 1991, the rate remained higher in this group than in any other age and sex grouping. These rates varied by geographic location, where rates from 15- to 19-year-olds from the South were 1427.7 for females and 1378.3 per 100 000 population for males, and by race, where rates for Black 15- to 19-year-olds exceeded 5000 cases per 100 000 population for both males and females. For syphilis, while rates between 1981 and 1991 actually fell in males from 10.0 per 100 000 population to 18.1 per 100 000 population,

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the rates in females increased from 18.4 per 100 000 to 35.0 per 100 000. While trend data are limited, recent findings from the continuing HIV serosurvey of Job Corps training program applicants have identified marked changes in infection rates between 1988 and 1992, with African-American female applicants experiencing a two-fold increase in seroprevalence rates from 3.2 per 1000 to 6.6 per 1000. In 1992, African-American females had seroprevalence rates that exceeded not only rates for White and Hispanic women, but also exceeded HIV seroprevalence rates for African-American males (DiClemente 1996). We recommend caution in interpreting these rates. While these subpopulation studies provide an assessment of the impact of HIV on adolescents, their utility for assessing temporal trends in seroprevalence is limited and the findings not generalizable to the adolescent population at large.

PREVENTION A close examination of different adolescent risk behaviors demonstrates similar epidemiological and etiological patterns. Not surprisingly, many of these similarities surface again in the important area of prevention. Prevention efforts, whether they are universal (tertiary), selective (secondary), or indicated (primary) (DiClemente et al. 1996b), often overlap across risk behaviors, and if they target individual risk behaviors, can often learn from successful programs which have targeted other risk behaviors. One of the important principles regarding interventions which address adolescent risk behaviors is that programs must attempt to change behaviors themselves, not just modify knowledge and attitudes. As social learning theory suggests, adolescents need to believe that they are competent to make decisions and changes in their behaviors. Interventions that include exercises in decision-making skills-building contribute to the adolescents’ self-confidence and ability to make decisions for themselves (Ponton et al. 1991). Role play, peer-group discussion, support, and role modeling are techniques that can be used to build decision-making skills in adolescents. A lively presentation style which integrates teen music, video, and peer-group interaction often enhances the effectiveness of the intervention. Use of teenagers who have experienced the negative consequences of high-risk behaviors makes adolescents aware that these consequences of such risk behavior could apply to themselves. Interventions must also be geared to the age, developmental level, and background of the adolescent target audience. As an example, HIV education should not be presented to adolescents who lack a firm grounding in sexual education. Mismatching of intervention and population reduces the effectiveness of the program.

In general, then, interventions that are theory-driven, emphasize motivational factors, provide skills training, and attempt to modify peer norms through the use of peer-based models are more effective at promoting the adoption of preventive behaviors (DiClemente et al. 1996a). For interventions to progress more rapidly, however, a comprehensive and coordination infrastructure to conceptualize, stimulate, and support the continuum of behavioral intervention research necessary to monitor and further understand the correlates and antecedents of risk behaviors, and reduce these behaviors is still of critical importance. Continued rigorous evaluation of prevention programs will further contribute to our understanding of how best to modify adolescents’ risk behaviors. Greater specificity will be necessary to more effectively tailor interventions to target populations, taking into account their gender, sexual orientation, ethnicity, and developmental level, as well as the setting in which the intervention will be implemented. In developing interventions for psychiatrically impaired youth, it is especially important to target their unique risk behaviors (Ponton et al. 1991). Sexual victimization, self-mutilation, and a variety of other risk behaviors are prevalent in those populations, and necessitate tailored interventions. Adolescent psychiatric populations may also lag behind in basic knowledge, vocabulary, or reading skills. An awareness of these differences can lead to appropriate modification of the interventions. One example of how each of the individual areas of risk behavior prevention can make important contributions to others is seen in the area of teenage pregnancy. Because it has been recognized as an adolescent risk behavior for decades, it has been targeted by multiple generations of intervention efforts. Although assessment of individual interventions has been flawed, each generation of intervention has contributed knowledge to the next about how teenage pregnancy can be prevented most effectively. Current interventions are at the fourth generation, spanning almost forty years. The knowledge gained within this field can be applied by newly recognized or developed risk behaviors such as HIV-related risk behavior and disordered eating (DiClemente et al. 1996b). Prevention programs that address these new behaviors have only been developed in the past ten years, but can incorporate knowledge from the older areas. The early work in teenage pregnancy illustrated this. Early programs that focused on providing knowledge about biology and contraception to teens resulted in increased knowledge and changed attitudes, but did not significantly alter teenage behavior. Later generations of prevention efforts yielded other necessary information such as the importance of early interventions which target elementary and middle-school children, with prevention efforts designed to reach the children before their ideas and intentions about their future behaviors are fully

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formed, perhaps even before attitudes about a behavior have been established (Stevens-Simon and McAnarny 1996). The type of ‘progressive learning’ which has accumulated from multiple generations of teenage pregnancy prevention programs is both time-consuming and expensive, and should be shared by the entire field of adolescent risk behaviors. It is also important to look at the field as a whole because the behaviors themselves have many complex connections. There are clusters of risk behaviors that occur together, for example alcohol and substance abuse and unintentional injury, as described by Lescohier and Gallagher (1996). Behaviors such as school refusal (i.e., dropping out) and teenage pregnancy frequently co-occur. Until recently, it was believed that teenage pregnancy preceded dropping out of school. It is now recognized (Sikorski 1996; Stevens-Simon and McAnarny 1996) that a whole spectrum of school-related risk behaviors – such as poor performance or school failure which ultimately results in school refusal – may have preceded a girl’s decision to become pregnant. Understanding an association such as the one observed between teenage pregnancy and school refusal not only increases theoretical knowledge but also allows for the development of more effective interventions. Psychiatrists and other health professionals can play an important role in targeted (primary) prevention efforts (DiClemente and Brown 1994). Psychiatrists can convey basic knowledge about adolescent sexuality and risk-taking activity, dispel common misconceptions, and discuss the normal behavior of other teenagers (peer norms, an area of considerable importance to adolescents). In addition, a psychiatrist working with adolescents should be knowledgeable about each adolescent’s individual areas of risk and be able to impart this knowledge to patients in a comfortable, non-threatening manner, enforcing what the adolescent already knows. The clinical situation offers an opportunity to help a young person exploring his or her own risk-taking process, focusing on both unconscious and conscious motivations for engaging in risk behaviors. Behavioral re-enactments of early traumatic experience are an example of unconscious factors that may play a large role in an individual adolescent’s risk-taking picture. The adolescent psychiatrist is in a unique position to help, successfully blending elements of treatment and prevention in order to provide the adolescent with an avenue for change.

TREATMENT Along with the entire spectrum of risk behaviors (serious adolescent risk-taking), there is a whole spectrum of severity, from mild to extreme. Most risk behaviors do not occur alone, and cluster together with other risk

behaviors and psychopathology. Psychiatrists and other mental health professionals working with adolescents need to be aware of the close connection between psychopathology and risk behaviors, and do a comprehensive assessment. This assessment is aided by a treatment approach which utilizes a comprehensive model, i.e., the biopsychosocial cultural approach, with a developmental perspective which integrates several treatment modalities, including physical assessment, laboratory testing if needed (e.g., to monitor substance abuse, among others), nutritional assessment (e.g., to evaluate disordered eating), and family evaluation in order to explore the roles that the family members play in the adolescent’s problems and to determine the roles they can play in an adolescent’s treatment. Individual assessment should include a general assessment of adolescent risk behaviors. In many cases, a written questionnaire may obtain the most information, highlighting risk behaviors that may be forgotten or difficult to ask about in a face-to-face interview. An example of such questionnaires, the Brown and Ponton Risk Assessment, is provided in this chapter. Once risk behaviors have been detected by a written questionnaire, they should be explored more thoroughly in a face-to-face interview with the adolescent. In order to do a comprehensive assessment, a developmental history, including a synopsis of the adolescent’s school history, should be taken. Parents, pediatricians, and teachers can provide necessary information for this part of the examination. Many risk behaviors are connected with mental disorders, for example school truancy with attention deficit disorder (Sikorski 1996). Runaway youth, compared to their non-runaway peer groups, are three times more likely to meet the diagnostic criteria for a mental disorder (Robertson 1992). Again, psychiatrists and mental health professionals need to be aware of the close connections between mental illness and risk behavior, and consider a spectrum of mental illnesses. Here again, written questionnaires, for example, the Connors Scales for problems related to attention and hyperactivity, and the Beck Depression Inventory for symptoms associated with affective disorders, are helpful. A mental status examination that pays attention to professed and observed risk behaviors and asks careful questions about mood, patterns of thinking, and cognition, is a vital piece of this assessment. Once the initial assessment has been conducted, the psychiatrist should meet with the teenager and family, share recommendations, and establish or refer to an ongoing treatment program. Treatment programs for risk behaviors are diverse in focus, with varying levels of intensity. The program needs to be designed for the individual adolescent, however, targeting his or her individual needs. Joe, a seventeen-year-old adolescent boy with a three-year history of a serious problem with drinking and alcohol-related

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motor vehicle accidents, profited from a treatment program that provided individual treatment with a psychiatrist who evaluated and treated his mood disorder, an after-school outpatient alcohol abuse/dependence program, an intervention with his school that identified and addressed the problem his peer group was having with alcohol and other substances and driving, and a family therapy component that addressed the role that his parents could play (Ponton 1997). Hannah, a twelveyear-old girl with a serious problem with disordered eating which evolved into anorexia nervosa, required a treatment program which included consultations with a dietician, careful medical monitoring by her pediatrician, psychotherapeutic evaluation and treatment by an adolescent psychiatrist who focused on issues related to self-esteem and how Hannah viewed her developing identity – ‘If only I were thin, I would be perfect’ – and the development of an eating plan contributed to by all members of the treatment team as well as Hannah and her parents. Supportive family therapy utilized a psychoeducational approach and helped Hannah and her parents understand the developmental pressures on adolescent girls (Ponton 1997). In summary, treatment should ideally provide the adolescent and his or her family with the right modalities at the appropriate intensity and should produce optimal outcome in terms of targeting treatment goals. Comprehensive assessment and treatment-matching are vital components.

SUMMARY Adolescents confront myriad challenges on their trajectory to adulthood, and many successfully surmount these challenges. However, there exist a number of counterveiling influences, such as cultural, environmental, social, and biological factors, that facilitate the adoption and maintenance of risk behavior. Many of these deleterious social influences abound in the adolescent’s environment, in either their interpersonal, familial, or the broader media environment. These challenges are complex. On the one hand, they create opportunities for adolescents to problem-solve and establish autonomy, to develop self-esteem and self-efficacy. In contrast, they also create opportunities for disastrous social and adverse health consequences. How youth navigates adolescence is critical to the attainment of a healthy, adjusted, productive, and fulfilled existence both during adolescence and in later life. Risk behavior among adolescents is not random, uncontrollable, or inevitable. Many factors, both individual (intrapersonal) and social (interpersonal) contribute to an adolescent’s propensity to engage in risk behaviors. Thus, adolescents’ risk behaviors are not a simple behavioral response. They

represent the outcome of a complex social and interpersonal interaction which reflects a multifactorial decisionmaking process in which many influences – biological, developmental, social, and psychological – underlie the decision-making process (DiClemente et al. 1996a). And, most importantly, many of these factors are modifiable. To avert further increases in adolescent risk behaviors and the adverse health and social consequences that accompany them, the development of effective prevention and treatment interventions is urgently needed. Accessibility is critical for intervening with adolescents. Thus, attaching prevention efforts to sites where adolescents are being treated for a severe consequence of a risk behavior, such as a hospital emergency room post suicide attempt, or a psychiatric clinic or hospital for treatment for an eating disorder, is another recommended innovation. Early assessment of risk-taking in a school-based clinic will also prevent the behavior from evolving into entrenched, dangerous patterns. Such linkages ensure that high-risk groups which formerly fell through the cracks will not be forgotten, only to surface again in need of acute care. The child and adolescent psychiatrist has an important role to play in this effort. Recognizing that the population of adolescents with psychiatric diagnoses are at high risk for dangerous risk-taking is crucial. Completing a developmental history and risk assessment is also important. Recognizing that the risk behavior and the psychological illness have to be treated conjointly is key. The adolescent psychiatrist also has a role to play in the community as he or she works with parents, teachers, and other health professionals to develop prevention efforts. Lastly, the adolescent psychiatrist has the opportunity to work with adolescents individually and encourage them to examine, understand, and change their behavior.

REFERENCES American Academy of Pediatrics and Center to Prevent Handgun Violence. STOP: Steps to Prevent Firearm Injury, 1994. Baker, D.G., Mossman, D. Potential HIV exposure in psychiatrically hospitalized adolescent girls. American Journal of Psychiatry 148: 528–530, 1991. Children’s Defense Fund. The State of America’s Children: Yearbook 1994. Washington, DC, 1994. D’Angelo, L., DiClemente, R.J. Sexually transmitted diseases and human immunodeficiency virus infection among adolescents. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 333–368.

Adolescent risk-taking and risk behavior 99 DiClemente, R.J. The emergence of adolescents as a risk group for human immunodeficiency virus infection. Journal of Adolescent Research 5: 7–17, 1990. DiClemente, R.J. Adolescents at risk for Acquired Immunodeficiency Syndrome: Epidemiology of AIDS, HIV prevalence and HIV incidence. In Oskamp, S., Thompson, S. (eds), Understanding and Preventing HIV Risk Behavior. Newbury Park, CA: Sage Publications, 1996, pp. 13–30. DiClemente, R.J., Brown, L.K. Expanding the pediatrician’s role of HIV prevention in adolescents. Clinical Pediatrics 32: 235–240, 1994. DiClemente, R.J., Ponton, L.E. HIV-related risk behaviors among psychiatrically hospitalized and school-based adolescents. American Journal of Psychiatry 150: 324–325, 1993. DiClemente, R.J., Ponton, L.E., Hartley, D., McKenna, S. Prevalence of sexual and drug-related risk behavior among psychiatrically hospitalized adolescents. In Woodruff, J., Doherty, D., Garrison Athey, J. (eds), Troubled Adolescents and HIV Infection. Washington, DC: Child Development Center, Georgetown University, 1989, pp. 70–88. DiClemente, R.J., Hansen, W.B., Ponton, L.E. Adolescents at risk: a generation in jeopardy. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996a, pp. 1–4. DiClemente, R.J., Ponton, L.E., Hansen, W.B. New directions for adolescent risk prevention and health promotion research and interventions. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996b, pp. 413–420. Fingerhut, L.A. Firearm mortality among children and youth. In Advance Data from Vital and Health Statistics of the National Center for Health Statistics. US Department of Health and Human Services, 1993, p. 231. Freud, A. Adolescence. Psychoanalytic Study of the Child 13: 255–278, 1958. Gelman, D. A much riskier passage. Newsweek, Special Edition: The New Teens, 1990. Hall, G.S. Adolescence and its relation to psychology, anthropology, sociology, sex, crime, religion, and education. Volumes 1–2. New York: AppletonCentury-Crofts, 1904. Hansen, W.B., O’Malley, P.M. Drug use. In Handbook of Adolescent Health Risk Behavior. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 161–192. Igra, V., Irwin, C.E. Theories of adolescent risk-taking behavior. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 35–51.

Irwin, C. Risk-taking behavior in the adolescent patient: are they impulsive? Pediatric Annals 18(2): 122–133, 1989. Jessor, R. Risk behavior in adolescence: a psychosocial framework for understanding. In Rodgers, D., Ginzberg, E. (eds), Adolescents at Risk: Medical and Social Perspectives. San Francisco: Westview Press, 1990. Jones, E. Some problems of adolescence: Papers on psychoanalysis. London: Baillière, Tindall, and Cox, 1922; republished 1948. Lescohier, I., Gallagher, S.S. Unintentional Injury. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 225–258. Lightfoot, C. The culture of adolescent risk-taking. New York: Guilford Press, 1997. National Center for Health Statistics. Monthly vital statistics reports; Advance Report of Final Mortality Statistics, 1991. Hyattsville, MD: Public Health Service, 42(2), suppl. 1993. National Institute of Mental Health. Suicide Facts. Office of Suicide Information, 1993. Nutbeam, D., Aar, L., Catford, J. Understanding children’s health behavior: the implications for health promotion for young people. Social Science and Medicine 29: 317–325, 1989. Offer, D., Schonert-Reichl, K. Debunking the myths of adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 31: 1003–1014, 1992. Ponton, L. The Romance of Risk: Why Adolescents Do the Things They Do. New York: HarperCollins/Basic Books, 1997. Ponton, L.E., DiClemente, R.J., McKenna, S. An AIDS education and prevention program for psychiatrically hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 30: 729–735, 1991. Robertson, M.J. The prevalence of mental disorder among homeless people. In Jahiel, R.I. (ed.), Homelessness: A Prevention Oriented Approach. Baltimore, MD: Johns Hopkins University Press, 1992, pp. 57–86. Rosen, D., Xiangdong, M., Blum, R.W. Adolescent health: current trends and critical issues. Adolescent Medicine: State of the Art Reviews 1: 15–31, 1990. Sells, C.W., Blum, R.W. Current trends in adolescent health. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 5–34. Sikorski, J.B. Academic underachievement and school refusal. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 393–411. Stevens-Simon, C., McAnarney, E.R. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of

100 Risk behavior, risk-taking, and sexuality Adolescent Health Risk Behavior. New York: Plenum Press, 1996, pp. 313–332. US Department of Health and Human Services. Adolescent health: State of the nation monograph series, no. 1. CDC Publication 099-4112. In Mortality Trends, Causes of Death, and Related Risk Behaviors among U.S. Adolescents. Public Health Service, Center for Disease Control and Prevention, 1993.

Webster, L.A., Berman, S.M., Greenspan, J.R. Surveillance for gonorrhea and primary and secondary syphilis among adolescents, United States, 1981–1991. Morbidity and Mortality Weekly Report 42: 1–11, 1993. Yankelovich, D., Clancy, K.J., Shulman, R. America and their guns. Time/CNN Telephone Poll, pp. 20–21, January 29, 1990.

2.3 Alcohol and substance abuse among adolescents: prevention and intervention DONALD A. PAOLETTI, KATHARINE E. STEWART, AND RALPH J. DICLEMENTE

INTRODUCTION

EPIDEMIOLOGY

In 2001, an estimated 16 million individuals in the United States used illicit drugs (SAMHSA 2002). Adolescents are not immune to these statistics, and over 50 per cent of high school seniors have tried illicit drugs at least once (Johnston et al. 2002). Some 80 per cent of these students report previous use of alcohol, and over 60 per cent have been drunk. Recent surveys have shown significant increases in adolescent use and abuse of cigarettes and drugs, reversing the downward trends of the 1980s. In addition, the surveys reveal that drug and alcohol experimentation is occurring earlier in an adolescent’s life. Teenagers – the age group most likely to begin experimentation with cigarettes and/or alcohol – are also at the highest risk for progression to other substances and higher-frequency use patterns. With adolescence being such an important developmental phase, the risks associated with recreational drug use have lifelong implications. Education efforts are focused on the harmful effects of drug and alcohol use, while prevention efforts are aimed at delaying experimentation by teaching skills that decrease the probability of drug use. Regardless of prevention efforts, however, there will always be individuals who experience dyscontrol with their drug use. Associated with drug and alcohol use, these teenagers will engage in other risk-taking behaviors that may lead to other potential medical and psychological problems, such as suicide and sexually transmitted diseases including HIV (Santelli et al. 2001; Greene and Ringwalt 1996). Clinicians are obliged to be aware of these issues and include drug and alcohol use questions in their assessments of teenagers.

The Monitoring the Future Survey (Johnston et al. 2002), which began in 1975, surveys 15 000 to 19 000 high school seniors each year. In 1991, the survey was expanded to include 8th and 10th grade students. The survey selects schools to provide an accurate cross section of US students, and covers twenty classes and subclasses of drugs, including alcohol and cigarettes. Trends in lifetime and annual use of illicit drugs have stabilized among 8th, 10th, and 12th graders, but have done so at markedly higher levels than those seen ten years ago. In 2001, 26.8 per cent of 8th graders reported a history of illicit drug use. For 10th graders, lifetime use in 2001 was 45.6 per cent. Approximately 54 per cent of seniors reported having ever tried an illicit substance. Marijuana is the most commonly used, with lifetime use in 2001 for 8th, 10th, and 12th graders of 20.4, 40.1, and 49.0 per cent, respectively. Annual use, which reflects more recent use of marijuana, reveals upward trends for older age groups. Annual use statistics in 2001 were 15.4, 32.7, and 37.0 per cent for 8th, 10th, and 12th graders, respectively. Hallucinogen use is decreasing in all three age groups, but remains significant. The prevalence data for lifetime use in 2001 for the three grades were 4.0, 7.8, and 12.8 per cent. The data for stimulants, which revealed increases from 2000 to 2001, showed lifetime prevalence rates of 10.2, 16.0, and 16.2 per cent, respectively. These increases were concordant with increased perceptions in teenagers that drugs were not harmful and were more available. Results for licit substances, although illegal for minors, included significant decreases in lifetime tobacco use in

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2001 for 8th and 10th graders (prevalence rates of 36.6 and 52.8%, respectively). Eighth and 10th graders also reported a decreased prevalence of ever being drunk, whereas 12th graders’ rates were relatively constant over successive years. The 2001 prevalence rates of ever being drunk for 8th, 10th, and 12th graders were 23.4, 48.2, and 63.9 per cent, respectively. Lifetime and annual use, however, do not reflect regular users who are at significant risk for negative life consequences. Questions regarding monthly and daily use better identify these individuals. The monthly use rates of marijuana for 8th, 10th, and 12th graders in 2001 were 9.2, 19.8, and 22.4 per cent, respectively. Monthly use of hallucinogens remained steady in 2001 at 1.2, 2.1 and 3.2 per cent, respectively. Alcohol use is also prevalent. For 12th graders, 49.8 per cent of the seniors had consumed alcohol in the previous thirty days, as had 21.5 per cent of 8th graders and 39.0 per cent of 10th graders. Binge drinking was also prevalent in teenagers: 29.7 per cent of the seniors reported having five or more drinks in a row at some time in the previous two weeks. Approximately 25 per cent of the 10th graders and 13.2 per cent of the 8th graders reported the same behavior in the previous two weeks. With regard to daily use, 10th graders’ prevalence rates for marijuana increased significantly in 2001, although the prevalence of daily cigarette use decreased. There was also a significant decrease for 8th graders in prevalence of daily use of cigarettes. However, prevalence of daily use of alcohol increased among 12th graders, to 3.6 per cent. There has been an alarming increase in regular users of drugs. Over the past ten years, the statistics show significant increases in past thirty-day use for 8th graders with marijuana, hallucinogens, cocaine, crack, heroin, stimulants, tranquilizers, and alcohol. With 10th graders, there have been significant increases in monthly use of marijuana, hallucinogens, cocaine, crack, stimulants, tranquilizers, and cigarettes. Seniors experienced significant increases with marijuana, hallucinogens, cocaine, crack, heroin, stimulants, barbiturates, tranquilizers, and cigarettes.

DIAGNOSIS How can we best identify problem users in this atmosphere of high-prevalence use? The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) includes substance-specific diagnoses (i.e., intoxication, withdrawal, delirium, etc.) as well as the diagnoses of Substance Abuse and Substance Dependence, which have criteria consistent across all classes of substance. Substance Abuse, in general, results in a loss of behavioral control which results in a maladaptive pattern of use. Consequently, adverse consequences of use are

experienced, and the individual continues to use. The criteria for Substance Abuse are listed in Table 2.3-1. Substance Dependence (see Table 2.3-2) consists of continued use despite recurrent negative consequences, but adds both a behavioral and a physiological component. The individual exhibits compulsive drug-taking behaviors as illustrated by consumption in larger amounts or for longer periods than intended, investment of a great deal of time to obtain a substance, and the inability to cut back use. The physiological components

Table 2.3-1 Criteria for Substance Abuse (DSM-IV) The patient’s maladaptive substance use pattern causes clinically important distress or impairment as shown in a single 12-month period by one or more of the following: 1 Because of repeated use, the patient fails to carry out major obligations at work or at home. 2 The patient uses substances even when it is physically dangerous. 3 The patient repeatedly has legal problems from substance use. 4 Despite knowing that it has caused or worsened social or interpersonal problems, the patient continues to use the substance. In addition, for this class of substance, the patient has never fulfilled criteria for Substance Dependence.

Table 2.3-2 Criteria for Substance Dependence (DSM-IV) The patient’s maladaptive pattern of substance use leads to clinically important distress or impairment as shown in a single 12-month period by three or more of the following: 1 Tolerance, shown by either of: markedly increased intake of the substance is needed to achieve the same effect; or with continued use, the same amount of the substance has markedly less effect. 2 Withdrawal, shown by either of: the substance’s characteristic withdrawal syndrome; or the substance (or one closely related) is used to avoid or relieve withdrawal symptoms. 3 The amount or duration of use is often greater than intended. 4 The patient repeatedly tries without success to control or reduce substance use. 5 The patient spends much time using the substance, recovering from its effects or trying to obtain it. 6 The patient reduces or abandons important social, occupational or recreational activities because of substance use. 7 The patient continues to use the substance, despite knowing that it has probably caused physical or psychological problems.

• • • •

Alcohol and substance abuse among adolescents: prevention and intervention 103

of dependence are tolerance and withdrawal. Tolerance is the diminished effect of the same amount of substance which is experienced with continued use of the same substance. The individual will increase the amount of substance in order to achieve a desired effect. Withdrawal is a substance-specific syndrome that occurs with cessation of, or reduction in, heavy and prolonged substance use. Withdrawal involves both physiological and cognitive components. For example, nicotine withdrawal involves physiological aspects such as restlessness, decreased heart rate, and insomnia. Cognitive components include anxiety, difficulty concentrating, irritability, and frustration. DSM-IV criteria can be difficult in their application to adolescents. Much of adolescent use is episodic with weekend bingeing extremely common. Polysubstance use is also more prevalent in adolescents versus adults (Rounds-Bryant et al. 1999). These factors contribute to the relative absence of specific withdrawal syndromes in teenagers and to less pronounced tolerance symptoms. Teenagers often do not have adult-role responsibilities, and consequently, assessment of life-role impairment is more difficult. Adolescents are also more likely to be protected from adverse consequences of using because enabling social systems, such as family members or school officials, may ignore or rescue the teenager. Even with these restrictions, adolescent Substance Abuse and Dependence can be diagnosed. The assessment must frequently include all aspects of the adolescent’s life and collaboration from other sources (i.e., family, friends, school, and police records) to properly identify the diagnosis. There are helpful publications to assist with this endeavor (Department of Health and Human Services 1993, 1994).

PATHOGENESIS/ETIOLOGY An excellent review of etiological risk factors with implications for prevention and treatment has been prepared by Chatlos (1996), who conceptualizes a developmental framework consisting of three sets of factors occurring at separate points in time through the course of the illness. The first set describes predisposition, which includes genetic, constitutional, psychological, and sociocultural factors, and is considered antecedent to the development of substance abuse/dependence. Concomitants to the process of initiation and progression of drug use comprise the second set, such as the introduction to new substances and more frequent use patterns. Finally, enabling systems represent the social influences necessary for progression and maintenance of drug and alcohol use. Research has established genetic and familial vulnerabilities to addiction (Miller 1997; Miller et al. 1997), although they may be better termed and understood as liabilities to the development of the disorder (Dinwiddie

1997). The liabilities take into account the increase in prevalence of alcoholism among the general population over the course of this century that cannot be explained by genetic changes. The major portion of this increase in alcoholism is comprised of individuals with positive family histories. Thus, a liability for addiction in tandem with sociocultural changes may be postulated to result in an increased expression of the disorder. Adoption studies have revealed that sons of alcoholic fathers, whether raised by alcoholic biological parents or non-alcoholic adoptive parents, are three to four times more likely to develop alcoholism (Goodwin 1985; Cloninger 1988). Twin studies also support genetic influences with increased concordance rates between monozygotic versus dizygotic twin pairs (Hrubeck and Omenn 1981). An interesting finding in a recent study (Heath et al. 1999) compared male–female twin pairs. The concordance rates comparing male co-twins of affected females versus female co-twins of affected males suggested that females require a more extreme genetic liability for alcoholism (60% of male co-twins were affected and 15.1% of female co-twins were affected). There have been studies looking for differences in the biology of sons and other first-degree relatives of alcoholics compared to controls. These constitutional factors include physical, biochemical, physiologic, and neurodevelopmental characteristics. Research has revealed differences in the metabolism of alcohol (Vesell et al. 1971; Shuckit and Rayses 1979), as well as in effects of the alcohol (Shuckit 1994). Shuckit and Gold (1988) report correctly identifying 83 per cent of controls and 70 per cent of sons of alcoholics with the use of several markers. The heterogeneity of addiction limits the identification of biologic markers that are both sensitive and specific. Further research should investigate constitutional factors and the roles they play in the development of addiction. Many psychological and sociocultural factors place adolescents at risk for substance use. Unfortunately, most studies of these factors are correlational in design or have methodological flaws that reduce the generalizability of their findings. There are, however, some factors that have been repeatedly found to be associated with the development of drug and alcohol abuse. Kandel (1980) finds that parental norms are important in the prediction of alcohol misuse at most age levels, including the prediction of alcohol misuse at the earliest grade level. Dielman and colleagues (1990–1991) conclude from their review that early childhood exposure to deviant parental norms and behaviors with respect to drug and alcohol use increases the child’s tolerance of deviant behavior. This, in turn, leads to increased susceptibility to peer pressure and an attraction to peer groups in which there is increased exposure to deviant peer norms and behaviors. Risks for adolescent problem behaviors including alcohol and drug abuse are increased with poor parenting practices, high levels of conflict in the family, and a low degree of

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bonding between children and parents (Brook et al. 1990). Examples of parenting practices involved in the prediction of adolescent substance use include inconsistent parental discipline (Penning and Barnes 1982) and low parental educational aspirations for their children (Donovan and Jessor 1978). Family management techniques that are characterized by unclear expectations for behavior, poor monitoring of behavior, few and inconsistent rewards for positive behavior, and excessively severe and inconsistent punishment for unwanted behavior are associated with increased adolescent substance use (Hawkins et al. 1992). Peer involvement in adolescent drug use has also received considerable attention. The best predictors of adolescents’ use of substances are the proportion of friends who are users and the friends’ tolerance of use (Olds and Thombs 2001; Reifman et al. 1998). In addition, initial involvement in substance use is most strongly affected by peer influences (i.e., modeling, providing substances, and encouraging use) (Newcomb and Bentler 1989). Dielman and colleagues (1990–1991) have suggested, however, that the intrapersonal dimension of susceptibility to peer pressure is at least as important as peer use and peer norms. Adolescents who use substances tend to demonstrate low levels of conventionality. This has been measured in various ways, including attitudes about school, religion, and aggressive behaviors. Substance users, in general, have lower expectations of and are less committed to school. School performance is associated not only with substance use, but in students’ skills in refusing alcohol and other drugs when they are offered (Donohue et al. 1999; Kandel and Davies 1996). Prognostic factors for drug abuse in a longitudinal study involving fifteen-year-olds included truancy, placement in a special class, and early dropout from school (Holmberg 1985). Additionally, annual surveys have shown that drug use is significantly lower among students who plan to attend college than for those who do not plan to attend college (Johnston et al. 1985). Low religiosity in adolescents, usually measured by frequency of attendance of religious services, has been associated with increased risk of substance use (Donovan and Jessor 1978; Kandel 1982). Studies have reflected an alienation from the dominant values of society in adolescents who abuse substances (Penning and Barnes 1982; Kandel et al. 1999; Dobkin et al. 1998), supporting the low degree of conventiality in these individuals. Aggressiveness in boys during childhood has been found to predict antisocial behavior in adolescence, including drug use (Dobkin et al. 1996). Disruptive behaviors such as fighting were also related to substance use (Friedman et al. 1991; Dobkin et al. 1996) later in life in several other studies. Brook and colleagues (1996) concluded that childhood aggression is related to both young adult drug use and delinquency, and that drug use early in adolescence

has an impact on delinquency in early adolescence, late adolescence, and young adulthood. Most adolescents will experiment with licit or illicit substances, but the large majority will remain experimenters or casual users. Clinicians must evaluate teenagers with knowledge of risk factors that have been found to correlate with abuse of substances. Others (Johnson et al. 2000; Yamaguchi and Kandel 1984a,b; Kandel et al. 1992) have studied the progression of drug and alcohol use in adolescents. Their results support the ‘Gateway Theory,’ which suggests the period of major risk for initiation to alcohol and drugs has its onset between ages ten and fourteen years and is completed by the age of twenty-one years. The high-risk period for cigarettes, alcohol, and marijuana ends earlier (age twenty) than for cocaine and other illicit drugs (Kandel and Logan 1984). The general pattern was for alcohol use to precede marijuana use (Yamaguchi and Kandel 1984a). Interestingly, for women, either cigarettes or alcohol preceded marijuana use, establishing a more important role for cigarettes in their progression to illicit drugs. The use of marijuana appears necessary for progression to other illicit drugs (Yamaguchi and Kandel 1984b). The two most important predictors of progression are the age of initiation into use of a drug class and the extent of use of the drug (Kandel et al. 1992). Some 40 per cent of the men who initiated use of alcohol and/or cigarettes at age sixteen or older remained at that stage, whereas only 24 per cent remained at that stage if initiation was at age fourteen years or younger. The major implication toward prevention, therefore, is to prolong the age before initiation. The progression of drug and alcohol use into abuse and/or dependence in adolescence requires assistance from surrounding social systems. The adolescent is enabled by people and places that knowingly or unknowingly provide a structure for the adolescent that models, protects, or reinforces the use. There are many examples of such assistance including denial of use, removal of consequences, not providing information regarding harmful effects, and economic and social incentives. Physicians are not immune, and historically have failed to identify substance abuse problems in adolescents (Singer and Anglin 1986).

COMORBIDITY There has been an increasing awareness and interest in the importance of other psychiatric disorders coexisting with substance abuse. However, most of the studies have focused on adult populations. In a small study of adolescents in an inpatient setting, 85 per cent of substance abusers demonstrated psychiatric comorbidity (Hovens 1984). Relative to the comparative group of inpatient non-substance-abusing adolescents with conduct and/or

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oppositional–defiant disorders, substance abusers had a higher incidence of dysthymia, major depression, social phobia and other diagnoses. In a larger sample of dually diagnosed adolescent inpatients (Bukstein et al. 1992), 30.7 per cent had a comorbid diagnosis of major depression. When inclusive of other affective diagnoses, 51.3 per cent of the patient population received a comorbid diagnosis. In a community sample, Rohde and colleagues (1996) categorized adolescents by their alcohol use. Increased alcohol use was associated with depressive disorders, disruptive behavior disorders, drug use disorders, and daily tobacco use. More than 80 per cent of adolescents with alcohol abuse/dependence had another psychiatric diagnosis, with 45 per cent exhibiting both an internalizing and an externalizing disorder. Greenbaum et al. (1991) studied a population of severely emotionally disturbed adolescents treated in residential or day programs. Some 40 per cent of the teenagers had significant alcohol or marijuana abuse or dependency. With the high prevalence of comorbidity, a closer look at various diagnoses is indicated. One of the first studies to investigate the connection between Attention Deficit Hyperactive Disorder (ADHD) and substance abuse involved adults (Goodwin et al. 1975). Some 71 per cent of adult alcoholics had childhood ADHD. The increased prevalence of ADHD in the childhood of substance abusers has also been shown in subsequent studies. In an adolescent inpatient population (Hovens et al. 1994), 31 per cent of fifty-two substanceabusing teenagers were reported to have ADHD. An earlier inpatient study found approximately 25 per cent of substance-abusing youth had current ADHD (DeMilio 1989). An excellent review by Wilens and colleagues (1996) points out that the symptoms of one disorder may exacerbate the other, and that the comorbid combination has been associated with treatment resistance and poor outcome. Impulsivity, as part of ADHD, appears to be extremely problematic and presents a major obstacle in the treatment of substance abuse (Tarter and Edwards 1988). Substance abuse was one of the criteria of conduct disorder in the DSM-III, but the DSM-IV corrects this overlap. Despite the frequent co-occurrence of antisocial acts that are viewed as consequences to substance abuse, both disorders should be diagnosed if criteria are met. Conduct disorder has a high prevalence within the substance-abuse population. Individuals with substance use disorders are much more likely to have exhibited conduct disorder symptoms as children, when compared to non-substanceusing adults (Robins 1998). In addition, the total number of conduct symptoms was strongly associated with the probability of drug use. Two adolescent inpatient studies found 42 per cent (DeMilio 1989) and 70.5 per cent (Bukstein et al. 1992) of their substance-abusing teenagers met criteria for conduct disorder. An inpatient study (Grilo et al. 1995) comparing adolescents with substance

use disorders to non-substance use disorder patients found significantly higher rates of conduct disorder co-occurring with substance use (75.4% and 34.8%, respectively). Comorbid substance abuse or dependence and conduct disorder has historically described a population in which treatment has not been effective. Preliminary results in a study with multisystemic therapy (Pickrel and Henggeler 1996) are promising with regard to decreased substance abuse and serious criminal offending. There are also several outcomes concerning family and peer relations which show improvement. Depressive disorders have been consistently found in substance-abusing populations at elevated rates. In a community sample (Rohde et al. 1996), the rate of depression was three times greater in adolescents who used alcohol than in those who abstained. Hovens and colleagues (1994) found higher rates of dysthymia and major depression in substance abusers compared to non-substance abusers in an inpatient setting. In a larger inpatient study, Bukstein and colleagues (1992) diagnosed major depression in 30.7 per cent of their population of substance abusers. The number increased to 51.3 per cent when other affective disorders, including adjustment disorder with depressed mood, were included. In this study of 156 adolescents, secondary depression was much more common than primary depression (60.4% versus 16.7%, respectively). Interestingly, the secondary form did not differ in prediction of remission when compared to the primary form. That is, depressive symptoms did not decrease over the first three weeks of hospitalization in a manner to support clinical distinction of primary and secondary depression. The distinction of primary and secondary depression was also studied by Deykin and colleagues (1992) who looked at fifty-four adolescents in residential treatment who met criteria for major depression and alcohol or drug dependence. Depression occurred first in 35.2 per cent and occurred after the onset of substance dependence in 43.1 per cent of the sample. Both disorders had their onset concurrently in 21.6 per cent of the sample. The authors looked at variables that differentiated the temporal sequences. Primary depression occurred mostly in females, in individuals with mothers who had psychological problems and fathers with drug problems, and in adolescents with a history of abuse. Secondary depression occurred primarily in males, in individuals with history of academic difficulties, and in adolescents whose parents and/or siblings had problems with alcohol. Adult studies have suggested a higher relapse rate when comorbid depression is present (Marlatt and Gordon 1985), but there is a lack of data regarding long-term outcome in adolescents. Anxiety disorders in adults with substance use disorders have been shown to be more prevalent than in the general population (Skinstad and Swain 2001). Conversely, anxiety disorders double the risk of developing a substance use disorder (Himle and Hill 1991). In adolescent

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studies, anxiety disorders were significantly increased when substance use disorders were present whether the control group was community-based (Clark et al. 1995) (37% versus 10%) or conduct or oppositional–defiant disordered youth (Hovens et al. 1994) (33% versus 0%). Most common diagnoses were social phobia and PostTraumatic Stress Disorder (PTSD). In a pilot study by Stowell (1991), of 226 adolescents entering inpatient treatment for substance abuse, 43 per cent met criteria for an anxiety disorder. With the increased prevalence of anxiety disorders in this population, it is unfortunate that there are no data investigating the cause-and-effect relationship. The adolescent substance-abusing population experiences fewer withdrawal phenomena compared with adults, and the substance-induced anxiety symptoms generally mimic panic and generalized anxiety disorders. Consequently, the increase in social phobia and PTSD represents comorbidity which may have a unique relationship with adolescent substance abuse. A few prospective studies have been conducted with children which did not support a high rate of premorbid anxiety disorders regarding alcohol dependence (Hagnell and Tunvia 1974; Ensminger et al. 1983), but final conclusions cannot be drawn with the existing data.

TREATMENT Inpatient, residential, partial hospital/day and outpatient treatment make up the continuum of care for adolescent substance use disorders. The first step in the treatment process, which assists the clinician in placing the adolescent appropriately within the continuum of care, is a thorough evaluation, including a detailed history of substance use and substance use-associated experiences. Because of the adolescent’s resistance and defenses, collaboration from family, friends, school, and possibly the legal system is necessary to obtain an accurate clinical history. Substance abuse and dependence are accompanied by dysfunction and maladaptive behaviors in many areas of the adolescents’ lives. Instruments for the screening and assessment of adolescent substance abuse consist of groups of questions that evaluate these domains and attempt to assign a severity rating to the substance use. One such instrument, the Drug Use Inventory – Revised (DUSI-R©) (Tarter 1990), has ten domains. The first domain assesses drug and alcohol use, degree of involvement, and severity of the consequences of use. The other domains include behavior patterns (social isolation, anger, acting out, self-control), health status, psychiatric disorder, social competence (social interactions, social skills, refusal skills), family system, school performance, work adjustment, peer relationships, and leisure/recreation (quality of activities during leisure time). Other tools, such as the Teen Addiction Severity Index (TASI;

Kaminer et al. 1991), also include legal status among the domains. Both of these assessment instruments illustrate the need to evaluate all areas of the adolescent’s life for appropriate placement and effective treatment planning. Cohen (1996) emphasizes four developmental stages to the recovery process that help organize therapeutic strategies. Crisis control, the first stage, involves identification of the crisis, assessment of the presenting problems, interventions and contracting as the primary therapeutic strategies. Contracts are useful in determining severity of abuse as well as assisting the adolescent into treatment. Regarding the severity of use, an abstinence contract is frequently used to assess the adolescent’s ability to control his use. An individual treatment contract is a very powerful tool for recruiting the adolescent into treatment. In one study, adolescents completing substance abuse/dependence treatment rated a treatment contract as the most therapeutic intervention they had received (Kaminer et al. 1992). Their participation in setting specific and achievable goals is thought to enhance motivation and engagement of the adolescent, which ultimately results in favorable outcomes. The second stage of recovery is establishing stability and structure in the life of the adolescent and the family. Detoxification of the adolescent results in stabilization of his physical and, to a certain degree, his emotional status. Family agreements must be made pertaining to rules and responsibilities, expected behaviors and their consequences. The third stage occurs in a later period of treatment and includes the family and the adolescent learning to trust and rely on each other in managing life’s demands. Cohen terms this stage balance and consistency. Selfdifferentiation is an important goal of family interactions as the family handles emerging crises in safe and predictable ways. The final stage is attachment, which occurs when the teenager can relate to others in a fulfilling and respectful manner. The importance of a multi-disciplinary approach has been illustrated by the many considerations regarding risk factors, assessment domains, and system (family, school, legal) interventions (Jaffe 1990). Even the evaluation will often require a physician, psychologist, social worker, educational specialist, and/or others. Modalities of treatment within a program include individual treatment planning, individual therapy, group therapy, family therapy, pharmacotherapy, and drug toxicology screening (Nageotte and Amato 1997). Individual therapy is primarily cognitive–behavioral and supports the initiation and maintenance of abstinence. As treatment progresses and the abstinence period lengthens, individual therapy will most likely expand to include self-examination, identity issues, and dealing with the emergence of emotions (Brown 1985). Group therapies include self-help groups, drug education, social skills training, anger management, relapse prevention, and less-structured process groups. Group therapy is used for support, education,

Alcohol and substance abuse among adolescents: prevention and intervention 107

teaching new skills, facilitating appropriate expression of feelings, and developing interpersonal skills. Peer support and peer confrontation are extremely important in the group therapy process, and help to lessen the ‘threatening’ presence of an authority figure. Adventurebased therapy is a form of task-oriented group therapy that has great appeal to teenagers. Teenagers are exposed to challenging outdoor experiences and learn the importance of teamwork in problem solving. Individuals face self-imposed limitations during these tasks, and gain insight into issues regarding trust of self and others. Active involvement of the family is one of the most important elements in an adolescent’s treatment for substance abuse. Family therapy has as its objectives to change the enabling system, to increase communication, and to help the family address their own personal program for recovery (Smith and Margolis 1991). Emphasis is placed on unifying and strengthening the parental dyad in handling the adolescent’s behaviors and establishing a healthier family interactive style. Family abstinence is recommended to provide a role model to the adolescent and to convey that the adolescent’s addiction involves the whole family and not just the individual. In addition to individual family therapy, multiple family group therapy is utilized. Among the goals for multiple family therapy are educating the families to the role of the treatment program and the need to plan for relapse prevention, examining the families’ relationships for strengths and vulnerabilities that may affect treatment, helping families help one another to cope with the shame and helplessness associated with having a substance-abusing adolescent, planning and cooperating regarding treatment techniques for conflict resolution, and providing families with information about addiction, community resources, and self-help groups (Nageotte and Amato 1997).

PREVENTION Ideally, the prevalence of alcohol and other substance use among adolescents can be reduced, or progression to more problematic use and dependence can be prevented. Prevention efforts are generally focused on one of these two goals. Primary prevention focuses on reduction of risk factors, with the goal of preventing first use or regular misuse of substances. Secondary prevention is typically directed at adolescents who already use substances in an attempt to reduce the problems associated with substance use or to avoid substance dependence. Prevention programs have been implemented at several levels within the adolescent’s social sphere, most notably in family, school, community, and healthcare settings (Burt et al. 1998). Several risk factors for adolescent substance use involve parental modeling of substance use, poor parenting

skills, and lack of communication within families. Some prevention programs have targeted these early risk factors, including the Parent Communication Project (Shain et al. 1980) and Preparing for the Drug (Free) Years (Park et al. 2000). These are parent-training programs that teach listening and problem-solving skills, assist with establishment of family norms that are consistent with non-use, and reduce or eliminate substance-use modeling behavior by the parents or siblings. Although both of these programs demonstrated improvements in each of these areas in the short term, long-term evaluations on adolescent substance use were either non-significant or absent. Clearly, this promising area of prevention deserves more extensive evaluation. Interesting ethnic differences have been observed in adolescent substance use, with many findings related to familial variables. Barnes and colleagues (1994) found that Black adolescents were more likely to abstain from substance use and have lower rates of alcohol abuse than White adolescents, and that family religiosity accounted for a substantial amount of this difference. Parental drinking when the adolescents were young (twelve to thirteen years old) predicted alcohol use in later adolescence for both Black and White teens in another investigation (Windle et al. 1996), but other protective family variables were more common among Black parents than among White parents, including stronger norms against substance use, perceptions of use as more harmful, and less involvement of children in family substance use. School-based prevention programs are most common, probably because they allow for easy access to most adolescents because of compulsory school attendance regulations. These programs have undergone an evolution similar to that of school-based sexuality education programs (Shain et al. 1980), moving from informationonly interventions to more theory-based, active learning approaches. Several reviewers have suggested that this evaluation has resulted in more positive outcomes (Hawkins et al. 1992; Barnes et al. 1994; Peterson et al. 1994). The most successful programs have focused on skills training for adolescents that teach them resistance to peer influences that encourage substance use, and on changing adolescents’ normative beliefs about substances use, particularly the incorrect belief that ‘everyone is doing it’ (i.e., using drugs) (DiClemente et al. 1996). School-based assistance programs have also increased as a form of secondary prevention, focusing on ‘at-risk’ students who are identified by families, school officials, or the students themselves (Burt et al. 1998). Counseling, group programs, or other educational and treatment approaches have been evaluated as to their effectiveness in reducing substance use and/or dependence, but reviews of these approaches suggest that they are minimally effective (Botvin and Botvin 1992; Hansen 1992, 1993). Community involvement in itself may offer some protection from substance use, particularly involvement

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in organized youth groups such as YMCA/YWCA and Boys and Girls Club programs. However, primary prevention programs within the context of these groups have also been evaluated. The Stay SMART program in Boys and Girls Clubs (St. Pierre et al. 1992) demonstrated success in reducing thirteen-year-olds’ substance use and use-related attitudes. Other suggestions that are less well evaluated include increased opportunity for challenge and boredom relief through community-supported concerts or parties (O’Donnell et al. 1995), and community service activities (Klitzner et al. 1992; O’Donnell et al. 1995). On the legislative level, communities may also control adolescents’ access to substances, particularly substances that are legal for adults, such as tobacco and alcohol. Regulations regarding the sale of alcohol, the number of bars or sales outlets within the community, and other planning may reduce alcohol consumption (Gruenewald 1991; Saltz and Hennessey 1991). Training servers in restaurants and bars to refuse serving underage drinkers has been implemented in several communities, but this program has not demonstrated much effectiveness (Saltz and Hennessey 1991). However, increases in prices of alcohol do seem to influence alcohol consumption and reduce the negative sequelae of alcohol abuse (Chaloupka et al. 2002). Although the American Medical Association (1991) published guidelines for healthcare providers regarding preventive services, chart reviews suggest that pediatric and family-practice physicians rarely assess substance use and sexual risk-taking in their patients (Blum et al. 1996) although physicians in adolescent specialty clinics were somewhat more consistent. Middleman et al. (1995) found that residents were more likely to screen for substance use if they had completed an adolescentspecific rotation. These findings combine to suggest that many adolescents seen in healthcare settings are not being adequately assessed for their substance use. Critical opportunities for assessment, education, and intervention are therefore likely to be missed. The AMA (1991) suggests that annual preventive visits between the ages of eleven and twenty-one years should include guidance for both adolescents and parents, including methods that encourage reduced substance use, and parental monitoring. Substance use is a complex phenomenon, and as such will require complex preventive strategies. However, several approaches described above hold considerable promise. As in other areas of public health, prevention programs in this area are likely to be most effective when they combine several approaches (social normative, attitudinal, and familial changes), and when they incorporate proven theoretical models of substance use and abuse in specific populations. In addition, care should be taken to implement prevention approaches at all levels of substance use, from preventing first use in younger

adolescents to reducing substance-related problems and substance dependence among more regular users.

FUTURE DIRECTIONS An excellent summary of the past ten years of research has been produced by Weinburg and colleagues (1998). Risk factors need to be better delineated; this could occur with the addition of resiliency or aggravating factors specific to subpopulations. This would lead to more effective prevention programs and early identification of children at risk. Further research is needed to develop assessment instruments that result in indices which assist in appropriate placement in the continuum of treatment settings and individualization of treatment plans (treatment matching). This treatment matching must be linked to outcome studies that not only monitor drug and alcohol use, but also measure family functioning, school/work performance, other high-risk behaviors, and emotional well-being. Finally, the comorbidity of other psychiatric diagnoses (Axis I and Axis II) with substance use disorders must be understood more clearly with regard to epidemiology, effects on the course of illness, treatment strategies, and relapse prevention.

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Singer, M., Anglin, T. The identification of adolescent substance abuse by health care professionals. International Journal of Addiction 21: 247–254, 1986. Skinstad, A.H., Swain, A. Comorbidity in a clinical sample of substance abusers. American Journal of Drug and Alcohol Abuse 27: 45–64, 2001. Smith, H.E., Margolis, R.D. Adolescent inpatient and outpatient chemical dependence treatment: an overview. Psychiatric Annals 21: 105–108, 1991. St. Pierre, T.L., Kaltreider, D.L., Mark, M.M., Aikin, K.J. Drug prevention in a community setting: a longitudinal study of the relative effectiveness of a three-year primary prevention program in boys and girls clubs across the nation. American Journal of Community Psychology 20: 673–706, 1992. Stowell, R.J.A. Dual diagnosis issues. Psychiatric Annals 21: 98–104, 1991. Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2001 National Household Survey on Drug Abuse: Volume I. Summary of National Findings (Office of Applied Studies, NHSDA Series H-17, DHHS Publication No. SMA 02-3758), Rockville, MD, 2002. Tarter, R.E. Evaluation and treatment of adolescent substance abuse: a decision tree method. American Journal of Drug and Alcohol Abuse 16: 1–46, 1990. Tarter, R.E., Edwards, K. Psychological factors associated with the risk for alcoholism. Alcoholism Clinical and Experimental Research 12: 471–480, 1988. Vesell, E.S., Page, J.G., Passananti, G.T. Genetic and environmental factors affecting ethanol metabolism in man. Clinical Pharmacology and Therapeutics 12: 191, 1971. Weinburg, N.Z., Rahdert, E., Colliver, J.D., Glantz, M.D. Adolescent substance abuse: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37: 252–261, 1998. Wilens, T.E., Biederman, J., Spencer, T.J. Attention deficit hyperactivity disorder and the psychoactive substance use disorders. Child and Adolescent Psychiatric Clinics of North America 5: 73–91, 1996. Windle, M., Shope, J.T., Bukstein, O. Alcohol use. In DiClemente, R.J., Hansen, W., Ponton, L. (eds), Handbook of Adolescent Health Risk Behavior. New York, NY: Plenum, 1996, pp. 115–159. Yamaguchi, K., Kandel, D.B. Patterns of drug use from adolescence to young adulthood, II. Sequences of progression. American Journal of Public Health 74: 668–672, 1984. Yamaguchi, K., Kandel, D.B. Patterns of drug use from adolescence to young adulthood: III. Predictors of progression. American Journal of Public Health 74: 673–681, 1984.

2.4 Adolescent violence: implications for intervention ARLENE RUBIN STIFFMAN, JENNIFER A. ABELOFF, ESTER B. KAGGWA, DONALD E. MEISSNER, MICHAEL G. REGIER, AND CATHERINE A. WINN

INTRODUCTION Lamon, aged seventeen years, wanted to be a rap star. His idol was Tupac Shakur, the gangsta rapper with the violent lyrics who was gunned down in a drive-by shooting in Las Vegas in September. Lamon’s dream also ended in gunfire. Lamon was fatally shot during a fight between several students at a high school – the suspect (was) a fifteen-year-old freshman who, according to his mother, had been involved in several fights at the school and in his neighborhood. ‘My boy is bad, but not that bad,’ the suspect’s mother said. ‘He never shot nobody before.’ The youth’s father was shot to death at age 25 in March, 1984. (Bryan 1996; reprinted with permission of the St. Louis Post-Dispatch, ©, 1996.)

Adolescent violence is more than just an individual or a social problem. It is associated with an entire social and economic structure, as well as with a youth’s community and family environment, and mental health (Stiffman et al. 1999; Willams et al. 1998). This chapter summarizes the state of the art in the prevention and treatment of adolescent violent behavior. On the negative side, existing interventions are fragmented and unrelated to theory. They most often focus on punishment or removal of the violent individual from society. Treatment, when provided, usually focuses on a narrow behavioral approach that attempts to intervene only with the individual, focuses on hypothetical interim behaviors rather than violent behavior, and ignores the environment. On the positive side, there is increasing recognition of the inadequacies in past programs and the need for effective action. Recently, a spate of publications have

reviewed evaluations of violence interventions. Also, prompted by the dramatically increasing rates of adolescent violence, governmental and public health sectors have jointly called for mobilization and coordination of comprehensive efforts to develop new interventions (Rosenberg and Fenley 1991). At the same time, ethnic minority communities most afflicted by youth violence have recognized that communities must take responsibility for the behavior of their own youth and implement interventions within their own community (Urban League 1994).

LITERATURE REVIEW Violence, particularly among adolescents, constitutes a major public health concern in the United States (Koop and Lundberg 1992). Not only are adolescents increasingly the victims and perpetrators of violence, but shocking numbers of children and youth are exposed to the trauma of chronic, long-term violence in their families and communities (Lorion and Saltzman 1993; Osofsky et al. 1993; Snyder et al. 1996). Children and adolescents living in urban communities marked by poverty, crime, and drug-related activities witness significant numbers of homicides, assaults, robberies, and physical fights, and experience victimization themselves (Jenkins and Bell 1994; Fitzpatrick and Boldizar 1993; Gladstein et al. 1992; Hausman et al. 1994; Lorion and Saltzman 1993; Osofsky et al. 1993; Richters and Martinez 1993; Schubiner et al. 1993; Stiffman et al. 1996). Many are also exposed to the trauma of intra-familial violence (Groves et al. 1993; Osofsky et al. 1993; Richters and Martinez 1993), whose deleterious effects are well documented

Adolescent violence: implications for intervention 113

EPIDEMIOLOGY Data on epidemiological trends illuminate our understanding of adolescent violence. In this chapter, we focus on two sources of data: one from Morbidity and Mortality Weekly Reports (Centers for Disease Control 1996); the other from our own study of St Louis youths (Elze et al. 1999; Stiffman et al. 1997).

20 18 Rate per 100 000 population

(Council on Scientific Affairs 1993; Famularo et al. 1993; Kendall-Tackett et al. 1993; Kruttschnitt and Dornfeld 1993). Exposure to violence is associated with post-traumatic stress or anxiety symptoms (Burton et al. 1994; Fitzpatrick and Boldizar 1993; Jenkins and Bell 1994; Singer et al. 1995), as well as depressive symptoms (Fitzpatrick 1993; Singer et al. 1995). For AfricanAmerican adolescents living in or near public housing projects, family violence was associated with depression, hopelessness, and perceived less purpose in life (Durant et al. 1994). In addition, it appears that exposure is associated with desensitization to threats, increased risktaking (Garbarino et al. 1992), and either increased dependence or premature movement towards independence (Pynoos and Nader 1990). Most importantly, exposure to acute violent events is associated with both victimization and engagement in violent behaviors (Bell and Jenkins 1993; Durant et al. 1994; Jenkins and Bell 1994; Song et al. 1998). Despite the known association between trauma and youth problems, little is known about protective factors which may shield youths from the adverse effects of specific forms of violence exposure. The social contexts of adolescents’ lives, such as family, peers, school, and neighborhood, also affect their development and functioning (Crockett and Crouter 1995; Hurrelmann and Hamilton 1996; Jessor 1993). Ecological theories of human development (e.g., Bronfenbrenner 1980) and social work’s person-in-environment perspective (Germain 1991) focus on the interactions among multiple systems as key determinants of physical and mental health and social functioning. Research within the field of developmental psychopathology has examined the complex interplay between personal and environmental risk and protective factors in determining behavioral and mental health outcomes for children and adolescents (e.g., Garmezy 1985; Rutter 1990). A supportive family environment and other external support systems that strengthen coping efforts are among the factors that may protect highly stressed children from adverse outcomes (Garmezy 1991). Mental health professionals need to understand these related issues as well as the specific data, theories, risk factors, and interventions for adolescent violence.

15–24 Years 0–14, or GE 25 Years

16 14 12 10 8 6 4 2 0 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994

Figure 2.4-1 Firearm-related homicide rates, youth ages 15–24 versus all other age groups, United States 1985–1994 (Morbidity and Mortality Weekly Report 1996).

It can be seen from the data in Figure 2.4-1 that firearm-related homicides committed (per 100 000 population) by fifteen- to twenty-four-year-olds have tripled in number between 1985 and 1994, while numbers of homicides committed by other age groups have remained stable. Another startling fact is that homicide rates among fifteen- to twenty-four-year-olds in the United States are higher than the rates in any of the twentytwo developed countries that maintain such statistics (Prothrow-Stith 1991). National rates of homicide may be less useful to psychiatrists than the reported experiences of young people who are likely to seek the help of a provider. We therefore present results from a study concerning adolescents already in contact with helping professionals. This project, funded by the National Institute of Mental Health, interviewed approximately 800 youths from the city of St. Louis, Missouri, who had contact with public gateway service sectors: health, juvenile justice, child welfare, or education. In order to understand the relevance of this study, it is important to note that St. Louis, Missouri boasts the second-highest murder rate of any city in the United States, and has experienced a particularly large jump in adolescent homicides over the last decade (St. Louis Health Division 1993). Over 92.5 per cent of the youths reported at least one exposure to a violent event in the previous six months of their life. Three-quarters of the youths said that they had witnessed or heard neighborhood shootings, half had seen a killing or serious injury, and half had heard of neighborhood murders (Figure 2.4-2). Almost 40 per cent had had an acquaintance or friend beaten or killed, and one-quarter reported that they themselves had been attacked or beaten. The youths’ homes were also violent: over one-quarter reported physical fights in their home, more than one-fifth reported that a family member had

114 Risk behavior, risk-taking, and sexuality 80 70

72.6

Percentage

60 55.5

50

49.8

49.1

40 37.7

30 20

26 20.5

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Acquaint. beaten or killed

Neigh. shootings

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Used weapon

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Figure 2.4-2 Violence during the last six months.

been hurt or threatened with physical harm, and onefifth reported they had been hurt or threatened with physical violence in their home. These youths were not only exposed to high rates of violence, but over two-thirds reported engaging in at least one violent behavior in the previous six months. Half reported participating in a serious physical fight, and onethird reported having used a weapon. Almost one-quarter reported having been physically cruel to someone. Although there were no race, age, or socioeconomic status differences in the youths’ exposure to or participation in violence, males were exposed to approximately 50 per cent more violence than females, and averaged approximately twice as many violent behaviors as females. Exposure to violence was strongly and significantly associated with participating in violence (r ⫽ 0.54, P ⬍ 0.0001).

THEORIES OF VIOLENT BEHAVIOR Theories of violent behavior generally derive from theories of delinquency or deviance. These models include the concepts of social organization, opportunity structures, peer influences, and the influence of attitudes, norms, and values. Control theories assert ‘that delinquent acts result when an individual’s bond to society is weak or broken’ (Hirschi 1994, p. 250). The absence of conventional bonding to the family, school, or community systems may result in attachment to deviant peer systems (Jessor and Jessor 1977). To compensate for the lack of prosocial

bonds, economically deprived individuals and families may turn to violence and criminality as survival strategies (Liebow 1967). Similarly, social disorganization theory emphasizes the breakdown of community attachment or involvement, and of institutional, communitybased controls. Strain theory, the opportunity model, and culturaldeviance theory address the influence of societal values on deviant acts. Strain theory proposes that the inconsistencies between societal expectations of success and the available opportunities for success cause personal frustration and alienation, driving people to violent behavior (Merton 1968; Shelden et al. 1997). The opportunity model addresses linkage between limited opportunities and a toleration of violence (Fiala and LaFree 1988). Cultural-deviance theory asserts that delinquency is often the result of conformity to cultural values that may be in direct conflict with those of conventional society (Shelden et al. 1997). Social learning theory and social cognitive theory examine the individual’s internalization of deviant behavior from environmental exposure (Bandura 1986; 1978). This model proposes that criminal behavior is learned through association with others engaging in similar behaviors, and through direct experience with rewards and aversive events (Shelden et al. 1997). The theory of reasoned action examines the purpose and functionality of social behaviors (Ajzen and Fishbein 1980; Fishbein and Ajzen 1975). Predictors are threefold, including attitudes regarding violent behavior, societal pressure to perform violent acts, and intent to commit violent acts (Evans and Taylor 1995).

Adolescent violence: implications for intervention 115

Finally, the social development model integrates control theory with social learning theory in a developmental perspective, illustrating how adolescent violence may be a functional goal-oriented behavior related to the stage of adolescent development (Fagan and Wilkinson 1998). These factors develop and accumulate through a chain of events and experiences beginning as early as the prenatal period (Earls 1991; Shelden et al. 1997).

RISK FACTORS In order to reduce or prevent violence, one must be able to identify risk factors for violent behaviors. Risk factors include personal or environmental issues that are potential intervention targets. Although researchers have identified or speculated about a number of risks for violence, the difficulty lies in distinguishing the relative influence of biological, psychological, social, communal, and economic factors.

Individual factors Individual differences may be present from birth. Some view violent behavior as part of the instinctual nature of humans (DiLalla and Gottesman 1991). Others argue against inheritance, but still focus on a physiological contribution to violent behavior (Mednick et al. 1988). Violent youths have problems with attention, memory, and social–cognitive processing (Lochman and Dodge 1994; Calicchia et al. 1993). These problems may have their roots in hormonal or neurotransmitter problems (Lewis 1993), or may be related to environmental contaminants such as lead poisoning (Needleman et al. 1990). Several studies show an association between violence and other mental health problems, specifically depression, suicidal tendencies, and substance abuse (Ellickson et al. 1997; Grosz et al. 1994; Stiffman et al. 1996). In addition, young children who are alienated and rebellious are more likely to become violent adolescents (McWhirter et al. 1993). Beliefs or values concerning violence also play a key role. For instance, adolescents who believe that violence is an appropriate strategy for conflict resolution are more likely to engage in violent behavior (McWhirter et al. 1993).

Peer factors Violent youths are more likely to come from violent communities, associate with other violent youths, and belong to violent gangs (Earls 1991). Peers provide the motivation, rationalization, attitudes, opportunities and reinforcement for violent behavior. Violent peers may even punish prosocial behaviors (McWhirter et al. 1993).

Family factors Violent behavior may have its roots in early childhood through physical abuse, as well as observation of violence in families and in the community (Bailey 1996; Calicchia et al. 1993; Lewis 1993; Roper 1991; Salts et al, 1995; Stiffman et al. 1996). One study of convicted murderers found that two-thirds had experienced childhood brutality (Reiss and Roth 1994). Aggressive punishment styles (yelling, threatening, and spanking) and failure to establish clear behavior expectations are also associated with violence (Bandura 1978). Intervention studies support this association by showing that when parents adopt more positive, consistent, and less physical styles of discipline, their children’s antisocial behavior declines (McWhirter et al. 1993).

School factors The consistency with which violent youths have school problems suggests that school environment and student attitudes towards education are important risk factors. When school is valued and considered a viable option, violence is reduced (McWhirter et al. 1993). Time spent doing homework is inversely related to juvenile assault and robbery, and failure in elementary school is highly associated with increased violence (Friedman and Rosenbaum 1988). Further, since children who engage in antisocial behavior at school may be rejected by their more conforming peers, these children may join deviant groups in order to attain social support and acceptance (Bilchik 1995). Despite the association between violence and poor school performance, others assert that school problems and violence are both symptoms of deeper root problems (Earls 1991).

Community factors Aspects of the community or neighborhood may place a youth at risk (Saner and Ellickson 1996; Sommers and Baskin 1994). Community issues related to violence include the presence of gangs, underemployment, economic deprivation, the availability and use of illicit drugs, and access to lethal weapons (Cornwell 1994; Earls 1991). In the United States, violence is associated with minority status and low socioeconomic status. For example, minority communities have extraordinarily high rates of death or injury from violent behavior (Public Health Reports 1991), and studies show that black youths initiate violent behavior earlier than whites (Salts et al. 1995). Nevertheless, much of the racial variation in violent behavior may be due to community differences (Paschall et al. 1998). Differential homicide rates, particularly among young black males, may be due to ease of access to firearms (Cook et al. 1991). Increased levels of

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violence are also associated with community mobility, social disorganization, breakdowns of formal and informal social controls, and tolerant attitudes to drug abuse and violence (Land et al. 1990). In conclusion, despite our knowledge of risk factors, we still do not understand why, given similar risk factors, some youths never engage in violent behaviors, some engage in sporadic violent behaviors and then desist, and some develop criminal careers marked by continuing violence. We still do not understand the interaction between community and individual which contributes to violence (Earls 1991). Moreover, we do not know how to predict the level of dangerousness of a particular individual, although we know that a small percentage of active offenders commit most of the acts of violence (Earls 1991).

PREVENTION: EDUCATIONAL PROGRAMS Despite our knowledge about epidemiology and risk factors, the literature on violence prevention programs remains woefully underdeveloped. It consists largely of calls for action. Knowledge about violence prevention is fragmented, and few intervention attempts have been based on theoretical models or subjected to good outcome research (Cohen and Wilson-Brewer 1991; WilsonBrewer et al. 1991). Prevention focuses on reducing access to means for violence, controlling media, enhancing prosocial skills, intervening with peers and families, reducing risk factors, and intervening at multi-systemic community levels (Group for the Advancement of Psychiatry [GAP] 1999). Some resources for information on violence prevention are listed in Appendix 2.4-1.

Guns/firearms Preventive interventions to reduce the lethality of violence among youth have focused on firearm reduction by enforcing current laws and reducing the availability of firearms (Bilchik 1996). Data show that such measures are effective (GAP 1999). For instance, in Washington, DC, homicides due to firearms decreased by 25 per cent after the enactment of restrictive gun laws (Howell 1995).

Mass media Because research consistently demonstrates an association between exposure to violence in the media and increased violent behaviors (Bandura 1986), volunteer groups and legislators have called on the media to de-glamorize violence. For example, legislators met with executives in the entertainment industry, demanding more accurate portrayal of violence and its consequences (American Psychological Association 1996).

Life skills Life skills training teaches non-violent approaches, conflict resolution, anger management, and social skills to children and adolescents (see Wilson-Brewer et al. 1991). Such programs assume that violence is a learned behavior that can be changed and prevented (Belloni et al. 1991). Thus, these programs usually target youths from dysfunctional families or communities with high rates of violence (e.g., Hausman et al. 1995). They may address factors indirectly associated with violence, such as low academic achievement and drug use, and may include a combination of life skills training, mentoring, selfesteem development, peer tutoring, and violence prevention education (Boruch et al. 1991; Wilson-Brewer et al. 1991). These programs may begin as early as pre-school in order to prevent later aggressive behavior (Cahn et al. 1991). School-based life skill programs have one distinct advantage: because school attendance is mandatory, the programs can involve virtually all youths in a community. Unfortunately, data suggest that such interventions have limited behavioral success within the school setting (Lochman and Dodge 1994). No studies show that reducing aggressive behavior in primary school generalizes to later behavior in the community (Wilson-Brewer et al. 1991), and some studies suggest attempts at attitude change may cause a backlash (Hilton et al. 1998).

Peer Peer counseling and peer mediation are used to decrease violence, delinquency, and antisocial behaviors, because adolescents may listen to the advice of their peers more than to that of adults (Jaffe et al. 1992). Peer mediation programs offer support and conflict-management resolution from a trained peer mediator, who ‘helps the disputants examine the problem at hand, recommends changes and compromises, and helps develop a mutually agreed-on solution’ (Howell 1995, p. 77). Unfortunately, no conclusive data show that peer mediation or peer counseling programs are effective. In fact, like attempts at attitude change, peer counseling may even have negative effects on delinquency and associated risk factors, such as academic failure, rebelliousness, lack of commitment to school, and violent friends (Gottfredson 1987). In contrast to peer mediation or counseling, some youth-led violence prevention programs have been found effective (Howell 1995). In one project, juvenile corrections detainees created a video which documented personal experiences with violence, and made presentations on the effects of violence at local elementary schools. A Fort Worth, Texas, group planned summer evening activities such as basketball tournaments, game room activities, and dancing.

Adolescent violence: implications for intervention 117

Gangs embody the quintessential manifestation of peer impact on violent behavior. Six basic strategies are used to prevent violence by intervening with youth gangs:

• • • • • •

Neighborhood mobilization, with close coordination between schools, police, religious institutions, and youth agencies. Social interventions, such as youth outreach. Social and economic opportunities, through employment programs and legitimate, well-paying jobs. Gang suppression through incarceration, probation, or parole. Specialized police units for working with gangs (Howell 1998; Spergel et al. 1996). Early intervention in schools (since the peak period for gang recruitment falls between the 5th and 8th grades; Spergel et al. 1996), including having police officers or ex-gang members speak to students, as well as alternative social and recreational programs (Kadel and Follman 1993).

Family prevention Attempts to alter high-risk family systems are another common approach to the prevention of aggressive and violent behavior in adolescence (American Psychological Association 1993). Such programs generally target families during the early years of at-risk children’s lives. A few programs have helped parents reduce antisocial behavior of pre-adolescent children (Cahn et al. 1991), but the evaluations have several problems. Violent behavior is not measured and the sample does not include violent youths whose parents are not interested in, or capable of, participating. Parent training programs teach child and family management skills, and address both family conflict and early antisocial behavior (Howell 1995). However, such shortterm programs are least successful with the most highrisk families (e.g., those with multiple problems, including high conflict, unemployment, poverty, illness, and low stability) (Dumas 1989). Marital and family therapy approaches focus on changing the dysfunctional patterns of family interactions, addressing risk factors such as poor family management, family conflict, and early antisocial behavior (Szapocznik et al. 1989). These interventions demonstrate a significant reduction in children’s antisocial behavior (Hazelrigg et al. 1987) and possible long-term preventive effects on delinquency (Shadish 1992).

behavior contribute to violence when combined with a sense of powerlessness and lack of control (Belloni et al. 1991). Community prevention, therefore, focuses on decreasing cultural acceptance of violence, decreasing the social violence of racial and gender discrimination, and supporting more positive male role models (Rosenberg and Fenley 1991). Such methods always begin with recommendations for careful planning, forming partnerships, developing resources, involving all participants, setting goals, approaching problems from multiple directions, hiring qualified personnel, and evaluating programs (Belloni et al. 1991). Community interventions include resource enhancement such as mobilizing community members; developing school and recreational programs; and coordinating better financing for mental health, drug abuse, and social service programs (Cairns et al. 1991). They also include services such as role models, family interventions, neighborhood projects, education and job training (Greene 1993). Often they include criminal justice involvement through improving police images, and increasing police–resident interaction (Bilchik 1995). Unfortunately, while community approaches with an evaluation component have produced evidence of attitudinal changes, they have been unable to document changes in behavior or in neighborhood violence (WilsonBrewer et al. 1991). As we have discussed, violence is a manifestation of very complex economic, environmental, political, cultural, educational, and behavioral factors. Preventive interventions must echo that complexity through the coordination of services and foci of responses (Belloni et al. 1991). A multisystemic community approach to violence prevention should be based on a national plan for coordination and program development (Boruch et al. 1991), which would include public health, healthcare, mental health, criminal justice, social service, education, and the media (US Department of Health and Human Services 1990).

ISSUES IN TREATMENT Treatment for adolescent violence targets youths who are already involved in violent behavior (Cairns et al. 1991). Because we have addressed programs targeting at-risk youths and communities in the prevention section, the following discussion concentrates on adolescents who have already committed violent acts.

Psychopharmacological treatment Community intervention Community interventions are based on the presumption that resource inequity and high tolerance of violent

The literature on medications for aggressive and violent youths is woefully inadequate. Violent patients in hospital settings are often given medication for which there

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is no evidence of effectiveness, such as neuroleptics (Krakowski et al. 1993) or sodium valproate (Lindenmayer and Kotsaftis 2000). The literature speaks of controlling violence in adults by using medications for conditions comorbid to the aggressive and violent behavior. These include antipsychotics, lithium, antidepressants, sedatives, anxiolytics, anticonvulsants, opiate antagonists, betablockers, and clozapine (Bagby et al. 1999; Brayley et al. 1994; Corrigan et al. 1993; Wilson 1992). For youths, medications that focus on attention deficit disorder, impulsive, or hyperactive behaviors are known to have positive impact on social behaviors (Klein 1993; Klein and Slomkowski 1993), and thus may be prescribed for youths who exhibit violent behavior. These include stimulants such as methylphenidate (Hinshaw et al. 1989; Wilens and Biederman 1992), or dopamine receptor antagonists such as risperidone (Perry et al. 1997). Unfortunately, medications for violent behavior have neither been subjected to rigorous scientific testing nor approved by the Food and Drug Administration for individuals of any age.

Therapeutic approaches Treatments for violent youths derive from three different psychological perspectives: (i) psychodynamic/psychoanalytic; (ii) humanistic/non-directive; and (iii) behavioral/social learning. All three share the concept that violent behavior is due to a shortcoming within the individual. All assume that, if interventions target the deficiency, effective and healthy behavior will follow (Goldstein 1986). Some reviewers of evaluated interventions conclude that no approach has demonstrated clear superiority (Kazden 1987; Wilson-Brewer et al. 1991). Others argue that the results of repeated evaluation studies comparing the three different psychological approaches tend to support the effectiveness of behavioral or social learning approaches (Blakely and Davidson 1982; Mayer et al. 1986). Within the social learning approach, the techniques of conflict resolution, anger management, and skills training treat the individual as lacking skills rather than as needing therapy (Goldstein 1986). Results have shown that aggressive youths can learn a range of psychosocial skills, including interpersonal skills, aggression and anger management, and emotion control (Goldstein 1986). Although research supports the short-term effectiveness of such skills training, there appears to be difficulty transferring prosocial behaviors to the youth’s everyday environment, particularly if the environment is marked by frequent violence or abuse (Goldstein 1986). In contrast, studies have not demonstrated the effectiveness of behavioral interventions based on fear of punishment, such as ‘Scared Straight’ (Andrews et al. 1990). Our lack of knowledge about effective individual treatment for violence is compounded by the fact that

many treatment services target and evaluate intermediate behaviors rather than violent acts (Mayer et al. 1986). Thus, programs focus on substance abuse and gang-related activities (US Department of Health and Human Services 1990; Ostos 1991), or focus on mediating factors such as antisocial attitudes and peer associations, parental affection and monitoring, anticriminal role models, or prosocial skills (Andrews et al. 1990).

Criminal justice treatment Traditionally, violent youths were removed from society. Mainstream criminology has viewed clinical rehabilitative services as ineffective, and prefers the dominant and accepted method of punishment (Andrews et al. 1990). However, despite extensive use, the criminal justice approach has never been proven effective in reducing juvenile crime (e.g., Romig 1978). For example, a metaanalysis of twenty-one studies suggests that criminal sanctioning without rehabilitative services does not reduce recidivism (Andrews et al. 1990). However, when combined with psychologically and empirically based interventions, it has shown a 50 per cent reduction in recidivism (Andrews et al. 1990). Such services include more intensive treatment of higher risk cases, services targeted at reducing the offenders’ need to commit criminal behavior, and services tailored to the abilities and learning style of the offenders (e.g., Romig 1996).

Residential treatments Residential treatment, in contrast to punishment, provides youths with individual intervention while removing them from society. Unfortunately, because the behavior of violent youth may tax the resources of the staff and place other non-violent residents at risk, few programs are willing to accept them. Many such youths are shuffled from one program to another and finally end up in adult jails (Agee 1986). Diversion programs are popular because of the belief that crowded and poorly supervised juvenile facilities expose less-violent youths to more-violent youths. Within this approach, bootcamps (frequently used for adolescents convicted of their first felony) make time spent in an institution unpleasant, and enforce high discipline. Likewise, wilderness camping programs attempt to remove youths from their normal surroundings, and challenge them to cooperate for survival. For participants in such programs, recidivism rates show little improvement (GAP 1999).

Multi-systemic interventions Multi-systemic treatments (MST) combine cognitive intrapersonal strategies with family, peer, and school

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interventions. The approach involves collaborative work with the school, parents, teachers, and peers to reduce aggressive and violent behavior. Research shows behavioral improvements lasting up to one year (American Psychological Association 1993), effectiveness on both pre- and post-evaluations, and reduced recidivism at a four-year follow-up (Henggeler et al. 1997; Borduin 1999). A variant of MST, multi-systemic family preservation therapy (MFP), has demonstrated improvement in targeted violent behaviors, as well as in mothers’ psychological distress and family functioning (Scherer et al. 1994). In summary, treatment approaches to violence have the same major problems as prevention approaches. Typically, communities are not involved and services are both uncoordinated and underfunded (USDHHS 1990). For instance, although the government pays the total cost for the juvenile justice system, 52 per cent of preventive and treatment programs have had to rely on foundation funding, with only one-third funded by federal, state or local governments (Green 1991).

FORENSIC ISSUES Dealing with a violent patient or client always presents ethical concerns, which are magnified when the client is a minor. In this case, the therapist must weigh the confidentiality of the client versus the public good, and also the competency versus the legal culpability of the juvenile client. Neither of these situations is uniformly clear. Practices and statutes vary widely from state to state. For instance, in some states the parent or guardian is automatically privy to information that would, in an adult client, be confidential between the therapist and that client. The issue of therapists’ duty to protect client confidentiality versus public good has been debated in the court system since the 1976 case of Tarrasoff versus the University of California Board of Regents. In 1976, at the second hearing of the case, the California Supreme Court ruled that: ‘When a therapist determines, or pursuant to the standard of his profession should determine, that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger’ (Tarrasoff vs. Regents of University of California, p. 346). The Tarrasoff ruling and the ensuing lawsuits in different states have created five concerns: 1) the therapists’ duty to protect the intended victim, rather than to warn; 2) the ambiguity of whether the threat has to be specific to an identifiable target; 3) the difficulty of actually predicting dangerousness; 4) the implication that commitment might be used to protect during an era of increased difficulty in obtaining orders of commitment; and 5) a pattern of expanding therapist liability in many of the related state lawsuits (Beck 1985; Bednar et al. 1991).

CONCLUSION In this chapter, we have freely criticized existing programs. However, we recognize that it is easy to do so, and more difficult to say what should be done. Literature, research, and experience quite clearly point to the necessity of multi-faceted interventions targeting multiple risk factors. The authors would propose multi-directional interventions with some focusing on the personal level and some focusing on the environmental level.

Interventions on a personal level What are the most effective ways of treating violent behavior on the individual level? Clearly, many violent youths lack skills in problem solving and anger control. However, we know that these skills are trainable, particularly if implemented at a very early age. Therefore, pre-school or elementary-school social skills’ training would be an appropriate individual level treatment. Effective personal intervention would also involve changing youths’ future outlook through goal setting and/or job training. Many youths involved in violent behavior have no future goals, and cannot visualize themselves respectfully and gainfully employed. Therefore, changing the individual youth’s perception of his or her future, and preparation for that future would be helpful. Note that it is financially easier to influence the perception of one’s future than it is to influence actual opportunities. However, it is also possible to better prepare youths to take advantage of existing opportunities. Effective personal intervention would also include treatment for addiction. Violent behavior often revolves around the world of alcohol and drugs, which has the double problem of disinhibition for users and violence associated with illicit dealing.

Interventions on an environmental level Youths’ environments include families, school, peers, and neighborhoods. The acceptability and modeling of violent behavior must be reduced at every level. This is not easy, as issues of censorship, the profit-making motive of the media, societal welfare, and individual freedom must be balanced. Skills training, goalsetting, influencing perception, and efforts to develop self-esteem are all likely to fail unless intervention includes consideration of youths’ family environments. Many personal-level interventions are crippled by the problematic nature of violent youths’ families. For instance, youths may have an incarcerated parent, a drug-using parent, and/or an unstable and violence-filled home. Further, youths may lack adequate food and shelter, supervision, and schooling. Until parents are prevented

120 Risk behavior, risk-taking, and sexuality

from engaging in spousal abuse or violent forms of discipline, children will first be exposed to models of violent behavior in their own homes. Additionally, we must reduce access to weapons that, when handled by a violent or angry youth, are likely to kill rather than just injure. The difficulties are two-fold: political issues; and the cyclical nature of attack and defense. The National Rifle Association’s outcry that the constitution guarantees the right to bear arms must be balanced politically against the need to protect the population. We must break the cycle in which community violence leads youths to carry weapons to protect themselves, which, in turn, increases community violence. The youths’ environment must have increased positive opportunities for activities which will reduce the likelihood of violence, and decreased opportunities for violent behavior to flourish. Violence often ignites during idle moments when groups of youths are unsupervised. Programs trying to increase constructive idle time include midnight basketball leagues, and other clubs, sports activities, or choir activities sponsored by churches and community centers. Neighborhood environments can be enhanced through positive adult role models and desirable future opportunities. Many gender- and ethnic-specific mentor and rolemodel programs have already been instituted. These programs must also provide the educational, financial, and social support youths need to emulate the models. In many areas where violence rates are highest, the most common employment opportunities are through an underground illicit economy that allows the growth of gangs, turf wars, and violent behaviors. Real possibilities for gainful employment, and for adequate, effective, and appropriate education must be expanded. Finally, we must also stop community-sanctioned violence: police violence is accepted as a fact of life, school systems allow corporal punishment, and sports heroes become violent during games. Any societal acceptance of violence is likely to engender youths’ future involvement in violence. In conclusion, violence cannot be stopped by incarceration alone. A comprehensive program would teach youths and their families skills for problem solving and coping without resorting to violence, provide meaningful career opportunities, provide alternative diversionary activities, make all violent behavior unacceptable, and reduce access to lethal weapons. If we do that, then our adolescents will not have to, want to, or be able to resort to violence.

ACKNOWLEDGMENTS These research studies were supported by the Center for Mental Health Services Research at the George Warren

Brown School of Social Work, Washington University, NIMH Grant #5R24MH50857.

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APPENDIX: RESOURCES FOR VIOLENCE PREVENTION Center for the Study and Prevention of Violence Institute of Behavioral Sciences,

University of Colorado at Boulder, Campus Box 442 Boulder, Colorado 80309-0442 Tel: (303) 492-8465 Fax: (303) 443-3297 Web site: www.colorado.edu/cspv/ Center to Prevent Handgun Violence (CPHV) 1225 Eye Street, NW, Suite 1100, Washington, DC 20005 Tel: (202) 898-0792 Fax: (202) 371-9615 Web site: www.handguncontrol.org/ Children at Risk Program (five cities: Austin, Texas; Bridgeport, Connecticut; Memphis, Tennessee; Savannah, Georgia; Seattle, Washington) Center on Addiction and Substance Abuse (CASA) Columbia University, 633 Third Ave., 19th Floor, New York, NY 10017-6706 Tel: (212) 841-5200 Fax: (212) 956-8020 Web site: www.casacolumbia.org/ National Crime Prevention Council 1000 Connecticut Ave., NW, 13th Floor, Washington, DC 20036 ATTN: Youth Division Tel: (202) 466-6272 Fax: (202) 296-1356 Web site: www.ncpc.org/ National Crime Prevention Council and Street Law, Inc. 1600 K St., NW, Ste. 602, Washington, DC 20006 Tel: (202) 293-0088 Fax: (202) 293-0089 Web site: www.nationaltcc.org National Urban League, Inc. Stop the Violence Clearinghouse, 500 East 62nd Street, New York, NY 10021 Tel: (212) 310-9000 Web site: www.nul.org The Comprehensive Strategy for Serious, Violent, and Chronic Juvenile Offenders Office of Juvenile Justice and Delinquency Prevention (OJJDP) 810 7th St., NW, Washington, DC 20531 Tel: (202) 307-5911 Fax: (202) 307-2093

2.5 The effects of sexual abuse on adolescent development and adaptation GRAEME HANSON

INTRODUCTION During the past twenty years we have seen a significant increase in awareness of the extent of sexual abuse of children. With this awareness there has been a concomitant expansion of research into the prevalence, epidemiology, sequelae, and treatment approaches for children and adolescents who have been sexually abused (Finkelhor 1984; McLeer et al. 1998). In addition to the physical and psychological trauma at the time of the violation, sexually abusive experiences can have a profound effect on the psychological development of children and adolescents; such experiences can affect children’s sense of self and self-esteem, their maturing sexuality, and ability to develop intimate relationships. If the abuse has been incestuous, the child’s view of the family and how families function will also be distorted. This chapter presents a summary of the effects of abuse in early childhood on the psychological functioning of children confronting the complex developmental issues of adolescence; the problems of children who are abused during their adolescence will also be explored.

DEFINITION Reaching a consensus on the definition of sexual abuse presents a problem in itself. There are legal definitions and there are definitions based on the developmental stage of the child and the ensuing psychological consequences. The definition used in this chapter is a combination of two other writers’ definitions; the first is that of Green (1996), who notes, ‘Child sexual abuse may be defined as the use of a child under 18 years of age as an object of gratification for adult sexual needs and desires.

Incest refers to the sexual exploitation of a child by a family member. The legal definition of incest is cohabitation between persons related to a degree where marriage would be prohibited by law. Sexual abuse ranges in intensity from exhibitionism and gentle fondling to forcible rape resulting in physical injury.’ One would add to this definition the use of a child in pornography. The second writer is Sgroi (1982), who defines sexual abuse as ‘a sexual act imposed on a child who lacks emotional, maturational, and cognitive development … .Authority and power enable the perpetrator, implicitly or directly, to coerce the child into sexual compliance.’ By combining the two definitions, many of the descriptive, legal, developmental and psychological issues involved in the sexual molestation of children are addressed, albeit in a rather summary fashion.

EPIDEMIOLOGY Although prevalence studies are fraught with difficulties (e.g., relying on memory of adults, little corroborating information, serious limitations in obtaining information from children), a number of excellent studies have found that between 25 and 35 per cent of girls, and between 8 and 15 per cent of boys (a more difficult group to study), are sexually abused before age eight years (Browne and Finkelhor 1986; Finkelhor 1987; Garnefski and Diekstra 1997; Green 1996; Russell 1983). Taking into account the physical and emotional trauma that we know results from sexual abuse, this presents a significant public health problem (Massie and Johnson 1989; Nelson et al. 1994). Other than the fact that 90 per cent of perpetrators are male, the total spectrum of sexual abuse is extremely varied and therefore complicates our attempts to study its effects. The abuse can be ongoing or a one-time event,

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each scenario presenting its own unique conditions. It most often occurs in contexts in which it is inextricable from other manifestations of social and familial difficulty or dysfunction. This is especially true in incestual abuse, where family dysfunction, for example parental discord, alcoholism/drug abuse, and reversal of the usual parent–child roles, is very common. It is impossible to evaluate the effect of this type of abuse independent of the familial and social/cultural context. Incest is rarely a one-time experience: it is usually ongoing, with an average age of onset at around eight years. In a study conducted by Diana Russell (1983), stepfathers were more likely to abuse than biologic fathers. Uncles, brothers, and grandfathers were also frequently named as the perpetrators. Literature on the subject is often presented according to whether the abuse was intra- or extra-familial. It is important to note, however, that in approximately 85 per cent of the cases of extra-familial abuse, the perpetrator is well known to the child and often is in a position of trust.

SEXUAL ABUSE IN CHILDHOOD The psychological reactions to being sexually abused vary a great deal from child to child, depending on a number of factors:

• • • • • • •

the developmental level of the child; the nature of the relationship to the perpetrator; the frequency of the abuse; whether force was used; when and whether the abuse was revealed to caretakers or reported to authorities; whether there were legal proceedings; and whether treatment was provided.

There are distinguishing features between the abuse of younger children and the abuse of adolescents, particularly girls. With younger children, physical force is rarely used. The child is most frequently seduced, coerced, or threatened into some kind of sexual activity with the perpetrator. In adolescence the abuse takes a form more consistent with that of rape of an adult, where physical force is frequently used. For the child, one of the most destructive aspects of the coercive sexual abuse is the use of threats by the perpetrator, either to harm the child or to harm the family if the child reveals what has occurred. These frightening threats combined with the need to keep a secret produces one of the more profoundly disturbing psychological sequelae of sexual abuse. Especially in the case of incest, the pre-adolescent child makes an accommodation to the situation through a number of psychological mechanisms (Summit 1983), including secrecy, the use of certain defenses such as dissociation, passive acceptance

of the situation, and faltering attempts at disclosure. Frequently in early adolescence, aided by an increasing wish – and indeed capacity – to develop autonomy, victims will begin either to protest the abuse or to pursue self-destructive mechanisms such as running away or making suicide attempts as a way to end it. Another aspect of sexual abuse which results in psychological damage to the child, particularly in cases of incest, is denial on the part of adults that the abuse could be happening. It is not uncommon when a child reveals the abuse in a halting and unclear fashion that a parent will deny the reality of the situation, adding difficulties to the child’s attempts to deal with the abuse.

Crisis of disclosure In addition to the destructive psychological forces affecting the child at the time of the abuse, a major psychological upheaval is produced by the disclosure, even though the disclosure may come months or years after the abuse has taken place. I term this ‘the crisis of disclosure.’ It is a crisis for both the child and the family in that it usually involves reports to child-abuse authorities and investigation by the police. It is not uncommon for a child to have been relatively asymptomatic until disclosure is made, at which time he or she becomes markedly symptomatic. Negative responses of adults to disclosure have a harmful effect on the child. I have already alluded to the unfortunately common reaction of denial on the part of adults; other unfortunate reactions may include:

• • •

expressing anger at the child for revealing the abuse; accusing the child of being to blame; and demonstrating the belief that the child is now damaged goods and is ruined for life.

A daughter’s revelation of having been abused may reactivate memories of the mother’s own abuse which had been forgotten for many years. Such a mother must suddenly deal with a double psychological trauma, that of her daughter and the reawakening of memories of her own abuse. When a boy reveals that he has been sexually abused not uncommonly his parents worry that this event will somehow result in his becoming homosexual; the implications of that worry can have a profound effect both on the parent–child relationship and on the parents’ expectations for the boy (see case example #1).

Long-term effects Researchers have identified an extensive array of long-term effects of sexual abuse of children. No specific constellations of behaviors have been found to be pathognomonic of sexual abuse, although several clinical conditions, such as heightened aggression (especially with boys), depression, low self-esteem, feelings of guilt, and problems in

The effects of sexual abuse on adolescent development and adaptation 127

trust tend to be common (Browne and Finkelhor 1986; Finkelhor 1987; Green 1996; Tebutt et al. 1997; Shapiro and Dominiak 1990). Many children have symptoms consistent with post-traumatic stress disorder (PTSD), diagnosable by DSM-IV criteria. Many younger victims manifest hypersexual or sexually aggressive behaviors, particularly towards other children, or prostitution (Silbert and Pines 1981). Sexual abuse in childhood has also been identified as one of the risk factors in the development of borderline conditions in childhood and adolescence or of borderline personality disorder in adults (Guzder et al. 1999; Paris 1994).

Effects on adolescent development The entry into adolescence is a psychologically complex period; new and powerful sexual feelings become intimately involved in the formation of an identity as a sexually and reproductively mature individual with the capacity to develop a romantic relationship which will eventually include sexual intimacy. Young adolescents experience anxiety about sexual functioning at a concrete, physical level; for example, they may have concerns over adequacy of their genital apparatus and their physical and sexual attractiveness. Concomitantly they are struggling to establish their individual morality and ethics of sexual conduct as well as attempting to find the boundaries of sexual fantasy and behavior. In other words, they are defining for themselves what is personally acceptable as distinct from what society finds acceptable. All of these events and endeavors contribute to making early adolescence an exciting yet conflicted and anxiety-filled time for young people in relation to their sexuality. The entry into adolescence may reactivate memories of an earlier abuse, especially if the abuser was a young teenager. For example, a boy had been seduced and molested at age eight by a fifteen-year-old male, a friend of the family. The older male pressured the boy to come to his house after school and would have anal intercourse with him. The younger boy developed symptoms of school avoidance and anxiety, and eventually was referred for treatment. The sexual abuse continued to haunt him and when he turned fourteen he found himself having the impulse to molest seven- and eight-year-old boys. Luckily this young man was in treatment and was able to work through those feelings rather than act on them. Some adolescents abused as children are at high risk to develop similarly delayed acting-out symptomatology. Children with a history of sexual abuse, then, enter adolescence with increased vulnerability to a variety of difficulties. As Green has noted (1996), “In essence, there appear to be two contrasting adaptive styles in sexually abused persons: one seeking mastery through active

repetition of the trauma, and the other coping by avoidance of sexual stimuli.” Many children with a history of sexual abuse bring with them into adolescence symptoms that are commonly demonstrated in younger latencyaged children, such as poor self-image, the so-called ‘damaged-goods syndrome’ (Sgroi 1982), depression, and suicidal behavior (Brand et al. 1996). MacVicar (1979) observed that sexually abused adolescents are vulnerable to depression. Anderson (1981) reported case histories of adolescent girls who attempted suicide following the disclosure of incest, and Sansonnet-Hayden et al. (1987) reported a 71 per cent incidence of major depression in sexually abused adolescents who had been admitted to a psychiatric hospital. In the latter study, the sexually abused adolescents had a much higher incidence of suicide attempts than their non-abused hospital peers. Friederich et al. (1986) reported that 46 per cent of a sample of sixty-one sexually abused girls had significantly elevated scores on internalizing disorders. Poor school performance has frequently been found to be associated with sexual abuse in childhood. Certainly the young teenager who is being molested on an ongoing basis would be at high risk for poor school performance. Researchers have also seen a correlation between histories of sexual abuse and the development of eating disorders. Oppenheimer et al. (1985) found that two-thirds of a sample of patients with eating disorders reported a history of sexual abuse. Sloan and Leighnor (1986) documented a history of sexual abuse in five out of six inpatients on an eating-disorders unit. An association between drug and alcohol abuse and history of sexual abuse has also been found. Disturbances in sexual behavior early in adolescence can be specifically linked to sexual trauma. In James and Meyerding’s retrospective study of adult female prostitutes (1977), it was found that 36 per cent were incest survivors. A study by Runtz and Briere (1986) showed that adult women who had histories of sexual abuse before age fifteen years were significantly more likely than those not abused to have engaged in adolescent behaviors that were considered delinquent or acting-out; specifically, those in the abused group were more likely to have had such difficulties as skipping school, avoiding sports, doing poorly, having conflicts with authority, developing anorexia-like behaviors, and having an early awareness of their own sexuality, including being overtly sexual in their attire, and having homosexual contacts.

CASE EXAMPLES Case 1 The thirteen-year-old only son of recently immigrated parents from Central Europe was attacked on his way

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home from school after swimming one night, dragged behind an empty building, and anally raped by an adult. He went home and the parents called the police. The boy was brought into the Child and Adolescent Sexual Abuse Resource Center at San Francisco General Hospital, where he was evaluated and treated prophylactically with penicillin. He and his parents were encouraged to come back for follow-up counseling. They refused the counseling. A few days later the father appeared in the clinic with the boy, claiming that he felt the boy had not been given enough penicillin. The father had had some medical training in his country of origin. After much discussion with the father and attempts to placate him, the chief resident decided to give the boy additional penicillin, hoping this would settle the father’s concerns. About a week later the father returned with the boy still worried that his son had not had enough medication. At this point, the child psychiatrist was called in to evaluate the situation and the following scenario unfolded: the father first complained bitterly about the care that his son had received at the clinic, and that these kinds of things (the rape) would never have happened in his country of origin. He went on to say that this was his only son and how close he had been to him. He had been worried about his son because he, the son, was not very athletic, was too interested in reading and in the arts, and was probably too close to his mother. As the discussion continued it became clear that the father had had long-standing concerns about the boy’s masculinity. Following the boy’s rape by an older man the father was even more concerned about the boy’s sexuality. The father also acknowledged that since the rape he felt his son had somehow been sullied, and that he now found it difficult to touch or embrace his son even though they formerly had a fairly close physical relationship. The boy was dismayed at his father’s pulling away from him and was even more troubled by his mother’s grief over what had happened to her son. He said, ‘I could get over this, but every day I come home to my mother’s sad face.’ This was a very painful example of how the parents’ fantasies and resulting reactions to the child’s sexual abuse can be a serious impediment to the child’s recovery process.

Case 2 A fourteen-year-old girl from a Central American country was brought in, having been raped by a stranger. She came from a large extended family, most of whom arrived with her in the emergency room. The medical and counseling staff were concerned at the family’s (particularly the older brother’s) rather open discussion about how now that this girl had been raped she was no longer a virgin and therefore would not be able to attract a very desirable husband. Her mother and sisters felt sorry for her, but in their response conveyed that she was

indeed now less desirable. She was seen as damaged goods, and this view of her was unfortunately readily accepted by the extended family.

Case 3 A girl who used a specific defensive maneuver, dissociation, in order to protect herself while being abused by her stepfather reported to our clinic at age eighteen years with a concern that she was having difficulty when she and her boyfriend, with whom she was quite close, tried to develop a sexual relationship. She gave the following history. From age ten to about fifteen years she had been regularly molested with vaginal intercourse by her stepfather. During these molestations she described classic dissociative states where her mind would ‘leave’ her body and ‘go up on the ceiling and be as if watching the event from afar’; she would feel totally disconnected from any sensations in her body. She finally broke off the relationship and eventually fell in love with a peer. As they began to develop a sexual relationship, she found that the same dissociative states would occur whenever they tried to be sexual. This caused her a great deal of distress in the relationship. Another case is an example of how a developmental process may have a significant role in the evolution of symptoms. A boy aged eleven years, who was an only child and living with somewhat distant and emotionally isolated parents, developed a friendship with a neighbor, a man in his early thirties, who became a kind of ‘big brother’ for the boy. About a year-and-a-half after their friendship had become closer, the neighbor began to take the boy on outings and even for weekend trips to Disneyland, and so forth. Eventually, the neighbor seduced the boy into a sexual relationship. The boy did not protest; in fact, he found the relationship in some ways enjoyable, although he was conflicted about it. He broke off the relationship when he was aged sixteen, feeling that he was no longer comfortable in it. Over the following year he became increasingly depressed and began to wonder whether he might be gay. He was uncomfortable trying to date girls because he felt he was somehow different. He was not at all symptomatic in late latency when the sexual relationship began. When he reached mid-adolescence and the developmentally appropriate interest in forming heterosexual relationships became manifest, he developed internal conflicts regarding his relationship with this man and subsequently became symptomatic. This is an example of how the process of development can determine when symptomatology may become manifest.

Other cases Other examples include those not uncommon cases of adolescent girls who present, having been raped in the

The effects of sexual abuse on adolescent development and adaptation 129

context of some forbidden activity: for instance, girls who had been in a place where they should not have been or had been with peers who were taking illicit drugs, or in a variety of other situations that were forbidden and which put them at risk. The awareness that they had been doing something against parental wishes at the time they were raped complicated their responses to the trauma.

homosexual orientation later (Gundlach 1997). Other studies, however (Finkelhor 1987), show no correlation between sexual abuse in childhood and the development of sexual orientation.

PSYCHOPATHOLOGY

Sexual abuse during adolescence generally falls into two major categories: abuse that takes the form of rape similar to that of adults, including date-rape; and abuse which is a carryover into adolescence of ongoing incestuous activity or activity with an older perpetrator who is in a close relationship with the child. Interventions would of course differ in these two categories. When the abuse is accompanied by physical trauma, immediate medical attention is necessary to address what physical damage the victim may have incurred, and possible infection with a sexually transmitted disease. This would be accompanied by crisis intervention and counseling, with follow-up counseling to address the immediate psychological problems resulting from the trauma. It is not uncommon for girls who are in an incestuous relationship to break off that relationship in early adolescence. Sometimes the girl will resort to running away or making a suicide attempt. In these situations, again, attention needs to be paid first to the possibility of physical damage or sexually transmitted diseases, followed as soon as possible by intervention to deal with the behavior itself, as well as the trauma of the family dysfunction, the disruption of the long-standing relationship, and the complex, often negative response of the family. In these instances, the child may benefit from family therapy as well as individual therapy, depending on the family’s ability to be supportive to the child. In both the rape and incest situations, some programs have found that with adolescents, a group therapy approach has been particularly helpful in reducing the sense of isolation. In this way the child sees that she is not alone and can share her experience with peers.

Most researchers (Browne and Finkelhor 1986; Finkelhor 1987; Garnefski and Diekstra 1997; Green 1996) agree that there is no particular constellation of symptoms that are unique or invariably linked to sexual abuse in children and adolescents. Some common symptom areas associated with sexual abuse are: 1) depression; 2) suicidal behaviors; 3) problems in sexual functioning, including promiscuity and predator-like behavior; 4) eating disorders; 5) multiple-personality disorders; and 6) acting-out/ risk-taking behaviors. A recent study of a non-clinical sample of sexually abused children, of ages six to sixteen years, revealed a high rate of PTSD symptoms immediately following the abuse (McLeer et al. 1999). Several studies (Brown et al. 1997; Luster and Small 1997; Garnefski and Diekstra 1997; Rosenfeld and Lewis 1993; Runtz and Briere 1986) have found a significant increase in risk-taking behaviors in adolescents who have a history of sexual abuse. Such behaviors include increased drug use, promiscuity, unprotected sexual activity with a risk for HIV infection, and runaway behavior. Gershenson et al. (1985) indicated a very high incidence of coercive sexual behavior in unwanted teenage pregnancies, while Stock et al. (1997) found a significant correlation between teenage pregnancy and history of sexual abuse.

MALE–FEMALE DIFFERENCES Most in-depth studies of the effects of sexual abuse have been conducted on the female population, but in the past few years the number of studies of male victims has increased (Watkins and Bentovim 1992). Recent comparisons of male and female reactions to sexual abuse reveal that both have very similar responses, with boys showing slightly more externalizing behaviors. A recent study from the Netherlands (Garnefski and Diekstra 1997) revealed that the abused boys in their sample were significantly more suicidal than non-abused counterparts. With males, since in the majority of cases the abuse is by a same-sex perpetrator, issues of homosexuality and homophobia are more pronounced than in girls. Few studies have indicated that there may be an association between being homosexually abused and exhibiting a

INTERVENTIONS

PREVENTION Efforts towards prevention of sexual abuse have been mainly in the form of education: 1 Education of the public at large about the ubiquity of sexual abuse and the forms that it takes. 2 Education of children and adolescents to enable them to recognize potentially dangerous situations, and to give them tools to resist seduction or attempted rape. A number of children who are sexually abused develop sexual acting-out and predator-like behaviors toward other children; early identification and treatment of children

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who have been sexually abused is also a preventive measure. It is hoped that early recognition and treatment would help minimize the subsequent development in the victim of sexually abusive behavior.

SUMMARY When children who have been sexually abused enter adolescence, they bring with them a host of psychosocial problems and vulnerabilities that may significantly interfere with their ability to adapt successfully to the complexities of adolescent development. Epidemiological studies indicate that between 15 and 35 per cent of children are sexually abused before age eighteen years; therefore a significant percentage of adolescents are at risk for psychiatric problems in adolescence and will need treatment. In addition, some children will be sexually abused for the first time in adolescence (the epidemiology of this trauma is not well established). They too require urgent and appropriate treatment to mitigate the negative effects on their attempts to adapt to the demands of adolescent development. Sexually abused adolescents engage in a wide variety of risk-taking behaviors. This, along with the psychological suffering many of these children endure, constitutes a significant public health problem.

REFERENCES Anderson, L. Notes on the linkage between the sexually abused child and the suicidal adolescent. Journal of Adolescence 4: 157–162, 1981. Brand, E.F., King, C.A., Olson, E., et al. Depressed adolescents with a history of sexual abuse: diagnostic co-morbidity and suicidality. Journal of the American Academy of Child and Adolescent Psychiatry 35: 34–41, 1996. Brown, K.K., Kesel, S.M., Lourie, K.J., et al. Influence of sexual abuse on HIV-related attitudes and behaviors in adolescent psychiatric inpatients. Journal of the American Academy of Child and Adolescent Psychiatry 36: 316–322, 1997. Browne, A., Finkelhor, D. Impact of child sexual abuse: a review of the research. Psychological Bulletin 99: 66–77, 1986. Finkelhor, D. Child Sexual Abuse: New Theory and Research. New York: Free Press, 1984. Finkelhor, D. The sexual abuse of children. Psychiatric Annals 17: 233–241, 1987. Friedrich, W.N., Urquiza, A.J., Beilke, R. Behavioral problems in sexually abused young children. Journal of Pediatric Psychology 11: 47–57, 1986.

Garnefski, N., Diekstra, R. Child sexual abuse and emotional and behavioral problems in adolescence: gender differences. Journal of the American Academy of Child and Adolescent Psychiatry 36: 323–329, 1997. Gershenson, H.P., Musick, J.S., Ruch-Ross, H.S., et al. The prevalence of coercive sexual experience among teenage mothers. Journal of Interpersonal Violence 4: 204–219, 1985. Green, A.H. Overviews of child sexual abuse. In Kaplan, S.J. (ed.), Family Violence: A Clinical and Legal Guide. Washington, DC: American Psychiatric Press, 1996, pp. 73–104. Gundlach, R. Sexual molestation and rape reported by homosexual and heterosexual women. Journal of Homosexuality 2: 367–384, 1977. Guzder, J., Paris, J., Zekowitz, P., et al. Psychological risk factors for borderline pathology in school-age children. Journal of the American Academy of Child and Adolescent Psychiatry 38: 206–212, 1999. James, J., Meyerding, J. Early sexual experiences and prostitution. American Journal of Psychiatry 134: 1381–1385, 1977. Luster, T., Small, S.S. Sexual abuse history and number of sex partners among female adolescents. Family Planning Perspectives 29: 204–211, 1997. MacVicar, K. Psychotherapy of sexually abused girls. Journal of the American Academy of Child and Adolescent Psychiatry 18: 342–353, 1979. Massie, M.E., Johnson, S.M. The importance of recognizing a history of sexual abuse in female adolescence. Journal of Adolescent Health Care 10: 184–191, 1989. McLeer, S.V., Dixon, J.F., Henry, D., et al. Psychopathology in non-clinically referred sexually abused children. Journal of the American Academy of Child and Adolescent Psychiatry 37: 1326–1333, 1998. Nelson, D.E., Higginson, G.K., Grant-Worley, J.A. Using the youth risk behavior survey to estimate prevalence of sexual abuse among Oregon high school students. Journal of School Health 64: 413–416, 1994. Oppenheimer, R., Howells, K., Palmer, L., et al. Adverse sexual experiences in childhood and clinical eating disorders: a preliminary description. Journal of Psychiatric Research 19: 357–361, 1985. Paris, J. Borderline Personality Disorder: A Multidimensional Approach. Washington, DC: American Psychiatric Press, 1994. Rosenfeld, S., Lewis, D. The hidden effect of childhood sexual abuse on adolescent and young adult HIV prevention. AIDS and Public Policy Journal 8: 181–186, 1993. Russell, D.E.H. The incidence and prevalence of intrafamilial and extrafamilial sexual abuse of female children. Child Abuse and Neglect 7: 133–146, 1983. Runtz, M., Briere, J. Adolescent ‘acting out’ and childhood history of sexual abuse. Journal of Interpersonal Violence 1: 326–334, 1986.

The effects of sexual abuse on adolescent development and adaptation 131 Sansonnet-Hayden, H., Haley, G., Marriage, K., Fine, S. Sexual abuse and psychopathology in hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 26: 753–757, 1987. Sgroi, S. Handbook of Clinical Intervention in Child Sexual Abuse. Lexington, MA: Lexington Books, 1982. Shapiro, S., Dominiak, G. Common psychological defenses seen in the treatment of sexually abused adolescents. American Journal of Psychotherapy 44: 68–74, 1990. Silbert, M.H., Pines, A.M. Sexual abuse as an antecedent to prostitution. Child Abuse and Neglect 5: 407–411, 1981. Sloan, G., Leighnor, P. Is there a relationship between sexual abuse or incest and eating disorders? Canadian Journal of Psychiatry 31: 656–660, 1986.

Stock, J.L., Bell, M.A., Boyer, D.K., et al. Adolescent pregnancy and sexual risk taking among sexually abused girls. Family Planning Perspectives 29: 200–227, 1997. Summit, R.C. The child sexual abuse accommodation syndrome. Child Abuse and Neglect 7: 177–193 1983. Tebbutt, J., Swanston, H., Oates, R.K., et al. Five years after child sexual abuse: persisting dysfunction and problems in prediction. Journal of the American Academy of Child and Adolescent Psychiatry 36: 330–339, 1997. Watkins, B., Bentovim, A. Male children and adolescents as victims: a review of current knowledge. In Mezey, G.C., King, M.B. (eds), Male Victims of Sexual Assault. Oxford: Oxford University Press, 1992, pp. 27–66.

2.6 Pregnancy and parenthood during adolescence LARRY K. BROWN AND KEVIN J. LOURIE

INTRODUCTION Adolescent pregnancy and teenage parenthood are found in all ethnic and socioeconomic groups in the United States today, although the prevalence is greatest for lowincome minorities. Adolescent pregnancies are associated with increased infant morbidity and mortality as well as subsequent problems with parenting and longterm risks for the young mothers and their children. These outcomes are associated with poor prenatal and postnatal care, limited educational and occupational opportunities, and financial instability. Depression, family instability, conflict in relationships, poor parent–child relations, child neglect and abuse, father abandonment, substance abuse and sexual risk-taking are outcomes indirectly related to teenage pregnancy and parenthood. However, these risk factors may be anticipated and prevented in the community-based, clinical setting. Pregnancy and parenting interventions by clinicians offer the opportunity to combine healthcare delivery, education, risk prevention, social services, and family planning programs. Mental health, medical and social service programs can be tailored for high-risk teenage parents to develop educational goals, safer sexual behavior, and parenting skills.

EPIDEMIOLOGY One million adolescents become pregnant annually in the United States. Of these adolescents, more than half a million give birth, constituting 20 per cent of all firstborns in the United States, while approximately 40 per cent abort and 10 per cent miscarry (Centers for Disease Control [CDC] 1996a). The number of teenagers who gave birth fell in 1994 as part of a general decline in the nation’s birth rate. Among teenagers aged fifteen to seventeen years, the absolute number of births rose

2 per cent in 1994 to 195 169, largely a reflection of the 3 per cent rise in that age group. Because of the continuing increase in the number of adolescents, by the year 2000 it is predicted that there will be approximately 570 000 babies born to women aged between fifteen and nineteen years – some 13 per cent higher than the 1994 total (CDC 1996a). Birth rates differ substantially according to marital status and ethnicity. For example, while the fertility rate for white women declined by 1 per cent overall, the birth rate for unmarried white women increased by 7 per cent, and the rates for Hispanic and African American teenagers (aged 15–19 years) were 2.3 to 3.4 times the rates for white teenagers in 1994. Between 1993 and 1994, the rates for Mexican American teenagers (aged 15–17 and 18–19 years) rose sharply by 9 and 6 per cent, respectively – faster than for any other ethnic group (CDC 1996a). Rates for adolescent childbearing reflect the complex interaction of economic, social, and cultural factors influencing medical and psychological outcomes for young parents and their children (Musick 1993). Some 40 per cent of female adolescents become pregnant at least once before reaching the age of twenty years, although four-fifths of these pregnancies are considered ‘unintended’ (Lawson and Rhode 1993). The mean age for mothers aged thirteen to nineteen years in the United States in 1994 was 17.5 years. Of the half million teenage births, almost half were white, more than one-quarter African American, and more than one-fifth Hispanic (CDC 1996a). Less than 5 per cent of teenage mothers are married at the time of the birth of their child, this being largely a reflection of relationship problems, unstable social environments and structural barriers to marriage for poor teenagers. Welfare laws in many states dictate that young mothers lose Aid to Families with Dependent Children (AFDC) if married (Congressional Budget Office 1990). In two small, clinic-based studies, as many as half of urban teenage mothers surveyed lived alone with their children, usually after a brief period at home

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with their own parents, and more than 90 per cent received public assistance, including Medicaid and AFDC (Overby and Kegeles 1994; Brown et al. 1998). However, contrary to popular misconceptions, there is no conclusive evidence that welfare payments motivate a significant proportion of births to adolescents living in poverty (Caldas 1993).

DIAGNOSIS: MEDICAL AND PSYCHOLOGICAL SEQUELAE Pregnant teenagers have been shown to suffer from higher rates of medical risk (including anemia, hypertension, and poor or excessive weight gain) and related risk behaviors such as cigarette smoking. Prematurity, low birth weight and sudden infant death syndromes (SIDS) are more frequent occurrences for infants born to young adolescent mothers. There is a consensus that these increased risks are due largely to poverty rather than the age of the mother (Klerman 1993). Poverty and minority status are associated with insufficient prenatal care, poor maternal nutrition, low educational attainment, and lifestyle and health behaviors during pregnancy that are detrimental to birth outcome (Friedman 1994).

Obstetrics Despite recent gains in improved prenatal care, as many as 50 per cent of pregnant teenagers still receive no medical care during the first trimester (CDC 1996b). Only 45 per cent of teenage mothers aged under fifteen years, and 64 per cent of mothers aged fifteen to nineteen years, received timely prenatal care, this being substantially lower than for all other age groups (CDC 1996b). The most common maternal medical risk factors – hypertension, diabetes, and anemia – are disproportionately higher among young mothers (CDC 1996a). Many clinical studies also report that rates for cephalopelvic disproportion and poor or excessive weight gain during pregnancy among teenage mothers are higher than among older mothers (cf., Stevens-Simon and White 1991).

Neonatal/infancy Rates of low birth weight, premature delivery and SIDS are significantly higher among infants born to mothers under fifteen years of age. For example, in 1994, approximately one in ten infants born to young adolescent mothers was low birth weight, compared with one out of fifteen infants born to mothers aged twenty-five to thirty-four years (CDC 1996a). Poor nutrition, drug use, cigarette smoking and lack of prenatal care during pregnancy are directly associated with low birth weight.

For example, among white mothers in 1994, the smoking rate was highest for those aged eighteen to nineteen years (CDC 1996a). A study of 1004 pregnant women in Spain found that smoking prevalence during pregnancy was significantly greater among adolescents than in older pregnant women (Bolumar et al. 1994). Preterm births, which are the cause of more than half of all infant deaths, are also significantly higher among young adolescent mothers (CDC 1996a; Berkowitz and Papiernik 1993). SIDS, accidental trauma, poisoning and infant mortality rates, in general, are found to be as much as three times greater for adolescent mothers (Brooks-Gunn and Furstenberg 1986).

Psychological factors Research indicates that pregnant adolescents more frequently have engaged in unprotected intercourse before becoming pregnant than have non-pregnant teenagers (Holden et al. 1993). Following the birth of their first child, more than 40 per cent of young adolescent mothers will become pregnant again within a year, and as many as one-third will go on to have a third or fourth birth within five years of the index birth (Jones and Mondy 1994; Rigsby et al. 1998). Furthermore, contrary to common assumptions, the pregnancy period does not represent a time of reduced sexual risks or transmission of sexually transmitted diseases (STDs) (Wilson et al. 1996). Young mothers continue to have unprotected intercourse and, although no more than other teenagers from urban areas, to engage in prostitution, abuse substances and suffer negative legal consequences (Berger et al. 1993; Lewis 1990; Ketterlinus et al. 1992; KoniakGriffin et al. 1994). Although a majority of teenage mothers use some form of hormonal contraception after the birth of their first child, few consistently use condoms or act to protect themselves from human immunodeficiency virus (HIV) (Stanton et al. 1996). There is a trend toward increased use of Depo-Provera® (medroxyprogesterone acetate) injections and hormonal implants among adolescent mothers in the post-partum period. However, this use often consists of a brief period of contraceptive experimentation rather than consistent long-term use (Brown et al. 1998). Adolescents are faced with a contraceptive ‘trade-off ’ or ‘dilemma,’ since the hormonal contraceptive methods most commonly used for prevention of pregnancy do not prevent STDs (Cates 1996). Only dual use of hormonal and barrier methods will prevent both outcomes. Even when young women recognize the risks of unprotected sex, they may feel incapable and powerless to discuss safe sex or request that their partners, who are usually older, use a condom (Amaro 1995). Perception of those behaviors as ‘unfeminine’ and fear of partner rejection contribute to female adolescents’ failure to actively plan sexual behavior (St. Lawrence 1993).

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PREGNANCY AND PARENTHOOD EXPERIENCE: ADOLESCENT MOTHERS Identity formation Pregnancy may be motivated by sexual acting-out, a wish for being mothered or to mother, or by conflicts and competition with mothers, older sisters or peers (Weeks et al. 1995). Adolescent females often report being pressured by older male sexual partners to have sex without a condom or to become pregnant against their will (Kellogg et al. 1999). At the same time, unprotected sex and pregnancy are not necessarily perceived as negative events by many low-income adolescents, since having a baby may appear to promise increased security and safety (Brown et al. 1998). Among disadvantaged adolescent females, unprotected sex and becoming pregnant can be two distinct strategies to increase the perception of trust, intimacy and commitment in a romantic relationship (Sobo 1993). Whether planned or unplanned, pregnancy can be a response to a sense of incomplete identity. The role of ‘mother’ may be perceived as a solution to this problem as well a strategy for rejecting others in the family and becoming a ‘wife’ or member of a new family. Yet the adolescent mother, who has not herself fully developed, may not have the maturity to fulfill these roles. For example, she may have difficulty perceiving the boundary between her own identity and that of her developing child (Trad 1993). Having a baby and making the transition to motherhood does sometimes provide a more complete sense of identity and to a certain extent fulfills expectations for womanhood within the family and community (Flanagan 1998). However, the transition to motherhood may also retard developmental progression and may result in the greater dependency of the young mother upon her own parents or her male partner (Furstenberg et al. 1987; Trad 1993).

Cognitive and psychological development There is great variation in the skills and strengths of teenage mothers at the time of their child’s birth (Flanagan et al. 1995). Although conceptual abilities may be unrelated to age, many studies suggest that the cognitive and social development of teenage mothers is impeded when the normative sequence of education, employment, marriage and childbearing is disrupted (Zabin 1990; Holden et al. 1993). For some, early motherhood can disturb the normal development of adolescent autonomy, experimentation with intimate relationships and emotional growth. The process of acceptance of a more mature, adult body may also be disrupted. The physical transformation during pregnancy is marked by the physical effects of gestation, weight gain and

post-partum physical changes which can create increased concern regarding the stability and regulation of one’s body. Boyfriends, other peers, families and the mothers themselves often have mixed reactions to these bodily changes (Trad 1995; Stevens-Simon and McAnarney 1996). Although the research is varied, there is a consensus that pregnancy and parenthood significantly affect the development of autonomy and relationships. Focus on the new baby and childrearing tasks can contribute to a positive sense of family identity and individual selfesteem for young mothers, although some studies have found that pregnant adolescents tend to have more unrealistic expectations about the ease of parenting and lower self-esteem than do non-pregnant adolescents (Holden et al. 1993). The research on cognitive and psychological development post partum is inconclusive (Lesser et al. 1999; Secco and Moffatt 1994). Many of the positive social effects of parenthood tend to diminish after the children are no longer infants. Conflicts may arise after the infancy stage because young parents are dependent upon their own families and are simultaneously faced with the responsibilities of parenting.

Peers, partners, family, and culture Other than general socioeconomic status (SES), social support is the strongest predictor of success among adolescents with children over the first two years post partum (Osofsky et al. 1993). Some friendships are maintained within the family, with peers and with other teenage mothers in the community. At the same time, many of the tasks of peer formation are abruptly terminated because of pregnancy and childbirth. Teenagers sometimes pursue pregnancy to fulfill perceived expectations for womanhood within their community and to achieve autonomy (Weeks et al. 1995). However, along with this autonomy come new responsibilities. Studies suggest that affect regulation in the family is often more difficult for teenage mothers compared to older mothers, as they cope with the pressures of being a parent in addition to stress from conflicts with their own parents and families, school difficulties, and economic concerns (Cervera 1994; Osofsky et al. 1993). Furthermore, newfound familial and community supports for the young mother often deteriorate soon after the child’s birth, once the primary relationship with the baby’s father ends, and after social stresses become more apparent (Marsiglio and Scanzoni 1990). Changes in the family structure after pregnancy and birth differ widely according to SES and ethnicity (Zabin 1990). In some sociocultural groups, especially among Hispanic Americans, motherhood often legitimizes the status of womanhood and sexual behavior in the community. Relations between the young mother and her

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own mother and father can improve as a result of this rite of passage. Motherhood is prized and may be seen as an appropriate maturing experience, especially among immigrant ethnic groups (Amaro 1995). At the same time, unprotected sex, pregnancy and teenage childbirth reflect the conditions of the social setting and the examples set by other female role models in the family and community. To a certain extent, teenage pregnancy and parenting occur as part of a cycle of unemployment, the uncertainty of marriage and the limits of the welfare system (Musick 1990).

Child–parent relations Teenage mothers are often described as less soothing and less responsive than older socially disadvantaged mothers and their infants (Weil and Boxer 1990; Garcia Coll et al. 1987). Studies report teenage mothers as being less ‘realistic’ and more punitive in their childrearing attitudes compared with adult mothers (Frodi et al. 1990). These differences are considered to be largely due young mothers’ developmental immaturity and the frustrations which result from their poor social status. Because the teenage mother may resent having to sublimate her needs for the child, the pregnancy and the relationship with the infant may be experienced as negative (Trad 1993). Since adolescents often have cognitive difficulty with abstraction, they may experience more difficulty anticipating the impact of their behavior and may act less empathically. There is also evidence that fewer children of teenage mothers are securely attached (Osofsky et al. 1993). Failure to bond securely with the infant and poor stress coping skills may presage abuse or neglect (Fisher and Scharf 1980). While there is no absolute relationship between mother’s age and child neglect and abuse, many studies find greater aggressiveness, more use of physical punishment, and more intolerance among teenage parents compared to older parents, even when controlling for socioeconomic status (SES) (de Paul and Domenech 2000; Haskett et al. 1994). Due to cultural norms, socioeconomic conditions and their older ages, the male partners of pregnant and parenting teens are often removed from the birth and childrearing experiences, and the brunt of the burden of childrearing falls on teenage mothers and their parents and grandparents (Lourie et al. 1998).

PREGNANCY AND PARENTHOOD EXPERIENCE: ADOLESCENT FATHERS Unfortunately, there is a paucity of research on teenage fatherhood and only some of the programs for pregnant teenagers in United States cities also provide services for the male partners (Robinson 1988; Joshi and Battle 1990;

Weinstein and Rosen 1994). Adolescent fathers are frequently from a low socioeconomic background, often unemployed, and usually older than the teenage mothers (Heath and McKenry 1993). In one survey, 70 per cent of the male partners of teenage mothers were reported to be over twenty years of age, and 15 per cent over twenty-five years (Males 1992). In contrast, in 1985, 22 per cent of all births to teenage mothers were to males aged less than twenty years (Joshi and Battle 1990). For low-income, adolescent males, non-monogamous sexual activity and the desire to be a father are often related to the lack of economic opportunities and accepted peer norms for male behavior (Marsiglio 1989; Sobo 1993). For some men, unprotected sex is not perceived to be associated with particular health risks or negative consequences. Rather, the interpersonal and social benefits of sexual intercourse are perceived to outweigh any such risks. Heterosexual activity and fatherhood may be perceived as verifications of one’s masculine identity and an essential element of a deep, committed relationship (Sobo 1993). For example, in a relationship with a woman who already has a child from a previous partner, childbearing may be seen as proof of her commitment to the new relationship (Lourie et al. 1998). Some research suggests that males are more likely to act responsibly (e.g., use birth control) if they are in a stable relationship, have an internal locus of control, and have stable plans for the future (Furstenberg 1976; Harrison 1990). However, even when young fathers want to participate in caretaking, many are apprehensive about the financial obligations of marriage and fatherhood and about their own abilities to meet these obligations (Barret and Robinson 1982; Rhein et al. 1997). Like young mothers, teenage fathers have concerns about gestation, neonatal care, the health of the baby and mother, and how to be a good father. Yet they also face major social stresses, including educational barriers, how to provide financially, and fears about getting trapped into marriage (Elster and Panzarine 1983). Although no large, controlled studies have been conducted, the majority of surveyed teenage fathers endorse positive attitudes about fatherhood and the responsibility of teenage fathers. In fact, one study found that almost half of the teenage parent couples surveyed were still together up to two years post partum (Toledo-Dreves et al. 1995). Most studies, however, find that less than one-quarter of the fathers of the children of teenage mothers are likely to play an active role two years after the child’s birth (Anthony and Smith 1994). Knowledge of child health, developmental milestones, and parenting skills (e.g., appropriate disciplining and appropriate expectations) are often lacking among teenage fathers (Rivera et al. 1986; Weinstein and Rosen 1994). Although some teenage fathers express the desire for assistance with child development issues and their own education and employment opportunities, there are few intervention programs specifically designed for them

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(Toledo-Dreves et al. 1995; Jones 2000). Interviews with small samples find that fathers express a negative view of health and social service agencies and report that they anticipate rejection, discrimination and a lack of services (Anthony and Smith 1994; Joshi and Battle 1990). Although the research is limited and inconclusive, some studies report that many adolescent fathers, like adolescent mothers, are impatient and intolerant with their children and tend toward abusive and inappropriate behavior in their childrearing practices (Elster and Lamb 1986).

PSYCHOSOCIAL OUTCOME AND PSYCHIATRIC PROFILES The assessment of the longitudinal course of young adolescent parents is complicated by several factors. Many important factors such as psychological status, family functioning and cultural values are difficult to measure and to control adequately. Furthermore, the length of follow-up dictates the data on long-term, lasting changes. Research in this area is slowly moving from simplistic linear models (e.g. young adolescent parenthood causes stresses which in turn cause negative outcomes) to a more complex view of transactional behavior and outcomes (Osofsky et al. 1993). Moreover, because pregnant and parenting teens constitute a highly heterogeneous population, accurate understanding is needed of the different ethnic, subcultural and community groups (Lourie et al. 1998).

Outcome for teenage mothers Seminal longitudinal studies that control for the effects of poverty, aptitude, culture and education find no relationship between mother’s age and outcome (see Furstenberg et al. 1987, who reported a seventeen-year follow-up study of predominantly black adolescent mothers). Despite the obstacles, many young mothers function productively. For example, in two follow-up studies, more than two-thirds of the sample ultimately graduated high school or passed their GED (General Educational Development) high school equivalency examination and were later employed or supported by their partner (Horwitz et al. 1991; Furstenberg et al. 1987). However, many cross-sectional studies have also found that young parents and their children are worse off than older parents and their children. For example, Warren and Johnson (1989) found that adolescents who chose abortion or to put their baby up for adoption had better incomes and more supportive family environments than those who kept their baby. It is difficult to determine if pregnancy and parenthood alone hasten drop-out from school and long-term

economic stress. However, it is known that low educational attainment is in turn associated with poor jobs and less adult income, even when SES and aptitude are controlled. One longitudinal study found that young adolescent mothers received less education than controls over a twelve-year period after the birth of the child (Klepinger et al. 1995). It appears that young mothers tend to go on to attain lower levels of education than women of the same age groups from the same socioeconomic background (Jones and Mondy 1994; Hoffman et al. 1993). Less education and poor job income are also directly associated with increased rates of substance abuse and family conflict, including divorce and troubled interpersonal relationships (Kokotailo and Adger 1991; Nord et al. 1992). A variety of psychological dysfunctions are reported more often for young adolescent mothers than their older peers, such as attention deficits, withdrawal, aggressive behaviors, depression, and suicidal behavior (Trad 1995). Thomas and Rickel (1995) found significantly more emotional maladjustment and negative childrearing practices among 179 pregnant/parenting teenage mothers compared with 241 non-pregnant/non-parenting teenage girls in public schools. While informal reports from mental health clinics are inconclusive, most studies indicate more identity diffusion, less autonomy and trust, and lower self-esteem among pregnant and parenting adolescents than among non-pregnant adolescents (Osofsky et al. 1993; Holden et al. 1993). As suggested by a recent review of the international literature, teenage mothers are at substantially increased risk for suicide (Frautschi et al. 1994). A study in Great Britain which adjusted mortality ratios for suicide by women in the first year after childbirth and during pregnancy, found that teenage mothers were at five times greater risk for suicide during pregnancy than mothers over twenty years of age (Appleby 1991). Research does not point to a definite causal relationship between teenage parenting and psychopathology, but does suggest an association between accompanying social stresses and psychological dysfunction (Rhodes and Woods 1995). Wiemann et al. (1996) found no clear relationship between adolescent pregnancy and psychopathology. However, the young mothers in their sample who lacked a relationship with the baby’s father were more likely to report high scores on thought problems (odds ratios [OR] ⫽ 4.2), withdrawal (OR ⫽ 2.8) and delinquency (OR ⫽ 3.1). In a study of 200 first-time mothers aged between fourteen and thirty-eight years in Ireland, Greene et al. (1991) found significantly heightened depressive symptoms (according to the Center for Epidemiologic Studies Depression Scale) in the younger, single women during pregnancy. Similarly, among a sample of 192 financially impoverished, inner-city women aged between seventeen and forty years, the rate of post-partum clinical depression (23.4 per cent) was

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double that found for middle-class samples. Single women who did not have a cohabiting partner were at significantly higher risk for antepartum depression, which in turn significantly predicted post-partum depression (Hobfoll et al. 1995). Clinical observations also suggest that pregnant and parenting adolescents, especially young mothers with more than two children, are more prone to anxiety and distress. These psychosocial stresses are in turn associated with obstetric risk factors. One study of 219 pregnant women in Columbia reports a significant predictive interaction between anxiety and family dysfunction and future biomedical risks and perinatal complications (Herrera et al. 1992). A strong mediator of psychopathology is social support, without which young parents in distress may seek relief in alcohol and drugs. In environments where partners, peers, and relatives drink and use drugs, the pattern of risk-taking and negative life circumstances may include more pregnancies, child abuse and neglect, abandonment of education and vocational training, multiple sexual partners, homelessness, STDs and HIV infection (Klerman 1993; Guagliardo et al. 1999).

Outcome for teenage fathers Some studies find the quality of life for teenage fathers to be the same as or better than for other teenagers, especially if the birth leads to an experience of parental satisfaction (Heath and McKenry 1993). However, any positive effects for the mother and child occur only when teenage fathers stay consistently involved with their partner during prenatal activities and after birth (Brandt 1984; Royer and Barth 1984). Although many adolescent fathers try to be supportive of the mothers and their babies, few continue to provide support or play a significant role by eighteen months after the birth of the child (Westney et al. 1986). Studies report that between 50 and 80 per cent of adolescent fathers abandon their partners between the discovery of pregnancy and the birth of the child; in addition, the divorce rate is more than four times higher than for adults (Joshi and Battle 1990). Psychosocial outcomes for teenage fathers are similar to those for the young mothers, including less education (Osofsky et al. 1993), fewer occupational opportunities and less income, more social conflict (Card and Wise 1978), and greater psychological dysfunction. They tend to attain less education and lower-paying jobs than adolescent males who postpone parenting until adulthood (Hendricks et al. 1984). In community surveys, teenage fathers are reported to experience more distress as young adults, compared with teenage males without children and adult fathers (Buchanan and Robbins 1990). Small studies have found that adolescent fathers are less trusting and have a more external locus of control than do non-fathers (Williams-McCoy and Tyler 1985). Among adolescent fathers, significant rates of post-partum

depression (21 per cent) and isolation (17 per cent) have also been reported (Vaz et al. 1983). In a study comparing fathers of planned versus unplanned pregnancies, for example, Clinton and Kelber (1993) found that fathers with unplanned pregnancies reported significantly more distress and powerlessness than non-parents. Of course, it is difficult to interpret these findings due to small sample sizes, cross-sectional designs, lack of objective psychological measures and difficulty controlling for background variables (Joshi and Battle 1990; Robinson et al. 1983).

Outcome for children Although development is no different during the preschool years, fewer children of teenage mothers compared to adult parents are securely attached (Weil and Boxer 1990). Problems in affect regulation, including subdued affect and inappropriate aggression, are commonly reported (Osofsky et al. 1993). Children of young adolescent mothers may have slightly lower scores in verbal functioning on many cognitive and educational tests (Moore and Snyder 1991). Although few behavioral differences are documented based on mother’s age alone, living in a single-parent, impoverished environment can also lead to higher rates of behavior problems, school difficulties and mental health risks (Osofsky et al. 1993). In one study, 43 per cent of the children born to young adolescent mothers had two or more behavior problems, including temper tantrums, lying and bedwetting, compared to 33 per cent of the children living with both parents (Furstenberg 1976). During the high school years, the children of teenage mothers are more likely to have repeated a grade, and to display more disruptive and delinquent behavior. However, when maternal education, family size, and poverty are controlled, maternal age has a less noticeable impact.

CLINIC AND SCHOOL-BASED INTERVENTION PROGRAMS The most successful pregnancy and parenting intervention programs for adolescents are multi-modal and clinic based (although often embedded in inner-city school health clinic programs). Intervention programs which specifically target pregnant students and adolescent parents seek to improve parenting skills and reduce sexual risk behavior and repeat pregnancies by providing assistance with pre- and postnatal medical care, contraceptive skills training and access to family planning services, mental health referral, educational guidance, job counseling and community outreach (Weinman et al. 1999). Combined pregnancy and teenage parenting interventions have been successful on a small scale, although they

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dramatically under-serve the male partners or the child’s father. Despite the barriers, parenting programs are an important opportunity to include men (Jones 2000; Toledo-Dreves et al. 1995). School-based pregnancy prevention programs are typically knowledge based or values based and appear to have little or no long-term effect on adolescent pregnancy-related behavior (Kirby et al. 1994). Many intervention approaches in the schools, such as the Ford Foundation-funded Postponing Sexual Involvement program, have been primarily effective in delaying sexual involvement rather than reducing pregnancy rates. For the sexually active, there are no sustained differences between intervention and control groups, indicating that factors that delay the initiation of sexual intercourse are different from those that promote condom use (Howard and Mitchell 1993). Projects which combine school, clinic and community services for abstinence-based intervention programs for adolescents before they become sexually active have been somewhat effective in improving young teenagers’ knowledge and attitudes about safer sex and occupational and family planning. Stanton and colleagues (1996) enrolled 383 young African-American adolescents, aged between nine and fifteen years, from nine recreation centers associated with three public housing developments in a six-session HIV and pregnancy prevention program. After the computer-based intervention, more than 80 per cent of the youth who used oral contraceptives also used condoms. Even the best school-based clinic interventions have had little measurable long-term impact on student contraceptive and pregnancy behavior (Kirby 1992; Kirby et al. 1991). Behavioral intervention data often only point to trends rather than long-term changes in sexual activity (Jorgensen 1991). Furthermore, programs may not always be possible in communities with conservative norms (Steven-Simon and McAnarney 1996). Despite these barriers, health clinic-based intervention programs in high schools which include contraceptive services and referral have been more effective than the standard school-based prevention programs in the reduction of adolescent pregnancy in high-risk areas (Kirby et al. 1991). Furthermore, current clinic-based treatment programs specifically designed for young adolescent mothers have shown a decrease in infant morbidity and maternal school dropout (Koniak-Griffin et al. 2000).

Parenting and second-pregnancy interventions Multi-modal, school-based programs, such as the Special School Program (Jones and Mondy 1994) and the Family Development Project (D’Andrea 1994), offer prevention activities for pregnant and parenting adolescents within health promotion and mental health counseling programs.

These programs attempt to decrease the secondary consequences of early pregnancy by teaching educational and job skills that will enable future economic independence. The McCabe school-based intervention program, which targeted 102 inner-city black, low-income, school-aged mothers, reported a significant effect on those students who participated on a daily basis for longer than seven weeks, including educational improvement and reduced rates for repeat pregnancies (Seitz et al. 1991). A foursession AIDS prevention group demonstrated moderate effectiveness in improving knowledge and safer sex behaviors among young, inner-city pregnant women (Hobfoll et al. 1994). Clinic-based interventions for pregnant and parenting adolescents are perhaps the most effective, such as the nationally recognized Adolescent Pregnancy Program at the Johns Hopkins Hospital (Hardy and Zabin 1991). The program, which enrolls between 300 and 325 adolescents under the age of eighteen each year, emphasizes discussion groups on parenting, encourages participation of the fathers, and includes a range of health issues. It has been effective in reducing the frequency of pregnancy and perinatal complications. A four-year follow-up study of fifty-two black, urban teenage mothers found that those adolescent mothers who received clinic-based, pre- and post-partum service intervention programs over a two-year period were significantly more likely to delay repeat pregnancy (Kuziel-Perri and Snarey 1991). The long-term outcome of costly community outreach services, such as the home-visit Resource Mothers Program for teenage mothers and their families, is unknown; but these intensive programs serve a difficult to reach group of high-risk adolescents and improve prenatal care and family outcomes (Julnes et al. 1994). Another more recent clinic-based outreach program succeeded to help minority adolescent mothers delay subsequent pregnancy and stay enrolled in or complete school (Solomon and Liefeld 1998).

CHILD AND ADOLESCENT PSYCHIATRY Clinical assessment offers the opportunity to identify the special needs and concerns of young adolescent parents. Several factors make parenting teenagers unique and must be considered in addition to the routine parameters of adolescent psychiatric assessment. Adolescent pregnancy and parenting often occur within a context of insufficient pre- and postnatal care, educational opportunities, and family support. Adolescent parents must quickly adopt an adult-like, parental role. While the general principles for assessment and treatment of depression, anxiety, attachment difficulties, and relational problems apply as to any other patients, distinct considerations must be made for young adolescent parents.

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Assessment Pregnant and parenting teenagers are in the predicament of being simultaneously adolescents and parents. They are faced with concerns about both themselves (e.g., finishing high school, a future career) and their children (e.g., nutrition, infant development). An important part of assessment is a careful investigation of how well these two domains have been integrated. Conceptualizations of the child and of the infant–adult relationship may be at odds with realistic possibilities. Pregnant and parenting adolescents may become more frustrated by the limitations and conflicts inherent in sacrificing their wishes to the needs of their child than might older parents. Frustrations caused by a diminished social life and increased economic stress may cause resentment toward the child, the father, and their own families, and warrant early detection and intervention by clinicians. Although young adolescent mothers are not at greater risk for postpartum depression than older mothers, depressive symptoms need to be carefully evaluated and not dismissed as merely reactions to the predictable psychosocial stresses. Maternal–infant attachment disorders may also require detection and prompt intervention. Some useful areas of assessment include:

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Expectations of the child: this may be unrealistic or inappropriate if the adolescent is unaware of the stages of infant and child development or is intolerant of the baby’s behavior. Useful probes for assessing these expectations include: ‘Why do you want to have this baby?’; ‘How do you envision life will be with your child?’ (for pregnant teenagers); ‘How do you see your child?’; ‘What kind of child do you have?’; and ‘What are your child’s needs?’ (for parenting teenagers). Expectations of parenthood: these are formed in the context of both personal and family transitions. Self identity as a teenager-parent will reflect the ongoing challenges and frustrations of the new role. ‘How will your life change if you have a baby?’; ‘How has being a mother (or father) been different than expected?’; ‘How have your relationships with friends changed?’; and ‘Can you still do the things that you have always wanted to do now that you are a parent?’ Expectations of the father: these are often unstable and change after the adolescent mother’s child is born, especially if both parents do not live together or see each other only infrequently. Because the young mother and her infant are often dependent upon the baby’s father and family support, changes in these relationships are important indicators of functioning and stability. ‘Will the father play a role in your baby’s life?’; ‘How will the birth of your child change your relationship with him?’; ‘What is your relationship with the baby’s father?’; ‘What is your baby’s relationship with his/her father?’

•

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Expectations of families: these are an important indicator of available social support and changing support networks during the course of pregnancy and early parenthood. ‘What has your family said about your pregnancy?’; ‘What will it be like at home when your child is born?’; ‘Who meets these needs day to day?’; ‘How does your family help out, and are there other ways that they could help?’; and ‘How have your relationships with your family changed as a result of you becoming a parent?’ Expectations of school and jobs: these usually change during teenage pregnancy and with the transition to parenthood, often becoming more future-oriented and unattainable due to the focus on pragmatic concerns related to childbearing. Pregnant and parenting teenagers should be questioned about their individual goals. ‘How has this new role changed your plans for school and work?’; ‘What are your new goals, now that you have a child, and are they realistic?’; and ‘Who will provide for you, if you cannot earn a living?’ Expectations of peers and the community: these also change during the transition to parenthood, as young parents conform to accepted cultural values yet isolate themselves from former social ties, schools and neighborhood peer groups. ‘As a young parent, who will be your friends?’; ‘Other than your family, with whom do you spend the most time?’; and ‘Who will be your baby’s playmates?’

Better understanding of young parents’ conceptualization of their baby, baby’s needs and their baby’s relationship to the rest of the world can help elucidate both the positive and the difficult aspects of their lives. In addition to this review of psychological functioning and social support, history of substance abuse and sexual victimization should be assessed. For example, in one study of 177 pregnant and parenting African-American adolescents, those with a history of sexual victimization were more symptomatic, had lower self-esteem, and had a more external locus of control than the non-victimized women (Rhodes et al. 1993).

CLINICAL CASE Many of the principles of assessment are illustrated by the following example. Sandy, a seventeen-year-old African American mother of two small children, presented at fourteen weeks’ gestation to the Children’s Hospital emergency room following an overdose of 15–20 Adapin® (doxepin) (75 mg). Initial evaluation revealed that the overdose was an impulsive act. Sandy had immediately informed her mother, who also had a history of suicidal behavior, of the attempt, but denied suicidal intent and strongly wanted to return home to her family. A more complete evaluation, that focused on the contextual issues of parenthood, revealed long-standing symptoms

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of depression, impulsive behavior, self-cutting, social stresses and discrete events over the preceding weeks that contributed to the overdose. According to Sandy and her mother, the father of her unborn child discouraged her from carrying to term, gave her money for an abortion, and recently began a relationship with another woman. During a week of feeling sadness and anger, Sandy spent the money elsewhere and decided to attempt to restore the relationship by having this man’s baby. Despite her denial of suicidal intent, the other issues raised serious concerns about her own safety and her ability to care for her two small children and prompted more intensive psychiatric treatment.

Intervention strategies By anticipating the impact of pregnancy and parenting on the individual and family development of young patients, clinicians can intervene to address imminent conflicts as well as refer the appropriate mental health, medical and social services. Pragmatic suggestions include: build an alliance with teenage parents; tailor the intervention to be culturally appropriate; facilitate support for parenting; involve the father or a male partner; and improve the parent’s negotiation skills and self-efficacy.

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Build an alliance with teenage parents by beginning the intervention process with affective, interpersonal trust issues, reinforced when possible by assistance from peer-led, multilingual clinical staff. Tailor the intervention to be culturally appropriate for each pregnant and parenting adolescent and make every effort to acknowledge provider differences and cultural conflicts. For example, second pregnancy may be seen as ‘recidivism’ by clinicians but ‘family planning’ by the patient. Facilitate support for parenting, by teaching adolescents that greater empathy for the child and utilization of health resources are aspects of the process of becoming a successful, responsible adult. If the intervention is to be part of the local support network, it should be concerned with improving education, overcoming chronic welfare dependency and the achievement of patients’ own life goals. Involve the father or a male partner in the life of the mother and child as soon as possible, even in situations where the parents are not a couple. Male adolescent sexual partners and fathers may be mistrustful of health care agencies but may need information and counseling about reproduction, contraception, childbirth, child development, and appropriate parenting. Improve the negotiation skills and self-efficacy that are needed to make decisions in everyday life. Adolescents get pregnant unintentionally and face difficulties as young parents in part because they lack access to relevant information. However, they also lack the

know-how and resources to apply their knowledge within certain social situations and under dire economic conditions. Social learning techniques should be used in the clinical setting, such as videotaping the interaction of the mother–infant dyad and previewing tapes of adaptive interactions between other mothers and their children. These techniques have been found to promote empathy for the child, improve communication between parents, facilitate accurate information about the mother and child, and to reduce rates of child abuse and neglect (McCullough and Scherman 1998; Trad 1993; Fulton et al. 1991; Rhodes and Woods 1995).

CONCLUSION Despite the slight decline in the rate of adolescent births since 1995, an increase in the number of young, unmarried women over the next several years will cause an increase in the absolute number of children born to teenagers. Adolescent pregnancies and births are associated with increased morbidity and mortality as well as subsequent problems with parenting, educational and occupational attainment, psychopathology, substance abuse and sexual risk behaviors. Because these risks sharply differ by ethnicity and socioeconomic status, intervention in the mental health setting, whether on an individual or group basis, should be carefully anticipated and specifically tailored to the needs of patients. Pregnant and parenting adolescents are faced with the unique developmental challenge of being both child and parent, and thus are simultaneously in need of support and required to provide support. Although many young adolescent mothers hope to achieve increased support and acceptance within the family, peer group and community by having a child, this early transition to parenthood may impede the normal process of adolescent psychological development and negatively affect the young parent’s self-concept, parent–child relations, and family life. The major issues facing socially disadvantaged, adolescent parents include the lack of social support and occupational opportunities; inadequate parenting and disciplining skills; substance abuse and sexual risk taking; and low self-esteem and depression. The research is divided on the etiology of the medical complications, psychopathology and long-term sequelae experienced by adolescent parents. It is clear, however, that these risk factors are indirectly linked to low socioeconomic status, history of physical and sexual abuse, family instability, substance abuse, family psychological variables and prior risk-taking in general. There is a consensus that early pregnancy and birth are associated with lower educational attainment and income up to twelve years post partum, even when controlling for socioeconomic status.

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Specific programs that deliver broad-based services to pregnant and parenting adolescents have been shown to improve outcome. By understanding the complex role of adolescent parenthood in the context of community values, child and adolescent psychiatrists can identify the services most suitable for young adolescent parents. Services include psychiatric intervention, parent training, ‘previewing,’ educational counseling, and vocational opportunities. Early detection of psychological dysfunction and insufficient social support and implementation of culturally appropriate interventions are important for the well-being of pregnant and parenting adolescents and their young children.

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142 Risk behavior, risk-taking, and sexuality of socioemotional development. Adolescence 25: 363–374, 1990. Fulton, A.M., Murphy, K.R., Anderson, S.L. Increasing adolescent mothers’ knowledge of child development: an intervention program. Adolescence 26: 73–81, 1991. Furstenberg, F.F., Jr. Unplanned Parenthood. New York: Free Press, 1976. Furstenberg, F., Brooks-Gunn, J., Morgan, S.P. Adolescent mothers and their children in later life. Family Planning Perspectives 19: 142–152, 1987. Garcia Coll, C.T., Hoffman, J., Oh, W. The social ecology and early parenting of Caucasian adolescent mothers. Child Development 58: 955–962, 1987. Greene, S., Nugent, K., Wieczorek, D., Dorit, E., O’Mahony, P., et al. The patterning of depressive symptoms in a sample of first-time mothers. Irish Journal of Psychology 12: 263–275, 1991. Guagliardo, M.F., Huang, Z., D’Angelo, L.J. Fathering pregnancies: marking health risk behaviors in urban adolescents. Journal of Adolescent Health 24: 10–15, 1999. Hardy, J.B., Zabin, L.S. Adolescent Pregnancy in an Urban Environment. Munich: Urban and Schwarzenberg, 1991. Harrison, A. High risk sexual behavior among black adolescents. In Stiffman, A.R., Davis, L.E. (eds), Ethnic Issues in Adolescent Mental Health. London: Sage, 1990. Haskett, M., Johnson, C., Miller, J. Individual differences in risk of child abuse by adolescent mothers: assessment in the perinatal period. Journal of Child Psychology and Psychiatry and Allied Disciplines 35: 461–467, 1994. Heath, D., McKenry, C. Adult family life of men who fathered as adolescents. Special issue: fathers. Journal of Contemporary Human Services 74: 36–45, 1993. Hendricks, L.E., Montgomery, T.A., Fullilove, R.E. Educational achievement and locus of control among black adolescent fathers. Journal of Negro Education 53(2): 182–188, 1984. Herrera, J.A., Hurtado, H., Caceres, D. Antepartum biopsychosocial risk and perinatal outcome. Journal of Family Practice Research 12: 391–399, 1992. Hobfoll, S., Jackson, A., Lavin, J., Britton, P., Shepherd, J. Reducing inner-city women’s AIDS risk activities: a study of single, pregnant women. Health Psychology 13: 397–403, 1994. Hobfoll, S., Ritter, C., Lavin, J., Hulsizer, M., et al. Depression prevalence and incidence among inner-city pregnant and postpartum women. Journal of Consulting and Clinical Psychology 63: 445–453, 1995. Hoffman, S.D., Foster, E.M., Furstenberg, F.F. Reevaluation the costs of teenage childbearing. Demography 30: 1–13, 1993. Holden, G.W., Nelson, P.B., Velasquez, J., Ritchie, K.L. Cognitive, psychosocial, and reported sexual behavior differences between pregnant and nonpregnant adolescents. Adolescence 28: 557–572, 1993.

Horwitz, S., Klerman, L., Kuo, H.S., Jekel, J. School-age mothers: predictors of long-term educational and economic outcomes. Pediatrics 87: 862–868, 1991. Howard, M., Mitchell, M.E. Preventing teenage pregnancy: some questions to be answered and some answers to be questioned. Pediatric Annals 22: 109–118, 1993. Jones, M. What is the influence of self-image and perceived parenting role expectations on adolescent fathers’ perceived role performance? Journal of Pediatric and Adolescent Gynecology 13: 99, 2000. Jones, M.E., Mondy, L.W. Lessons for prevention and intervention in adolescent pregnancy: a five-year comparison of outcomes of two programs for schoolaged pregnant adolescents. Journal of Pediatric Health Care 8: 152–159, 1994. Jorgensen, S.R. Project Taking Charge: an evaluation of an adolescent pregnancy prevention program. Family Relations 40: 373–380, 1991. Joshi, N.P., Battle, S.F. Adolescent fathers: an approach for intervention. Journal of Health and Social Policy 1: 17–33, 1990. Julnes, G., Konefal, M., Pindur, W., Kim, P. Communitybased perinatal care for disadvantaged adolescents: evaluation of the Resource Mothers Program. Journal of Community Health 19: 41–53, 1994. Kellogg, N., Hoffman, T., Taylor, E. Early sexual experiences among pregnant and parenting adolescents. Adolescence 34: 293–303, 1999. Ketterlinus, R.D., Lamb, M.E., Nitz, K., Elster, A.B. Adolescent nonsexual and sex-related problem behaviors. Journal of Adolescent Research 7: 431–456, 1992. Kirby, D. School-based programs to reduce sexual risk-taking behavior. Journal of School Health 62: 280–287, 1992. Kirby, D., Waszak, C., Ziegler, J. Six school-based clinics: their reproductive health services and impact on sexual behavior. Family Planning Perspectives 23: 6–16, 1991. Kirby, D., Short, L., Collins, J., Rugg, D., Kolbe, L., Howard, M., Miller, B., Sonenstein, F., Zabin, L. School-based programs to reduce sexual risk behaviors: a review of effectiveness. Public Health Reports 109: 334–360, 1994. Klepinger, D., Lundberg, S., Plotnick, R. Adolescent fertility and the educational attainment of young women. Family Planning Perspectives 27: 23–28, 1995. Klerman, L. Adolescent pregnancy and parenting: controversies of the past and lessons for the future. Journal of Adolescent Health 14: 553–561, 1993. Kokotailo, P., Adger, H. Substance use by pregnant adolescents. Clinics in Perinatology 18: 125–138, 1991. Koniak-Griffin, D., Nayamathi, A., Vasquez, R., Russo, A. Risk-taking behaviors and AIDS knowledge: experiences and beliefs of minority adolescent mothers. Health Education Research 9: 449–463, 1994.

Pregnancy and parenthood during adolescence 143 Koniak-Griffin, D., Anderson, N., Verzemnieks, I., Brecht, M. A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks postpartum. Nursing Research 49: 130–138, 2000. Kuziel-Perri, P., Snarey, J. Adolescent repeat pregnancies: an evaluation study of a comprehensive service program for pregnant and parenting black adolescents. Family Relations 40: 381–385, 1991. Lawson, A., Rhode, D.L. Introduction. In Lawson, A., Rhode, D.L. (eds), The Politics of Pregnancy: Adolescent Sexuality and Public Policy. New Haven: Yale University Press, 1993, pp. 1–19. Lesser, J., Koniak-Griffin, D., Anderson, N. Depressed adolescent mothers’ perceptions of their won maternal role. Issues in Mental Health Nursing 20: 131–149, 1999. Lewis, S.Y. Black teens parenting in the inner city: problems and recommendations. In Foster, D.S. (ed.), Sexuality. London: Sage, 1990, pp. 208–219. Lourie, K., Brown, L.K., Kumar, P., Davis, S., Flanagan, P., High, P. Teens, tots and condoms: HIV prevention and cultural identity among young adolescent mothers. International Journal of Adolescent Medicine and Health 10: 119–128, 1998. Males, M. Adult liaison in the ‘epidemic’ of teenage birth, pregnancy, and venereal disease. Journal of Sex Research 29: 525–545, 1992. Marsiglio, W. Adolescent males’ pregnancy resolution preferences and family formation intentions: does family background make a difference for blacks and whites? Journal of Adolescent Research 4: 214–237, 1989. Marsiglio, W., Scanzoni, J.H. Pregnant and parenting black adolescents: theoretical and policy perspectives. In Foster, D.S. (ed.), Sexuality. London: Sage, 1990, pp. 220–244. McCullough, M., Scherman, A. Family-of-origin interaction and adolescent mothers’ potential for child abuse. Adolescence 33: 375–384, 1998. Moore, K.A., Snyder, N.O. Cognitive attainment among firstborn children of adolescent mothers. Sociological Review 56: 612–624, 1991. Musick, J.S. Adolescents as mothers: the being and the doing. Zero to Three December: 21–28, 1990. Musick, J.S. Young, Poor, and Pregnant: The Psychology of Teenage Motherhood. New Haven, Conn.: Yale University Press, 1993. Nord, C., Moore, K., Morrison, D., Brown, B., Myers, D. Consequences of teen-age parenting. Journal of School Health 62: 310–318, 1992. Osofsky, J.D., Hann, D.M., Peebles, C. Adolescent parenthood: risk and opportunities for mothers and infants. In Zeanah, C.H. (ed.), Handbook of Infant Mental Health. New York: Guilford Press, 1993, pp. 106–119.

Overby, K.J., Kegeles, S.M. The impact of AIDS on an urban population of high-risk female minority adolescents: implications for intervention. Journal of Adolescent Health 15: 216–227, 1994. Rhein, L.M., Ginsburg, K.R., Schwarz, D.F., Pinto-Martin, J.A., Zhao, H., Morgan, A.P., Slap, G.B. Teen father participation in child rearing: family perspectives. Journal of Adolescent Health 21: 244–252, 1997. Rhodes, J., Woods, M. Comfort and conflict in the relationships of pregnant, minority adolescents: social support as a moderator of social strain. Journal of Community Psychology 23: 74–84, 1995. Rhodes, J., Ebert, L., Meyers, A. Sexual victimization in young, pregnant and parenting, African-American women: psychological and social outcomes. Violence and Victims 8: 153–163, 1993. Rigsby, D.C., Macones, G.A., Driscoll, D.A. Risk factors for rapid repeat pregnancy among adolescent mothers: a review of the literature. Journal of Pediatric and Adolescent Gynecology 11: 115–126, 1998. Rivera, F.P., Sweeney, P.J., Henderson, B.F. Black teenage fathers: what happens when the child is born? Pediatrics 78: 151–158, 1986. Robinson, B.E. Teenage pregnancy from the father’s perspective. American Journal of Orthopsychiatry 58: 46–51, 1988. Robinson, B.E., Barret, R.L., Skeen, P. Locus of control of unwed adolescent fathers versus adolescent nonfathers. Perceptual and Motor Skills 56: 397–398, 1983. Royer, T.D., Barth, R.P. Improving the outcomes of pregnancy: a knowledge-base and interventive strategies. Social Work 29: 470–475, 1984. Secco, M., Moffatt, M. A review of social support theories and instruments used in adolescent mothering research. Journal of Adolescent Health 15: 517–527, 1994. Seitz, V., Apfel, N.H., Rosenbaum, L.K. Effects of an intervention program for pregnant adolescents: educational outcomes at two years postpartum. American Journal of Community Psychology 19: 911–930, 1991. Sobo, E.J. Inner-city women and AIDS: the psycho-social benefits of unsafe sex. Culture, Medicine and Psychiatry 17: 455–485, 1993. Solomon, R., Liefeld, C.P. Effectiveness of a family support center approach to adolescent mothers: repeat pregnancy and school drop-out rates. Family Relations 47: 139–144, 1998. Stanton, B.F., Li, X., Galbraith, J., Feigelman, S., Kaljee, L. Sexually transmitted diseases, Human Immunodeficiency Virus, and pregnancy prevention. Archives of Pediatric and Adolescent Medicine 150: 17–24, 1996. Stevens-Simon, C., McAnarney, E.R. Adolescent pregnancy. In DiClemente, R.J., Hanson, W.B., Ponton, L.E. (eds),

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2.7 High-risk sexual behavior associated with sexually transmitted diseases and human immunodeficiency virus infections among adolescents RALPH J. DICLEMENTE

INTRODUCTION The risk of acquiring a sexually transmitted disease (STD), including human immunodeficiency virus (HIV) infection, is one of the most significant and immediate risks to the health and well-being of adolescents. From an economic and social standpoint, these infections continue to exact a significant toll on adolescents and ultimately on society. This toll can be measured in terms of projected costs of certain infections, such as chlamydia infections, or in terms of health outcomes, such as the number of ectopic pregnancies and the rate of infertility (Eng and Butler 1997; Institute of Medicine 1996). Often overlooked, however, is that sexually transmitted infections can be fatal. In particular, with the emergence of HIV infection, and the acquired immunodeficiency syndrome (AIDS), we have begun to measure the impact of STDs in terms of the death of adolescents and young adults from AIDS.

DEFINITION The term STD is not specific to any one disease, but denotes the more than twenty-five infectious organisms that are transmitted through sexual activity, and the dozens of clinical syndromes they cause. STDs are almost always transmitted from person to person through sexual intercourse. Moreover, STDs are not a stationary

group of infections and syndromes, but rather a group of diseases that has increased in number with the identification of new pathogens, most prominently HIV. This is the etiologic agent that causes AIDS. The advent of HIV and AIDS, particularly the non-reversible nature of infection and the high mortality rates associated with this disease, has catapulted the STD/HIV epidemic among adolescents from a hidden epidemic into an epidemic that has riveted the attention of the scientific community and the lay public. There are substantial epidemiologic data describing the prevalence of high-risk behaviors among adolescents that increase the probability of STD/HIV infection (DiClemente 1992, 1993a, 1996; Hein 1992). The behaviors that place adolescents at risk of STD infection, including HIV, are limited in number. Lack of condom use is one of the more important. Though the data are not definitive, correct and consistent condom use may reduce the risk of acquiring most STDs (Stone et al. 1999). In addition to inconsistent condom use, multiple sex partners (Aral et al. 1999; Alan Guttmacher 1994) and the use of alcohol and other drugs that result in greater sexual disinhibition are often associated with greater likelihood of engaging in risky sexual behaviors that increase exposure to STD/HIV (Wingood and DiClemente 1998; Morrison et al. 1998; Fullilove et al. 1990a,b). While each behavior singularly increases the probability for STD/HIV infection, they are more often reported in combination, further increasing the risk for exposure and infection (DiClemente et al. 1996a).

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Recent trend data, collected through the Youth Risk Behavior Survey, indicate that the proportion of adolescents who are sexually experienced has not risen from 1990 through 1995. Moreover, from 1991 to 1995, the proportion of adolescents who reported using condoms at last intercourse increased from 46 to 54 per cent. Although these findings, derived from a school-based sample of adolescents, are encouraging, they also suggest that many adolescents remain at substantial risk for STD/HIV infection.

Classification of STDs in adolescents Sexually transmitted diseases in adolescents can be classified by illness syndromes or by a specific disease agent. The syndromes most often seen in adolescents include urethritis (caused by Neisseria gonorrhea and Chlamydia trachomatis), vaginitis (caused by Trichomonas vaginalis, C. trachomatis, and N. gonorrhea), cervicitis (caused by N. gonorrhea and C. trachomatis), genital ulcers (caused by herpes simplex virus and Treponema pallidum) and, in females, pelvic inflammatory disease (C. trachomatis and N. gonorrhea). Also in females, cervical dysplasia and cervical carcinoma are most often the result of sexually transmitted infection with human papillomavirus. In both males and females, transmission of HIV infection can result in AIDS, and transmission of human papillomavirus can result in genital warts. In addition to these infections, other illnesses such as hepatitis caused by hepatitis B virus (HBV) and infectious mononucleosis caused by cytomegalovirus (CMV) (Sohn et al. 1991) are most likely to be sexually transmitted infections in adolescents.

EPIDEMIOLOGY Sexually transmitted diseases Defining the actual number of adolescents affected annually by STDs is difficult. Only syphilis and gonorrhea are infections for which reporting to public health authorities is mandated by law in all states. Other infections, such as chlamydia infections, are reportable in some areas. This lack of uniformity leaves no way to catalog on a national basis the number of cases of infections by organisms such C. trachomatis and T. vaginalis, both of which are felt to be the most likely organisms involved with STDs in adolescents and young adults. Similarly, there is no way to estimate accurately the rate of infection with human papillomavirus, the infectious agent linked to cervical cancer. Finally, we must acknowledge that even the data available on reportable diseases are limited by the differences in reporting from different jurisdictions and between private and public healthcare providers. While

data from public clinics specifically established to treat STDs are more reliable, they are heavily biased towards racial, ethnic, and socioeconomic groups that are forced to use these health services for care (Cates 1990). Despite these limitations, existing data about STDs in adolescents are both informative and disturbing. For instance, while the overall total number of cases of gonorrhea reported nationally between 1981 and 1991 decreased from 990864 to 620478, with an accompanying decrease in the overall rate of cases to 249.5 per 100000 population, the rates of gonorrhea in 15- to 19-year-old males actually increased from 868.4 per 100 000 in 1981 to 882.6 per 100 000 in 1991 (Webster et al. 1993). During this same time period, while the rate in 15- to 19-yearold females fell from 1253.7 per 100 000 in 1981 to 1043.6 per 100 000, the rate remained higher in this group than in any other age and sex grouping. These rates varied by geographic location, where rates from 15- to 19-yearolds from the South were 1427.7 per 100000 for females and 1378.3 per 100000 for males, and also by race, where rates for Black 15- to 19-year-olds exceeded 5000 cases per 100000 for both males and females. For syphilis, while rates between 1981 and 1991 actually fell in males from 20.0 cases per 100 000 to 18.1 per 100 000, the rates in females increased from 18.4 per 100 000 to 35.0 per 100000. Finally, for reported cases of AIDS, by the end of 1993, 1528 cases had been reported in individuals between the ages of ten and nineteen years (CDC 1994a,b). The majority of these cases (>58%) were reported in minority youth, and 27 per cent of cases were reported in women – the largest percentage of cases in any age group except children aged less than five years. Since syphilis and gonorrhea are reportable infections, they represent the most easily quantifiable of the STDs. Other infections, such as those caused by C. trachomatis and human papillomavirus, may actually be of greater overall economic and long-term medical significance, but are not reportable diseases in all states. We are therefore left guessing at the actual prevalence of these infections based on surveys in adolescent health clinics (Fraser et al. 1983; Webster et al. 1993) and studies of university student health centers (MacDonald et al. 1990). Best estimates give the prevalence of infection in asymptomatic females as 5–12 per cent for Chlamydia (Hammerschlage 1989) and 18–35 per cent for human papillomavirus (Martinez et al. 1988). Rates of both of these infections in males are even more difficult to establish, but studies of asymptomatic males puts the infection rate for chlamydia at about 8 per cent (Stamm and Cole 1986). Data are unavailable for rates of infection of HPV in males. Not surprisingly, the increase in both the reported number of STDs and the rates of these infections in adolescents is directly related to the decrease in the age of sexual initiation or ‘debut’ by teenagers. The median age of first intercourse is 15.9 years for males (Sonenstein et al. 1989) and 16.9 years for females (Forrest and

High-risk sexual behavior associated with STDs and HIV infections among adolescents 147

Singh 1990; CDC 1991). However, the age of sexual initiation is heavily dependent on a variety of socioeconomic (Rice et al. 1991; Rosenberg et al. 1994), ethnic and racial (Halsey 1992; Rolfs and Nakashima 1990) and educational factors (Huszti et al. 1989) and is also correlated with other risk behaviors such as substance use (Cox et al. 1992; Fullilove et al. 1990a,b). In addition to the age of sexual initiation, factors such as the number of sexual partners, the age of sexual partners, and the nature of sexual practices all influence the risk of acquiring a sexually transmitted disease (Alan Guttmacher 1994).

Human immunodeficiency virus Currently, there are no representative population-based studies for estimating HIV seroprevalence among adolescents. The absence of population-based data limits assessment of the magnitude of risk for adolescents and reduces the capability to monitor changes in infection rates over time. Much of the HIV seroprevalence data are derived from selected segments of the adolescent population, for example studies of applicants for military service or active-duty military personnel. Other studies have focused on disadvantaged youth receiving training in the Job Corps, homeless youth, adolescents seeking treatment in sexually transmitted disease clinics and adolescents seeking medical care. Overall, the results from a number of serosurveys conducted with selected adolescent populations indicate that African-American adolescents have, with few exceptions, markedly higher HIV seroprevalence rates than any other ethnic or racial group (DiClemente 1996). Of particular importance are data derived from HIV seroprevalence surveys conducted in inner-city STD clinics. Results from one survey indicated that the seroprevalence of HIV infection among adolescents ages fifteen to nineteen years is 2.2 per cent, with gender-specific rates of 2.5 per cent for females and 2 per cent for males. In this population, 28 per cent of the seropositive women were aged twenty years or less (Quinn et al. 1988). Likewise, in a review of seroprevalence studies conducted at STD clinics in the United States, the median seroprevalence rate for persons aged less than twenty years was 1.1 per cent, with rates ranging from 0 to 2 per cent. Persons aged between twenty and twenty-nine years, however, show a substantially higher median seroprevalence of 4.5 per cent (range 0.5–7.5%) (Cannon et al. 1989). These findings are of importance given the epidemiologic association that STDs, both ulcerative and inflammatory, increase both infectivity and susceptibility to HIV infection (Cohen 1998; Wasserheit 1992; DeVincenzi 1994). Thus, adolescents attending STD clinics are a population at increased risk for HIV infection (Quinn et al. 1992). While trend data are limited, recent findings from the continuing HIV serosurvey of Job Corps training program

applicants have identified marked changes in infection rates between 1998 and 1992, with African-American female applicants experiencing a two-fold increase in seroprevalence rates, from 3.2 per 1000 to 6.6 per 1000. In 1992, African-American females had seroprevalence rates that not only exceeded rates for white and Hispanic women, but also exceeded HIV seroprevalence rates for African-American males (Conway et al. 1993). Recent follow-up data indicate a significant decrease in HIV seroprevalence among Job Corps entrants from 1990 to 1996. For women, rates declined from 4.1 per 1000 in 1990 to 2.1 per 1000 in 1996. Likewise, rates for men declined from 2.8 per 1000 in 1990 to 1.4 per 1000 in 1996. Overall, HIV seroprevalence during this time period was highest among African-Americans (3.8 per 1000). More alarmingly, HIV seroprevalence was higher for African-American women (4.9 per 1000) than for any other gender and racial/ethnic group. Caution is recommended in interpreting these data. While these subpopulation studies provide an assessment of the impact of HIV on adolescents, their utility for assessing temporal trends in seroprevalence is limited to this at-risk population and the findings may not be generalizable to the adolescent population at large.

The STD/HIV epidemic as a psychosocial and cultural phenomenon The STD/HIV epidemic is not only a biomedical phenomenon, but also a psychosocial and cultural phenomenon in which individual’s behavior – more specifically, a person’s lack of appropriate preventive behavior – propels the epidemic (Santelli et al. 1999). The persistence of STDs as a major public health problem (Yankauer 1986, 1994) indicates that the presence of an effective medical treatment alone is not sufficient enough to control the epidemic. Thus, to control the STD/HIV epidemic the prevalence of STD/HIV-associated risk behaviors which result in exposure and infection must be reduced. Much of the behavior associated with STD/HIV exposure is of an interpersonal nature resulting from intimate sexual interaction. Precisely because STD/HIV infection links sexuality with disease, it is inextricably a psychosocial and cultural phenomenon. To most effectively meet the challenges posed by the STD/HIV epidemic, it is important to reconceptualize the epidemic as a psychosocial– biomedical phenomenon and confront it from an interdisciplinary perspective (DiClemente 1997). Of particular interest to psychiatrists and other mental health professionals is the high-risk sexual behaviors of adolescent psychiatric patients. While this adolescent subgroup remains understudied and underserved with respect to STD/HIV prevention interventions, there are accumulating empirical data indicating that the prevalence of risk-taking is substantial. For instance, early

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research (DiClemente et al. 1991) identified a high prevalence of sexual risk behaviors among psychiatrically hospitalized adolescents. In a more recent study, DiClemente and Ponton (1993) assessed the prevalence of STD/HIV-associated risk-taking among adolescents on an inpatient psychiatric service. Adolescents reported a high prevalence of risky sexual behaviors, with almost 53 per cent reporting as sexually active. The average age of sexual onset was 11.4 years, with 50 per cent of the sexually active adolescents having their sexual debut at age twelve years or younger. Of those who report being sexually active, only 38 per cent were monogamous at the time of the assessment, and only 23 per cent used condoms consistently (every occasion of sexual intercourse) during vaginal sexual intercourse, while almost 77 per cent reported rarely or never using condoms during anal sex. Approximately 20 per cent report past homosexual relationships, 20 per cent report having had sex with an intravenous drug user, and 15 per cent admit to sex-for-drugs trading. Other markers, such as a high lifetime prevalence of STDs (15%) and pregnancy among girls (27%), suggest that the risk of exposure to HIV among psychiatrically hospitalized adolescents is substantial. More recently, similar findings have been observed by Brown and colleagues (1997). While the rates of STD/HIV-associated risk-taking among psychiatrically hospitalized adolescents appears to warrant considerable concern by prevention scientists and mental health practitioners alike, one study provided a comparison between a school-based adolescent population and psychiatrically hospitalized adolescents (DiClemente and Ponton 1993). Relative to their schoolbased peers, psychiatrically hospitalized adolescents were two-and-a-half times as likely to be sexually active and almost twice as likely to report not using condoms during sexual intercourse. These findings suggest that adolescents with severe emotional disorders are at considerable risk of STD/HIV infection, as well as serving as a potential bridge for STD/HIV transmission to other adolescent and adult populations.

PREVENTION Sexual abstinence is clearly the most effective strategy for prevention of STD/HIV infection. However, a substantial proportion of adolescents (Hein 1992; Kann et al. 1991; DiClemente 1990; Anderson et al. 1990) do not adopt this preventive practice. Indeed, the expectation that sexually active adolescents will routinely adopt sexual abstinence as an STD/HIV prevention strategy is unrealistic. For sexually active individuals, appropriate and consistent use of latex condoms represents the most effective strategy for preventing transmission of viral pathogens, including HIV (Cates and Stone 1992; Van de Perre et al.

1987); moreover, their effectiveness as a risk-reduction strategy is dependent on appropriate and consistent use (Hein 1993; Roper et al. 1993).

Design of effective sexual behavior modification interventions: an historical perspective Behavioral interventions designed to reduce adolescents’ HIV-associated risk behaviors have evolved slowly over the course of the epidemic. Indeed, it was not until the mid-1980s that adolescents were even considered a population at risk for HIV infection (DiClemente et al. 1986) and the first wave of interventions initiated. Initially, the first generation of HIV-prevention interventions focused primarily on increasing adolescents’ knowledge of HIV and emphasizing the risk and consequences of disease. These interventions were predicated on a fundamental premise, namely, that if youth had greater knowledge about HIV and its association with sexual intercourse, and the consequences of HIV infection (i.e., AIDS), they would rationally choose to avoid unprotected intercourse. Unfortunately, these prevention programs were hastily developed and implemented. Few included an underlying theoretical model that conceptualized adolescents’ sexual behavior and decisionmaking based on well-defined psychological principles of behavior. Moreover, politicalization of the HIV epidemic severely constrained the ability of program planners to utilize a broad range of risk-reduction techniques and strategies to motivate adolescents’ adoption of safer sex practices. In general, this generation of HIV interventions, though well-intentioned, was not effective in promoting adolescents to modify their risk behaviors. The next generation of HIV-prevention interventions included considerable knowledge content, but did not give as much emphasis to the biology of HIV/AIDS and the biological consequences of infection. Instead, the interventions devoted much more emphasis to values clarification and the development of social competency skills, especially decision-making skills. The values clarification exercises were designed to help the adolescents become clearer about their basic values as well as their values about sexual behavior. Health educators gave adolescents dilemmas to solve and discuss; and they commonly did not emphasize that particular values were right or wrong. These programs emphasized generic skills, such as the basic steps involved in making a decision. When these skills and values were applied to sexual issues, the programs often spelled out the pros and cons of engaging in sexual intercourse. Proponents of this approach believed that if adolescents’ values became clearer and their decision-making skills improved, they would more likely avoid risk-taking behaviors.

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Numerous studies have measured the impact of these first two generations of programs upon the knowledge of adolescents. Findings from these studies are nearly unanimous: providing instruction about HIV did result in significant increases in knowledge of HIV and awareness of HIV-associated risk behaviors. However, it has become increasingly clear that increasing adolescents’ knowledge about HIV is only weakly associated with decreasing their HIV-associated risk behaviors. Clearly, while HIV knowledge may be necessary, as a foundation to enhance understanding of the disease and spread of the epidemic, it is not sufficient to motivate adolescents’ adoption of HIV-preventive practices. Empirical data derived primarily from recently completed observational cross-sectional and longitudinal cohort studies among diverse adolescent populations (DiClemente et al. 1996b; DiClemente 1991, 1992; Joffe 1993; Wight 1992), identifying the determinants of highrisk behavior and, more importantly, the determinants of safer sex behavior, have been integrated into the present generation of prevention programs. In general, the present generation of HIV-prevention programs, which are theory driven, emphasize motivational factors, provide skills training, including partner communication, sexual negotiation and resistance skills and condom application skills, and attempt to modify peer norms, are more effective at promoting the adoption of HIV-preventive behaviors (Jemmott and Jemmott 2000; Kelly and Murphy 1992; Fisher and Fisher 1992; Coates 1990; Choi and Coates 1994; DiClemente 1993b; Kirby 2000; Kirby and DiClemente 1994; D’Angelo and DiClemente 1996). These interventions have shown the capacity to reduce adolescents’ HIV-associated risk behaviors. However, while these HIV-prevention programs have been developed and evaluated, it does not mean that they cannot be improved. While demonstrating the ability to significantly enhance adolescents’ adoption and use of HIV-preventive strategies, the magnitude of observed behavioral changes reported (i.e., program effect sizes) have been, by and large, modest. To enhance interventions, family-based approaches that involve training parents to be STD/ HIV educators, enhance parents’ communication about sexuality-related topics, and develop parents’ monitoring skills may be an effective strategy (DiClemente and Wingood 2000).

Components critical to the success of STD/HIV prevention interventions There are several key theoretical and implementation features which appear to be associated with changing adolescents’ sexual risk behavior. Foremost, programs need to be tailored to meet the specific needs of different adolescent populations. Adolescents are not a homogeneous population, but rather a mosaic of subgroups,

each with differing subcultural values and norms. As such, the HIV epidemic among adolescents is not a unitary epidemic, but many epidemics, each differentially affecting selected adolescent populations. Thus, HIV-prevention programs need to acknowledge this diversity between adolescent subgroups and include specific intervention strategies tailored to meet the needs of different adolescent populations.‘Tailoring’ should include ensuring that interventions are culturally sensitive, developmentally appropriate and gender-relevant (Wingood and DiClemente 1992, 1995, 1996; Airhihenbuwa et al. 1992). Second, utilizing a theoretical model on which to base the intervention – one which addresses the interplay between the adolescents’ cognitions, attitudes and beliefs, and their behavior and environmental influences – improves the likelihood of program efficacy. This is a critical consideration. Sexual behavior, in particular, takes place within a sociocultural context. Understanding the contextual nature of adolescents’ behavior, the factors which promote the adoption of preventive behaviors, and the countervailing influences which reinforce risk-taking behavior, is programmatically important. One model that is particularly useful as a foundation for developing sexual risk-reduction behavior change interventions, especially for adolescents and multi-cultural populations, is the Social Cognitive Theory (Bandura 1994, 1992). The cornerstones of this model include the provision of timely and accurate information, development and mastery of social competency skills through observational learning techniques (e.g., social modeling) and active learning techniques (e.g., role playing, preferably a series of graded-intensity of high-risk situations), enhancement of self-efficacy to communicate assertively and effectively with sex partners, and development of a supportive peer network to reinforce the maintenance of safer sex behaviors. Many of the effective prevention interventions reviewed earlier were based on this model. Another key component is maintaining a narrow focus on reducing sexual risk-taking behaviors. Thus, each sexual risk behavior targeted for change, whether it is enhancing condom use, reducing the number of sexual partners, or even postponing sexual intercourse, should be clearly specified with appropriate strategies designed to directly address it. This is of critical importance, for too often prevention programs have targeted a broad spectrum of risk behaviors for change without including behavior-specific change strategies in the program. For example, designing a prevention intervention to enhance adolescents’ self-efficacy to reduce their number of sexual partners is an important and appropriate endpoint. However, the behavior-specific strategies and techniques used to enhance their self-efficacy may not increase their ability to assert themselves so that their sex partners use condoms. Thus, while there may be generalized effects attributable to participation in a prevention program, in general, the techniques and strategies should be narrowly

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focused rather than broad, with the assumption that the skills and knowledge will be translated by the adolescent to other behaviors or situations. Programs designed to reduce the number of sex partners and increase condom use are addressing two important, but qualitatively different risk behaviors. To be maximally effective, each risk behavior, the underlying psychosocial factors that reinforce the behavior, and the strategies and skills needed to achieve behavior change must be adequately addressed. Finally, there are specific psychosocial constructs which have been identified as associated with condom use (DiClemente 1992, 1996; Joffe 1993; Wight 1992; Crosby et al. 2000). Interventions which are tailored to emphasize these constructs are more likely to be effective in modifying adolescents’ behavior. Key constructs include: 1 Providing specific skills training in sexual communication, negotiation and assertiveness skills. 2 Enhancing adolescents’ perceptions of peer norms as supporting safer sex behavior. 3 Enhancing self-efficacy to avoid high-risk situations and refuse high-risk sex. 4 Increasing adolescents’ awareness of the effects of alcohol and drug use on their sexual behavior. 5 Providing condom use skills and increasing the availability of condoms. In a recent review of twenty-eight studies published between 1983 and 1993, Stanton et al. (1996) identified similar intervention components that appear to be important in intervention design with adolescents. Furthermore, this review indicated that more recent studies have included more of these components than earlier studies. This trend suggests that intervention researchers are now reaching closure in identifying intervention components that are critical for behavior change. Though we have identified core components of prevention interventions which have yielded promising results, given the magnitude of observed behavioral changes reported and the limited follow-up periods for evaluating the stability of treatment effects, new and innovative intervention approaches are needed. One approach, used by Slap and colleagues (1991), is to utilize peer educators to implement prevention interventions. Peer-based interventions represent an underutilized implementation strategy which may be particularly effective for promoting adolescents’ adoption of safer sex behaviors.

Peer Advocacy Models: a promising intervention strategy Peer Advocacy Models (PAM), derived from Social Cognitive Theory and based on developmental theory, recruit and train peers indigenous to a large target population to serve as leaders, educators and counselors and to become HIV-preventive behavior change agents. Peer

educators have been used effectively to prevent and, with less efficacy, to reduce adolescents’ use of substances such as tobacco, alcohol, and marijuana (Hansen and Graham 1991; Perry and Grant 1988; Robinson et al. 1987; Botvin 1986; Telch et al. 1990). With respect to HIV-associated behaviors, PAM-based interventions in clinic-based riskreduction studies have also demonstrated an ability to enhance HIV knowledge (Rickert et al. 1991) and decrease risk behaviors (Slap et al. 1989). PAM-based behavior change interventions, however, have not been extensively tested as an HIV-prevention strategy for adolescents. Peer Advocacy Models offer a number of advantages over adult-led programs when targeting interventions for adolescents. Peers may be more effective teachers of social skills, more influential models of health-promoting behavior, and can serve as credible role models because they are members of the adolescents’ social milieu. Peers can also help to change normative expectations about the frequency of the targeted behavior in the peer group. Finally, peers can offer social support for performance of desired behaviors and for avoidance of health-damaging behaviors (DiClemente 1993b). These advantages are particularly important when educating adolescents in environments where social networks are limited and social norms, which may encourage and support risktaking behavior, are highly influential (DiClemente and Houston-Hamilton 1989). Several studies have successfully used peer-based models for reducing high-risk sexual behavior in adult populations (Kelly et al. 1991). However, peer interventions, such as the one developed by Slap et al. (1991), are just now being evaluated with adolescents, particularly in countries most severely affected by the HIV epidemic (Aggleton et al. 1994). Available data indicate that peer leaders are positively perceived by other youth and are effective at communicating sexual risk-reduction messages and dispelling perceptions of high-risk sexual behavior as normative. Clearly, peer involvement in the implementation of HIV-prevention interventions warrants further consideration as one strategy for enhancing program efficacy.

TREATMENT Health care providers as behavior change agents: windows of opportunity for STD/HIV-prevention While school- and community-based prevention efforts are undoubtedly important in disseminating HIVprevention information, another critical, but underutilized access point for educating adolescents about HIV and other sexually transmitted diseases is during the provision of health care.

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Pediatricians and adolescent psychiatrists are most likely to be engaged in treating adolescents during the time of their onset of sexual and drug behaviors (American Academy of Pediatrics 1990). Thus, clinical interactions between the physician and adolescent patient become a window of opportunity to assess the prevalence of sexual and drug risk behaviors, evaluate the adolescent’s physical and psychological maturation, and provide developmentally appropriate HIV prevention information (DiClemente and Brown 1994). Unfortunately, ample data are available to indicate that this important channel for prevention information is not being adequately utilized, this being primarily attributable to physicians’ lack of training in prevention sciences, their discomfort in discussing sexuality, and the brevity of office visits. Clearly, the training of healthcare providers in prevention science theory and skills, as well as providing incentives to counsel their adolescent patients, is an area that requires greater attention.

adolescents require knowledge of the best counseling and preventive intervention approaches to help them in the formidable task of promoting the sexual health of adolescents. One subgroup of healthcare providers – child psychiatrists – need to be better informed about the intersection between traditional mental health problems and their association with STD/HIV-associated risk behaviors. The child psychiatrist is particularly likely to encounter the highest-risk youth. Being well situated with respect to accessing this high-risk population, child psychiatrists are readily able to identify those youth who are at risk. Thus, by alerting child psychiatrists to this important relationship, therapy – and even psychiatric evaluation – can become a potential opportunity to examine and modify adolescents’ risk behaviors. Finally, the child psychiatrist, after appropriate evaluation, can make referrals to developmentally appropriate HIV prevention programs, other medical specialties, such as infectious diseases or adolescent medicine, or recommend HIV testing, counseling, and follow-up as needed.

CONCLUSION Adolescents are at greater risk of acquiring STDs and are the fastest growing subgroup for HIV infection relative to other age groups. The reasons for this are a complex mix of biologic, behavioral, psychological, and social factors. While the health implications of STD infections have always been of considerable significance, in an era when as severe an infection as that caused by HIV exists, there is an overriding urgency to develop and implement HIV-prevention interventions designed to modify adolescents’ sexual attitudes, beliefs, perceived norms and, most importantly, sexual behaviors associated with HIV infection. Prevention programs designed to motivate adolescents to adopt and maintain HIVpreventive practices, particularly condom use during sexual intercourse and safer injecting drug use practices, represent the most practical strategy for controlling the HIV epidemic. Whilst modifying HIV risk-taking behaviors is, admittedly, a formidable challenge, such changes are achievable (Peterson and DiClemente 2000). While systematic STD/HIV prevention programs, adequately funded and innovative in design, offer the potential to effectively reduce adolescents’ STD/HIVassociated risk behaviors, these changes will be neither radical nor swift. STD/HIV behavior change will not be realized as a result of a single, static intervention administered at one time point. Rather, program effectiveness is enhanced when applied and evaluated continuously over an extended time period. Furthermore, to increase the comprehension and, perhaps effectiveness of STD/HIVprevention programs, these programs must be designed to be developmentally appropriate, culturally sensitive, and gender-relevant. Finally, those providing care to

ACKNOWLEDGMENT Preparation of this chapter was supported, in part, by grants MH54412 and MH55726 from the Center for Mental Health Research on AIDS, National Institute of Mental Health, National Institutes of Health.

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Stanton, B., Kim, N., Galbraith, J., Parrott, M. Design issues addressed in published evaluations of adolescent HIV-risk reduction interventions: a review. Journal of Adolescent Health 18: 387–396, 1996. Stone, K.M., Timyan, J., Thomas, E.L. Barrier methods for the prevention of sexually transmitted diseases. In Holmes, K.K., Sparling, P.F., Mardh, P., et al.(eds), Sexually Transmitted Diseases. New York, NY: McGraw-Hill, 1999, pp. 1307–1322. Telch, M.J., Miller, L.M., Killen, J.D., Cooke, S., Maccoby, N. Social influences approach to smoking prevention: the effects of videotape delivery with and without sameage peer leader participation. Addictive Behaviors 15: 21–28, 1990. Van de Perre, P., Jacobs, D., Sprecher-Goldberger, S. The latex condom, an efficient barrier against sexual transmission of AIDS-related viruses. AIDS 1: 49–52, 1987. Wasserheit, J. Epidemiological synergy: interrelationships between Human Immunodeficiency Virus infection and other sexually transmitted diseases. Sexually Transmitted Diseases 9: 61–77, 1992. Webster, L.A., Berman, S.M., Greenspan, J.R. Surveillance for gonorrhea and primary and secondary syphilis among adolescents, United States, 1981–1991. Morbidity and Mortality Weekly Report 42: 1–11, 1993. Wight, D. Impediments to safer heterosexual sex: a review of research with young people. AIDS Care 4(1): 11–21, 1992. Wingood, G.M., DiClemente, R.J. The influence of psychosocial factors, alcohol and drug on AfricanAmerican women’s high-risk sexual behavior. American Journal of Preventive Medicine 15: 54–59, 1998. Wingood, G.M., DiClemente, R.J. Cultural, gender and psychosocial influences on HIV-related behavior of African-American female adolescents: implications for the development of tailored prevention programs. Ethnicity and Disease 2: 381–388, 1992. Wingood, G.M., DiClemente, R.J. Understanding the role of gender relations in HIV prevention research. American Journal of Public Health 85: 592, 1995. Wingood, G.M., DiClemente, R.J. HIV sexual risk reduction interventions for women: a review. American Journal of Preventive Medicine 12: 209–217, 1996. Yankauer, A. The persistence of public health problems: SF, STD and AIDS. American Journal of Public Health 76: 494–495, 1986. Yankauer, A. Sexually transmitted diseases: a neglected public health priority. American Journal of Public Health 84: 1894–1897, 1994.

2.8 Adolescent homosexuality WILLIAM M. WOMACK

INTRODUCTION It is important to understand that the concept of human sexuality represents a spectrum of human behaviors, of which sexual orientation is an important component. The expression of sexual behaviors and lifestyle is a choice for all teenagers, regardless of sexual orientation. This expression is a concern for adolescents in the same way that relationships, intimacy, trust, and competent decisionmaking are also general concerns. For adolescents with same-sex orientation, the issue may loom larger simply because of lack of support, societal rejection, prejudice, and victimization. When the gay or lesbian adolescent is given the opportunity to develop within a supportive and accepting environment, the probability of serious mental health issues is no more likely than in the general adolescent population. Contemporary issues in adolescent medicine make it important that child psychiatrists, pediatricians, and family practitioners are able to deal with some of the primary care issues surrounding adolescent sexuality: sexually transmitted diseases (STDs) (including the possibility of HIV infection), teenage pregnancy, and the fact that there are still a large number of adolescents who are woefully lacking in education on sexuality. To be able as healthcare providers to truly be supportive of the gay/ lesbian teenager, it is important not only to have an understanding of same-sex orientation identity development and risk factors for this population, but also to have a clear understanding of general prepubescent and adolescent sexuality. This chapter will focus on the premise that adolescent homosexuality is a non-pathological variant in the spectrum of prepubescent and adolescent sexual identity development, and will discuss same-sex identity development, differences between gay and lesbian teenagers, and

particular risk factors for the homosexual adolescent. The importance of primary care issues, within the context of contemporary society, for the child psychiatrist and pediatrician in assessment and treatment will be addressed. Finally, practical advice will be given regarding support systems that reinforce positive strategies when dealing with the homosexual teenager.

ADOLESCENCE AS A CONCEPT The psychological, developmental, and societal theories that deal with the concept of adolescence are relatively new and are for the most part products of the twentieth century (Gonsiorek 1993; Irwin 1989; Jessor 1990; Ponton 1997). Prior to this time, puberty and the ability to engage in sexual activity were considered benchmarks for adulthood. This was true in our own society up until the industrial revolution, and remains true in many Third World countries today. Also, interestingly enough, there is a contemporary trend in middle and upper middle class society to extend the time frame of adolescence into young adulthood and the college years. This expansion of the definition of adolescence runs contrary to a current trend towards earlier biological sexual maturation. A dilemma for society today has to do with a higher incidence of early sexual activity, and its concomitant problems, in lower socioeconomic strata. Ironically, these same children become adults at an early age for a variety of reasons, including: poor parenting, family systems issues, and/or peer pressures (e.g., gang membership) that require the child to ‘grow up quickly’ to survive. The modern concept of adolescence often brings to bear a consensus among institutions, and perhaps a large numbers of adolescents themselves, that depicts the adolescent as immature and incapable of adult decision-making.

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That consensus heavily influences our understanding of adolescent sexuality. Therefore, sexual expression is reserved for heterosexual, married adults, and there are no adolescent prerogatives for sexual expression. Adolescent sexuality is to be categorized, legislated, pathologized and, ultimately, suppressed. There is no real support for education which could create a structure for informed decision-making. As a society we have forgotten that in earlier times individuals were fully sexual, adult, and reproducing at ages that are now viewed as immature. Contemporary society is also filled with easy access to erotic images that bear very little relationship to the viewpoint that sexual expression is only to be experienced within the construct of marriage. The conflicts between the biologic, cultural, and psychosocial realities of adolescence make for great confusion about adolescent sexuality and no understanding at all about adolescent homosexuality.

NORMATIVE DATA AND STATISTICS More than half of all adolescents are sexually experienced before the age of twenty. The unfortunate consequence of this increase in sexual activity is an increase in unintentional pregnancies and in the incidence of STDs in this population. Rates of STDs among sexually active youth are higher than among sexually active persons of any other age (Stewart and Hofmann 1997). The motivational factors which lead to an increased incidence of early sexual activity are complex. They include chronic dysphoria and low self-esteem with a belief that sexual intimacy will provide love and a sense of being wanted. Also, having a baby can mean that an adolescent will be recognized as an adult, along with the fact that the baby itself will provide unconditional love. The sense of disconnection from society at large is a growing issue with some teenagers and sexual acting-out is a way of expressing their sense of deprivation. Negative peer pressure and a wish ‘to belong’ because ‘everyone else’ is sexually active is also a factor. Finally, there are still teenagers who have early experiences with sexual intercourse because they are ‘in love’ and are ready to experience and test the lessons of intimacy. Stewart and Hofmann (1997) present the following data on the incidence of teenage sexual intercourse: 1 More than half of all of teenage girls (66%) and nearly three-quarters of all teenage boys (70%) have had sexual intercourse before their eighteenth birthday... 9 per cent of twelve- year-olds and 38 per cent of fourteen-year-olds are sexually active. 2 A significant number of youths have had multiple partners, with 13 per cent of 14- to 17-year-olds and 41 per cent of 18- to 21-year-olds having had four or more sexual partners during their lifetime to date.

3 There is a significant disparity in rates of sexual intercourse between adolescents of different ethnicities. More African-American high school students (79%) are sexually experienced than white (48%) or Hispanic students (56%). D’Augelli and Hershberger (1993) offer some comparison data relating to adolescence and sexual orientation. Same-sex orientation females report first same-sex sexual activity and first opposite-sex sexual activity at age fifteen years. Same-sex oriented males report first samesex sexual activity also at fifteen, but report opposite-sex sexual activity at age twelve years.

SEXUAL IDENTITY DEVELOPMENT Sexuality does not begin in adolescence, though puberty usually marks the beginning of self-conscious sexual expression, both biologically and psychologically. There are two developmental tasks which accompany puberty that include: (1) the formation of an adult sexual identity; and (2) decisions about intimate ties with others. Normal sexuality has three components: 1 Gender identity (the sense of being a man or a woman). 2 Gender role (expressions of femininity or masculinity which are culturally determined/defined). 3 Sexual orientation (persistent pattern of physical and/ or emotional attraction to members of the same or opposite sex). Included in this spectrum are heterosexuality (opposite-gender attraction); homosexuality (same-gender attraction); and bisexuality (attraction to members of both genders). As a general rule, adolescents are unsure of their orientation. Sexual experimentation is frequent during this period, and sexual behavior in this developmental phase does not predict sexual orientation. A firm sense of sexual identity for males occurs around the age of twentyone years. In most studies, only small percentages of high school students self-identify as homosexual or bisexual during early or mid-teens.

HOMOSEXUALITY Statistics for the prevalence of homosexual behavior and identity among adolescents remain to be defined (Bagley 1998). The gathering of these data for the adolescent population is almost impossible because of complex developmental issues, and also because of highly charged sociopolitical issues (Green 1998). Some-large scale studies have been reported of the prevalence of homosexuality among adults, and these might be used to consider trends in adolescence. One international study found

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that 8.6–11.6 per cent of females and 7.9–8.7 per cent of males report same-sex attraction after the age of fifteen years (Sell et al. 1995). Laumann et al. (1994) found lower figures: 7.7 per cent of males and 7.5 per cent females reporting same-sex interest after puberty. The traditional estimates are that 5–10 per cent of the population is predominantly homosexual, with the estimate for males approaching the higher figure, and for females, the lower. Ramafedi et al. (1992) found that 11 per cent of junior and high school students in Minnesota were ‘unsure’ of their sexual orientation, and only about 1 per cent clearly labeled themselves as lesbian, gay, or bisexual. The prevalence figures for same-sex attraction during adolescence may be larger than 10 per cent, but what does seem clear is that few adolescents engage in same-sex sexual activity exclusively, and fewer still identify themselves as lesbian, gay, or bisexual.

ETIOLOGY Researchers have yet to reach a consensus on the etiology of homosexuality, but there are two general lines of thought:

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biological; and environmental/psychological.

Included in the biological factors is research with nonhuman primates, where portions of the anterior hypothalamus have been implicated in the generation of male-typical sexual behavior. In a post-mortem study of the hypothalamic nuclei in women, men presumed to be heterosexual, and homosexual men, one of the nuclei was found to be more than twice as large in heterosexual men than it was in women and homosexual men. Since that nucleus is dimorphic for sexual orientation (at least in men), it suggests a biological component in human sexual orientation (LeVay 1991). More compelling research looks at genetic factors and monozygotic male twin pairs. In the largest study to date (115 male twin pairs and 46 males with adoptive brothers) 52 per cent of the monozygotic co-twins, 22 per cent of the dizygotic co-twins, and 11 per cent of the adoptive brothers were concordant for homosexuality (Bailey and Pillard 1991). The same investigators have presented preliminary data for female homosexuality that reveal a similar differential concordance for lesbianism in monozygotic and dizygotic cotwins and in adoptive sisters (Bailey et al. 1993). These studies clearly suggest a genetic component, but also take issue with the fact that genetic factors may not act alone, as in both these studies the twins were raised in the same environment. Finally, there are recent studies which have found a statistically higher prevalence of homosexuality in the brothers of homosexual males and in the sisters of

homosexual females than in the general population (Bailey and Benishey 1993). Environmental influences and family patterns, with regard to sexual orientation, are much more difficult to study, in large part because the data are primarily retrospective and no study has yet been devised which looks prospectively at the development of sexual orientation. Consequently, the attempt to understand the etiology of sexual orientation has to continue to rely on an integration of biology, family–cultural environment, and intra-psychic psychodynamics.

HOMOSEXUAL IDENTITY DEVELOPMENT There are several models for homosexual identity development (‘the coming-out process’) (Cass 1979; Cox and Gallois 1996; Ryan and Futterman 1997; Troiden 1988, 1989). This process begins in adolescence or in early adulthood, and describes stages which ultimately lead to a firm sense of sexual identity. Troiden (1989) has defined four stages: 1 ‘Sensitization.’ This is described as a feeling of ‘differentness’ as a prepubertal child or adolescent. This could be the first recognition of same-sex attraction before or during puberty. 2 ‘Sexual identity confusion.’ Confusion and turmoil stemming from self-awareness of same-sex attraction which may be at least to some degree a result of negative societal stereotypes. The psychosocial issues important at this stage include difficulty obtaining information about homosexuality, the difficulty finding positive gay role models, and not having an opportunity for socialization as a gay/lesbian individual. 3 ‘Sexual identity assumption.’ The consideration of homosexuality as a lifestyle and the acknowledgment and sexual exploration of one’s gay identity. This is a period of emotional, social, and sexual experimentation. If early attempts at establishing same-sex relationships are not successful, this can lead to the individual re-experiencing negative feelings about being gay or lesbian. 4 ‘Integration and commitment.’ A positive selfacceptance and the sharing of the newly acquired ‘gay identity’ with selected others. These decisions and this stage seem to be most often experienced as a young adult, but clearly in contemporary society this stage can be a part of adolescence. It is important to remember that all the homosexual identity development models presented here represent a retrospective view and must be understood within the context of a society which has defined same-sex attraction as abnormal and deviant. The stages are non-linear, and the individual may repeat stages depending on crisis events or lack of a support system.

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Gonsiorek (l993) describes in some detail the differences between lesbian and gay individuals during adolescence and the ‘coming-out’ process. He suggests that the process for males is more abrupt and more likely to be associated with psychiatric symptoms, but that women seem to go through this period with more flexibility and ambiguity. He ascribes some of these differences to opportunities for sexual socialization. Women in western society have a broader range of behavioral and emotional interactions with other women, and consequently lesbian teenagers may experience the emerging sexual intimacy as friendship. Men do not have the same opportunity for emotional or physical contact with other males without being perceived as homosexual. Men may be more likely to actively engage in sexual behaviors whereas women may be more reflective. Gonsiorek also postulates that men tend to sexualize relationships and are more competitive and independent rather than intimate. Women have an easier time with intimacy, but experience difficulty with autonomy and individuality. Successful same-sex male relationships have to find a balance of how to share in the relationship and how to contain competition and independence. Same-sex female relationships develop intimacy and cooperation easily, but the individuals have a tendency to merge and become dependent.

HOMOPHOBIA Our culture is hostile to homosexuality and socializes the members of our society to be negatively predisposed to same-sex sexual orientation. Homophobia refers to an irrational and distorted view of homosexuality. This is generally manifested as prejudice or discomfort with the concept of, and contact with gay/lesbian individuals. Prejudice can be seen within the heterosexual community, but can also be experienced and expressed by homosexual individuals as ‘internalized homophobia,’ which is a negative attitude that has implications for self-esteem and selfimage. Much of the discomfort and the psychological problems that affect the homosexual adolescent have their roots in the experience of the rejection and prejudice caused by homophobia. It is important for health providers and therapists to become knowledgeable about these external and internal forces that affect the patient. This awareness can positively affect the ability of the therapist to be both objectively and subjectively supportive.

RISK FACTORS (STRESSORS) FOR THE GAY/LESBIAN ADOLESCENT The risk factors that create psychosocial difficulties for the homosexual teenager are clearly related to the prejudice

and rejection associated with the experience of homophobia in our society. The central issue for the gay/ lesbian teenager is a feeling of isolation, a constant fear of rejection, and concern about being hurt either physically or emotionally by family, friends, or by society at large. Isolation is a core issue for the homosexual adolescent. There is a constant worry about the probability of ‘being different’ but not knowing who to talk to. Concerns about weight, dress, academic, or athletic ability are common comparison problems for teenagers generally, but the sanctions against same-sex orientation are so powerful, the likelihood of rejection creates much anxiety. Having support from a peer group during adolescence is very important developmentally, and for the homosexual teenager, the potential loss can create major psychological distress. As important to the teenager as peer support is family support. Parents commonly reinforce society’s negative viewpoint towards homosexuality and may openly reject the teenager, asking him to leave home, physically abuse the teenager, or create enough family system pressure through shock or anger that the teenager becomes a ‘problem focus’ for the family. There is no basic institutional support in that many schools, churches, and youth groups allow the open rejection of gay/lesbian youth. Name-calling and the instilling of guilt for being different are commonplace. Not being able to talk about same-sex attraction with friends and relatives creates the problem of constant worry that someone will find out and that rejection will follow. At the same time, openness has the potential repercussion of the loss of social support, and can lead to major psychological crises and acting-out behaviors. Within our society until recently, it has been difficult to find positive gay role models, and the linkage of human immunodeficiency virus (HIV) infection with same-sex orientation, along with society’s portrayal of negative stereotypes, has created for some teenagers a fear of what being gay/lesbian means. Finally, the issue of real victimization, characterized by verbal and physical assaults, homelessness, and the potential for exposure to violence, drug abuse, and prostitution, is an ultimate risk factor for the gay/lesbian teenager.

RISK-TAKING BEHAVIORS Many data exist in the literature which address the impact that societal discrimination and homophobia have with regard to clearly negative risk-taking behaviors for the gay/lesbian teenager. These include excessive alcohol/substance abuse, suicide attempts, unsafe sexual behavior, running away from home, and prostitution (D’Augelli and Hershberger 1993; Ramafedi et al.

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1991). Ponton (1997) argues that it is in the nature of adolescents to take risks to develop and define themselves: ‘Risk-taking is the major tool that adolescents use to shape their identities. ...’ However, for the adolescent to develop skill at positive risk-taking, they need family support in the form of positive role models from parents and support from parents to help them find opportunities for challenge in open and safe settings. They also need positive role models and support from peers and society at large. Peers become more influential as a child enters adolescence, and peer pressure can be either negative or positive. Adolescents seem most susceptible to peer pressure in early adolescence, and this begins to lessen after age thirteen or fourteen years. The peer group comes to represent the stamp of normality and an assurance of acceptance. It is not uncommon for parental abuse or neglect to push the teenager into associations with adverse peer influences. Schools are where adolescents typically spend most of the time that they are not at home. Doing poorly in school and/or dropping out of school are correlated with having behavioral, social, and legal problems. Friendships, skills, and mentoring are all positive experiences that can be obtained through school. D’Augelli (1996) writes that critical mental health issues for gay and lesbian youth are:

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stress associated with management of lesbian/gay identity; disruptions in peer relationships; conflicts about disclosure to family and consequences of disclosure; isolation from lesbian/gay/bisexual-affirming contexts; distress caused by discrimination, harassment, and violence based on sexual orientation; and anxieties related to sexual health, especially HIV infection.

Ramafedi et al., in a study evaluating risk factors for suicide attempts in gay and bisexual youth, states that in 44 per cent of his subjects the suicide attempts were attributed to ‘family problems,’ ‘including conflicts with family members, and parents’ marital discord, divorce, or alcoholism.’ Some 30 per cent of the subjects reported ‘personal or interpersonal turmoil regarding homosexuality.’ The study finally concludes that illicit drug use, feminine gender role, and age at time of bisexual or homosexual self-labeling (the younger the age the greater the risk of suicide attempt) are primary risk factors for suicide attempts. There is literature regarding protective factors that might be useful when thinking about strategies to help gay/lesbian teenagers who are engaged in negative risktaking behaviors. Garmezy (1986) lists three categories of protective factors: (1) personality dispositions (temperament); (2) a supportive family milieu; and (3) an external

support system that encourages and reinforces a child’s coping efforts and strengthens these by reinforcing the child’s positive values. The Kauai Longitudinal Study (Werner and Smith 1992) has reported that the ability to find and use an external support system is a significant protective factor for adolescents who are otherwise considered in jeopardy. Finally, there are suggestions that sex differences may also be relevant to protective factors and resilience. Girls seem to possess a wider range of coping skills than boys, particularly in forming relationships. It is important for the health provider to be aware that negative risk-taking behaviors during adolescence may be a signal of concern regarding issues of sexual orientation, and how these issues may be compounded by a system which does not offer to the gay/lesbian teenager the very supports which all adolescents need to deal with the developmental tasks of being a teenager.

Assessment and treatment issues We live in a society which is filled with erotic images, and through the media children and adolescents learn a great deal about sex, but very little about relationships and intimacy. Sexual orientation is openly discussed today. Gay, lesbian, bisexual, and heterosexual are terms which we hear often in most aspects of our society. However, even though the words and images surround us, there are still too many parents, children, adolescents, physicians and healthcare providers who are not well educated about normal sexual development. Primary care physicians, pediatricians, and child psychiatrists are often chosen or are in position to listen to concerns of the teenager about all aspects of life, sexuality being one of them. The following represent some suggestions for primary care providers which will allow them to be more supportive and understanding. 1 Physicians need to actively plan to take sexual histories routinely. Sexuality is an issue teens worry about, but may choose to not ask questions about because of embarrassment. 2 Physicians need to be able to counsel about safe-sex practices and to inquire how the teenager is being educated in areas of relationship formation, responsible sexual behavior, and what access they have to health resources. Boys may need help particularly in not using force and coercion when developing relationships. 3 The healthcare provider needs to use patient care skills that engender trust, respect, and a sensitivity to confidentiality between the teenager and the physician. 4 Physicians, when taking a history, should not presume a heterosexual orientation, but need to create an opportunity that allows the teenager to state his/her pattern of emotional and physical attraction. 5 Teenagers who are regularly sexually active need to be screened for STDs.

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6 Adolescents need to be reassured that ambiguity about sexual identity and orientation is part of normative development and that they will gradually develop a pattern of relationships which will help them to understand their sexual identity. There is no need for premature labeling. 7 The converse of the above is also true. Some teenagers will be certain about their orientation, and it is important for the physician to be non-judgmental about the information. 8 If personal convictions prevent the physician from being non-judgmental, the patient should be referred to a health provider who can be supportive. 9 Physicians should ask about the presence or absence of support systems and make recommendations regarding literature, support groups, or community agencies. 10 Disclosure regarding same-sex orientation or bisexuality can be risky if the teenager has not thought about whether a support system is available. Disclosure to parents particularly should be well thought-out, so that the teenager is protected in part from exposure to violence or abandonment. 11 Counseling (psychotherapy) may be appropriate for confusion or turmoil regarding sexual orientation. Therapy directed at forcing a label or changing the label is more harmful than helpful. Clarifying and helping the teenager to make choices which seem to be the best for that moment in time should be the goal of the psychotherapy, as well as looking at other developmental issues which would be pertinent to any teenager, regardless of sexual orientation. 12 Therapy is often helpful with family or environmental concerns. Sexual abuse is a major area for information gathering.

SUPPORT SYSTEMS It can be very difficult for the health provider who is trying to be supportive and non-judgmental of gay/lesbian youth to provide specific information about the literature and community agencies available to help and advise these teenagers. This is particularly true if the health provider does not deal in any focused way with gay/lesbian issues and/or patients. This section is designed to provide some practical advice about where to find resource materials dealing with same-gender and bothgender oriented adolescents. Free Your Mind: The book for Gay, Lesbian, and Bisexual Youth and Their Allies (Bass and Kaufman 1996), is a wonderful and sensitive basic primer written especially for teenagers, but which can clearly be used by the health provider to educate the provider and the youth asking for help. There is a very comprehensive resource section at

the end of the book covering many areas of inquiry important for the teenager and anyone interested in helping.

Youth resources One excellent resource is The Lambda Youth Network, which is designed to locate gay, lesbian and bisexual resources in your city and state. Sending a request by mail or by e-mail will get you a customized listing of groups and PFLAG chapters in your locality.

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Lambda Youth Network, PO Box 7911, Culver City, CA 90233. [email protected]

Books of interest to lesbian, gay, and bisexual youth Examples include:

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Bauer, Marion Dane (ed.) Am I Blue: Coming Out From The Silence. New York: Harper Collins, 1994. Brown, Rita Mae. Ruby Fruit Jungle. New York: Bantam Books, 1973. Cohen, S.D. When Someone You Know is Gay. New York: Doubleday Books, 1995. Due, L. Joining the Tribe: Growing Up Gay and Lesbian in the 90’s. New York: Doubleday Books, 1995. Fricke, A. Reflections of a Rock Lobster: A Story About Growing Up Gay. Boston: Alyson Publications, 1981. Harris, Robie H. It’s Perfectly Normal: A Book About Changing Bodies, Growing Up, Sex, and Sexual Health. Cambridge, MA: Candlewick Press, 1994. Heron, A. (ed.) One Teenager in Ten. Boston: Alyson Publications, 1983. Heron, A. (ed.) Two Teenagers in Twenty: Writing by Gay and Lesbian Youth. Boston: Alyson Publications, 1994. Mosca, Frank. All American Boys. Boston: Alyson Publications, 1983. Pollack, Rachel, and Cheryl Schwartz. The Journey Out: A Guide For and About Lesbian, Gay, and Bisexual Teens. New York: Penguin Books, 1995. Rench, J.E. Understanding Sexual Identity: A Book for Gay and Lesbian Teens and Their Friends. Minneapolis: Lerner Publications Co., 1990.

Family resources Examples include:

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Fairchild B., Hayward N. Now That You Know: What Every Parent Should Know About Homosexuality. San Diego, CA: Harcourt, Brace, Jovanovich, 1989. Griffin, C.W., Wirth, M.A. Beyond Acceptance: Parents of Lesbians and Gays Talk About Their Experiences. St. Martins Press, 1986.

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Parents, Family, and Friends of Lesbians and Gays (PFLAG), 1101 14th Street N.W., Suite 1030, Washington, DC 20005. Tel: (202) 638-4200; e-mail: pfl[email protected].

Community resources Examples include:

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Lambda Legal Defense and Education Fund, 666 Broadway 12th floor; New York, NY 10012-2317. Tel: (212)995-8585. The National Gay and Lesbian Task Force (NGLTF), 6030 Wilshire Blvd., Suite 200, Los Angeles, CA 90036. Tel: (213)934-9030.

SUMMARY Primary care health providers represent a large, potential resource community that can assist in preventing the suffering, emotional distress, and negative risk factor behaviors which can be part of the experience of teenagers who are gay, lesbian, or bisexual. These providers as educators and simple listeners can often make the difference between a teenager who feels alone and isolated, and a teenager who finds a way to link with support systems. There are many adolescents, however, who do not experience their homosexuality as shameful, or as a barrier to real success and achievement in life and these numbers are growing. Advocacy, education, and support can help all gay, lesbian, and bisexual youth take their rightful place as part of the spectrum of children of America.

REFERENCES Bagley, C. On the prevalence of homosexuality and bisexuality in a random community survey of 750 men aged 18 to 27. Journal of Homosexuality 36(2): 1–18, 1998. Bailey, J.M., Benishey, D. Familial aggregation of female sexual orientation. American Journal of Psychiatry 150: 272–277, 1993. Bailey, J.M., Pillard, R.C. A genetic study of male sexual orientation. Archives of General Psychiatry 48: 1089–1096, 1991. Bailey, J.M., Pillard, R.C., Neale, M.C., et al. Heritable factors influence sexual orientation in women. Archives of General Psychiatry 50: 217–223, 1993. Bass, E., Kaufman, K. Free Your Mind: The Book for Gay, Lesbian, and Bisexual Youth and their Allies. New York: Harper Perennial, 1996. Cass, V. Homosexual identity formation: a theoretical model. Journal of Homosexuality 4: 219–235, 1979.

Cox, S., Gallois, C. Gay and lesbian identity development: a social identity perspective. Journal of Homosexuality 30: 1–30, 1996. D’Augelli, A.R., Hershberger, S.L. Lesbian, gay, and bisexual youth in community settings: personal challenges and mental health problems. American Journal of Community Psychology 21: 421–448, 1993. D’Augelli, A.R. Lesbian, gay, and bisexual development during adolescence and young adulthood. In Cabaj, R.P., Stein, T.S. (eds), Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, 1996, pp. 267–288. Garmezy, N. Developmental aspects of children’s responses to the stress of separation and loss. In Rutter, M., Izard, C.E., Read, P. (eds), Depression in Young People. New York: Guilford Press, 1986, pp. 297–323. Gonsiorek, J.C. Mental health issues of gay and lesbian adolescents. In Garnets, L.D., Kimmel, D.C. (eds), Psychological Perspectives on Lesbian and Gay Male Experiences. New York: Columbia University Press, 1993, pp. 469–485. Green, B.C. Thinking about students who do not identify as gay, lesbian, or bisexual, but... Journal of American Colleges of Health 47(2): 89–91, 1998. Irwin, C. Risk-taking behavior in the adolescent patient: are they impulsive? Pediatric Annals 18(2): 122–133, 1989. Jessor, R. Risk behavior in adolescence: a psychosocial framework for understanding. In Rogers, D., Ginzberg, E. (eds), Adolescents at Risk: Medical and Social Perspectives. San Francisco: Westview, 1990, pp. 19–34. Laumann, E.O., Gagnon, J.H., Michael, R.T., et al. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press, 1994. LeVay, S. A difference in hypothalamic structure between heterosexual and homosexual men. Science 253: 1034–1037, 1991. Ponton, L.E. The Romance of Risk: Why Teenagers Do the Things They Do. New York: Basic Books, 1997, pp. 4–8, 273–280. Ramafedi, G., Farrow, J.A., Deisher, R.W. Risk factors for attempted suicide in gay and bisexual youth. Pediatrics 87: 869–875, 1991. Ramafedi, G., Resnick, M., Blum, R., et al. Demography of sexual orientation in adolescents. Pediatrics 89: 714–721, 1992. Ryan, C., Futterman, D. Lesbian and gay adolescents: identity development. In Ryan, C., Futterman, D. (eds), Adolescent Medicine: State of the Art Reviews. Lesbian and Gay Youth: Care and Counselling. Philadelphia: Hanley and Belfus, 1997, pp. 211–223. Sell, R.L., Wells, J.A., Wypij, D. The prevalence of homosexual behavior and attraction in the United States, the United Kingdom, and France: results of national population-based samples. Archives of Sexuality and Behavior 24: 235–248, 1995.

162 Risk behavior, risk-taking, and sexuality Stewart, D.C., Hofmann, A.D. Adolescent sexuality. In Hofmann, A.D., Greydanus, D.E. (eds), Adolescent Medicine. Connecticut: Appleton and Lange, 1997, pp. 457–472. Troiden, R.R. Homosexual identity development. Journal of Adolescent Health Care 9: 105–113, 1988. Troiden, R.R. The formation of homosexual identities. Journal of Homosexuality 17: 43–73, 1989. Werner, E.E., Smith, R.S. Overcoming the Odds: High Risk Children from Birth to Adulthood. New York: Cornell University Press, 1992.

Suggested reading Beaty, L.A. Identity development of homosexual youth and parental and familial influences on the coming out process. Adolescence 34(135): 597–601, 1999. Black, D., Gates, G., Saunders, S., Taylor, L. Demographics of the gay and lesbian population in the United States: evidence from available systematic data sources. Demography 37(2): 139–154, 2000.

Diamond, L.M. Development of sexual orientation among adolescent and young adult women. Developmental Psychology 34(5): 1085–1095, 1998. Ramafedi, G. Homosexual youth: a challenge to contemporary society. Journal of the American Medical Association 258: 222–225, 1987. Saewyc, E.M. Gender differences in health and risk behaviors among bisexual and homosexual adolescents. Journal of Adolescent Health 23(3): 181–188, 1998. Safren, S.A., Heimberg, R.G. Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. Journal of Consulting and Clinical Psychology 67(6): 859–866, 1999. Sells, C.W., Blum, R.W. Current trends in adolescent health. In DiClemente, R.J., Hansen, W.B., Ponton, L.E. (eds), Handbook of Adolescent Health Risk Behavior. New York: Plenum, 1996, pp. 5–35. Stronski Huwiler, S.M., Ramafedi, G.M. Adolescent homosexuality (review). Advances in Pediatrics 45: 107–144, 1998.

SECTION

3

Normal development EDITED BY DONALD SWANSON

Introduction Donald A. Swanson

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3.1 Sociocultural issues in adolescent development Ian A. Canino and Nilda M. Gonzalez

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3.2 Cognitive development Humberto Quintana

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3.3 Adolescent moral development Roy Lubit and Stephen B. Billick

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3.4 Adolescent interpersonal relationships Christopher J. Kratochvil and Martin J. Harrington

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Introduction DONALD A. SWANSON

An understanding of normal development is paramount to diagnose, treat, or prevent adolescent psychopathologies that have possible links to abnormal development. Normal development can occur across multiple pathways, and this section focuses on four topics: Sociocultural Issues; Cognitive Development; Moral Development; and Interpersonal Relationships. Canino and Gonzalez review some of the salient principles of sociocultural influences upon adolescents. They view adolescence as a stage in which cultural and ethnic development is increasingly influenced by exposure to society’s perception and evaluation of specific expected attributes, and to their multi-cultural peers. Despite the paucity of cross-cultural research, they posit that the data available suggest that there are cultural and contextual similarities and differences that interact powerfully to define the process, resolution, and future consequences of this developmental period. The chapter on cognitive development focuses primarily on the Piagetian theory of development, in which the basic element is the schema. This consists of a pattern of behavior in response to particular stimuli in the environment, and by means of assimilation and accommodation these schemata broaden and interact with a wider range of stimuli. Quintana describes the major stages of

cognitive development and how they affect children and adolescents. Lubit and Billick review the development of morality during adolescence, and see this development as a crucial aspect of adolescent development. The chapter expands upon the chapter on cognitive development by reviewing the evidence-based research of the social learning theorists, the cognitive developmental theorists, and the domain theorists. In each theoretical area Billick describes the development and expansion of the theory and how it has affected the moral development of adolescents. Finally, he describes the role of emotions, particularly guilt and anxiety, in the development of moral behavior with some information on the development and functioning of the superego during adolescence. Finally, in the chapter on interpersonal relationships, Kratochvil and Harrington describe adolescence as offering a diversity of relationships that are necessary for entry into adulthood. They see adolescence as a period of expanding relationships with parents, other adults, peers and, at times, with their own children. Adolescent interactions involve devaluation, distancing, authority conflict, instrumental aid, opportunities for friendships and affiliations as normal steps toward identity formation and individuation.

3.1 Sociocultural issues in adolescent development IAN A. CANINO AND NILDA M. GONZALEZ

INTRODUCTION The social and cultural influences on development are various and complex. They include the impact of childrearing patterns (i.e., discipline, achievement motivation, and gender role expectations), modes of parent–child interaction, language, peer relationships, and the overall influence of community and society in determining prescribed modes of behavior, perceptions, and meaning. In addition, they occur within the individual’s ability to understand social cues and respond and act within his developmental stage in a manner relevant to his culture and community. This requires an intact neurobiological system and hopefully a series of positive and reinforcing experiences during growth. The interactive and dynamic processes of these factors expose the growing child, under reasonable circumstances, to an opportunity to learn patterns of social and cultural behavior that are flexible and adaptive. Culture will help the child share representations of self and others and offer modes and guidelines for ways of thinking, dealing with human dilemmas, values, and socially adaptive skills. It will allow for the development of group identity, self-esteem and definition, and prepare the child to eventually take a role in society that will be constructive and creative. In addition, culture defines and shapes assumptions about oneself and others and perceptions about others’ reactions to the self (Chin 1988). Culture in our society is both highly pluralistic and constantly undergoing dynamic change. Adolescents are often exposed to a multiplicity of cultural attitudes through the media or through their communities. The additional impact of chronic family and social adversities, ethnic discrimination, hazardous living situations, and traumatic experiences can affect this process as much as can impaired cognitive, social, and physical limitations in the adolescent. In addition, sociocultural

beliefs and practices not only determine meanings on the etiology of distress and illness, but also affect symptom expression (Siegel et al. 1998), health-seeking behavior, service utilization (Pumariega et al. 1998), and response to treatment. Fully aware of the still limited methodologically sound empirical research in this area, it is the objective of this chapter to review some of the salient principles of sociocultural influences on adolescents, underlining the different pathways these may take in youngsters often seen by child and adolescent mental health professionals. Although a comparison of rearing practices and social development across all cultures is important, this chapter will focus on those aspects of development relevant to some ethnic/racial groups in the United States. Hopefully, this will address those sociocultural variables that are relevant to all.

ADOLESCENT DEVELOPMENT Adolescence, as a separate stage of psychosocial development, is observed in many societies. In many preindustrial and agrarian societies, children still assume adult roles and responsibilities at the onset of pubertal changes. In industrialized societies, the new tasks and the new abilities in adolescence allow for new competencies in dealing with the increasing demands of peers and society in general. Those children that enter adolescence with good social intelligence, persistence, a sense of personal control, a good sense of humor, who are flexible and adaptive and come from supportive community and family environments indicate resilient skills that should help them with major life transitions and events. There are new incentives for developing a sense of self (interests, values, and attributional styles), increasing independence and cognitive

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abilities, and consolidating the role of ones’ own sexual identity. These tasks can vary greatly in terms of timing according to the country of origin, rate of social change and institutional transitions, gender, social class, and culture. Cultural norms and expectations often offer guidelines for dating and related sexual behavior (Petersen et al. 1988) and can determine the nuances of family attachments and autonomy during this period (Shrier et al. 1996). They can affect the locus of control perceptions of this age (Chiu 1988), and influence peer relationships and career goals (Davis and Voegtle 1994; Spencer et al. 1990). Adolescence, itself a cultural phenomenon (puberty is its biological component), is thus highly defined by the context in which it exists.

ETHNIC DEVELOPMENT Even though there has been a paucity of cross-cultural research on temperament and behavior, studies often implicate culture as an important variable in the development of personality (Foulks 1996). Developmental studies have indicated that racial and ethnic concepts emerge through childhood and adolescence. Giles and Johnson (1981) state that three characteristics contribute to the clarity of group boundaries and thus to the development of group identification. ‘Distinctiveness’ refers to how well a group can be identified on the basis of language or physical features; ‘strength’ describes the group’s influence through a variety of activities; and finally ‘value’ addresses the positive or negative attitudes towards specific cultural norms. An awareness of ethnic and cultural differences is observed in children by the age of three or four years. Between the ages of four and eight years, children develop an ethnic orientation, better explanations of why they choose one social group over another, a consolidation of group concepts, and curiosity about other groups. As they grow they become aware of the nuances of ethnic cues such as language utilization and become increasingly cognizant of political power, discrimination, and the resources or lack thereof of their own group (Katz 1976; Goodman 1964; Aboud and Mitchell 1977; Porter 1971; Rotheram and Phinney 1987). In adolescence, ethnic identity will be constituted by both the objective criteria of ethnicity, ascribed identity, and the subjective criteria reflecting their choice of reference group or achieved identity (Ho 1992; Phinney and Rotheram 1987). Rotheram and Phinney (1987) define ethnic identity as a concept that encompasses ethnic selfidentification, ethnic awareness, ethnic attitudes, and ethnic behaviors. In a recent multi-ethnic sample studying these particular components of ethnic identity, Rotheram-Borus et al. (1998) found a variety in the

frequency of these components within each ethnic group. The adolescents varied along a continuum in their beliefs, values, social expectations, and self-perceptions. An adolescent’s self-perception does not necessarily address his group affiliation. Adolescents may deny their ethnicity or that of their families, they may over-identify with their ethnic group rejecting other groups, or they may integrate their sense of ethnicity to the mainstream culture if different from their own. In view of the increasing rates of interracial marriages (US Bureau of the Census 1991), there is an increasing number of youths who are bi-racial or bi-cultural (two religions or two culturally distinct groups) by birth. These youths may decide to integrate both cultures, or to select dimensions of each based on their own particular needs. Adolescents should, thus, be understood within the framework of both their behavioral competence in each group and their positive affect to both, neither, or one of them (Lambert 1977). Many adolescents define ethnicity by their choice of foods and activities, their conversational styles, or their ways of coping (Phinney and Rotheram 1987). Rosenthal (1987), in an excellent review of the literature, underlines the importance of understanding ethnic development as a dynamic process in which the adolescent’s own identity interacts with how those of his own group view him/her and how his group is viewed by others. The adolescent may identify with only parts of his culture or with the totality. Some cultural elements may be more salient than others. His cultural identification may be language centered, based on national origin, or on religious background. Adolescents may express their ethnic identification according to the ethnic identification of those surrounding them and belonging to the dominant culture or to a subgroup. This may make a difference in how much the cultural group plays a role. In addition, ethnic development will interact with race, level of experienced discrimination, class, religion, geographic region, intermarriage, and migration status (McGoldrick and Giordano 1996). There are many intragroup differences that are often determined by generation, social class, education, or physical attributes. The child’s response to ethnic stimuli may vary on whether the cues are perceptual, cognitive, or affective (Aboud and Skerry 1984; Ramsey 1987). Finally, differences in ethnic awareness and identity often occur in response to changes in generational or sociocultural groups, developmental growth, gender, or the interaction among these influences (Canino and Spurlock 1994). Many fourth-generation MexicanAmerican adolescents, for example, may not know the language or even much of their cultural history but may still identify with their ethnic group (Keefe and Padilla 1987). The process of ethnic and cultural development, in addition, includes two other processes: enculturation and acculturation (Berry et al. 1986). In the case of

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children, these processes are highly influenced by their parents and as they grow by their peer group, teachers and society in general. Enculturation refers to the awareness and acquisition of the social norms of one’s own cultural group. Acculturation includes one of two processes: assimilation or bi-culturalism. Assimilation is the attempt by one group to give up its own identity and culture and adopt fully that of the another culture. Bi-culturalism refers to the process whereby important aspects of the original culture are retained while adopting characteristics of another culture (Oetting and Beauvais 1990–1991; Rogler et al. 1991). The process of bi-cultural socialization is particularly important. Many factors have been described that affect the outcome of this process. The availability of cultural translators, models, and mediators, the degree to which the two cultures share norms and values, and the amount and type of corrective feedback offered by each culture are some. The degree of similarity in physical appearance in each culture, the congruence of the individual’s conceptual and problem-solving style with the other culture, and the degree of the individual’s language ability in the other culture have been others (de Anda 1984). Padilla (1994) describes the truly bi-cultural individual as confident, secure, well-adjusted, open to others, and socially and culturally tolerant. In a study assessing self-perceptions of competence in 123 Latino immigrant adolescents, Birman (1998) found that acculturation to the American culture predicted selfperception of competence with American peers. Acculturation to the Hispanic culture predicted competence perception with Latino peers, but perceived family competence was better predicted by acculturation to American rather than to Hispanic culture. Birman thus underlines the importance of knowing how individuals cope with situations where their cultural experiences diverge, converge or are in conflict with each other. Adolescents in multi-cultural settings may be at different points of this spectrum and often struggle with integrating not only one culture, but many. In addition, adolescents from ethnic minorities are often simultaneously involved in a dual-cultural perspective. One is the immediate social and physical environment of their culture (nurturing environment) and the other is that of the culture of the larger society (sustaining environment). If the differences between the two systems are big, then the potential for behavioral and value conflict increases (Norton 1983).

DEVELOPMENT OF PEER RELATIONSHIPS As the adolescent grows and explores his or her community, peers can provide a supportive environment without jeopardizing any growing sense of independence.

Erickson (1968) states that adolescents go through a time of identity crisis versus identity diffusion during which the need to belong to a group and conform to its rules is especially important. As the adolescent ages, the group becomes less essential to his/her sense of personal identity. This, nevertheless, may not apply to adolescents reared in non-industrialized societies or in large extended families where group cooperation and participation is often essential. In many – but not all – societies, early adolescence peer relationships are similar to those developed in childhood with a preponderance of same-sex peer groups. This preference may reflect a pursuit of separate activities by gender or less exposure to children of the other sex during daily activities. Girls tend to describe their same-sex groups as more supportive. Boys are more likely to have hierarchical organizations with established leaders and may be less open to new members (Gavin and Furman 1989). Between the ages of nine and thirteen years (Burkowski et al. 1993), same-sex friendships are rather consistent over twelve to eighteen months and reflect similar interests. Boys who prefer gross motor activities have a higher preference for being with other boys. Girls who like those activities have higher rates of other-sex friends. The need to conform to peer norms peaks around early adolescence and slowly declines afterwards. This is the time of dressing alike and following group norms to ‘fit in’, with cliques excluding those who do not. The ability of groups to allow others to join in, assume leadership roles and provide support for the adolescent varies with age and gender. Peer pressure, in addition, has been blamed for all sorts of maladaptive behaviors during this phase, with the protective role of social networks rarely discussed. Peer pressure is manifested in areas ranging from dress and speech styles, behavior towards parents, attitude towards work and academics, and attitudes towards drug and alcohol use, sexual activity and violence. In a confidential self-report study of a community sample of 1207 6th to12th graders, Brown et al. (1986) studied the difference between willingness to conform to peers, perceived peer pressure, and actual behaviors engaged in by the sample. Peer conformity to neutral situations was higher than to those viewed as antisocial. Peers were more likely to discourage antisocial activity. As in other studies, males were more likely to engage in misconduct than females. Within this framework, an adolescent’s acceptance by his peer group is often determined by his status, his looks, and frequently by attributes highly valued by the society he lives in. If the adolescent belongs to a group that is undervalued and discriminated against, his socialization experience may be fraught with many challenges. If straight hair and blue eyes are highly valued, or physical ability in sports highly pursued, then an adolescent with curly hair who is clumsy physically but competent

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academically will have a different perception of his level of acceptance by his peers.

FAMILY AND COMMUNITY INFLUENCES Family events, positive or negative (divorce, loss, illness), as well as household moves and family and community traditions can influence adolescent tasks and their resolution. The importance given to emotionality, dependence, family loyalty, religion, scholastic achievement, and peer socialization often varies according to family beliefs and cultural values (McGoldrick et al. 1982). For example, if the adolescent comes from a culture where the extended family is emphasized and family dependence is fostered, the loss of a family member by death or migration will certainly have a different impact than in a household where this is not the case. In addition, different cultures emphasize different value orientation profiles in terms of time, activity, relational approaches, and beliefs in the relationship of man to nature (Spiegel 1982). An indigenous Native-American adolescent may be more comfortable in defining himself as a member of a particular tribe and someone in the process of becoming more in harmony with his environment, than on what scholastic achievements he has acquired or what his parents do for a living. Differences between rearing styles across ethnic groups have been described by several authors. However, it is frequently difficult to separate the effects of culture from those related to educational and/or socioeconomic factors. In a study of family interactional styles and competence in 186 community-recruited, mostly two-parent household families, no significant differences were found among Caucasian-American, African-American, and Mexican-American families. Subtle differences were, nevertheless, observed. Mexican-American families as a group discouraged aggressive behavior while encouraging dependency in their children. African-American families were more likely to discourage dependency. The Caucasian-American families’ view of dependence was somewhere in the middle between these two groups. Other subtle effects, across all ethnic groups, were found between class and family competence. Higher socioeconomic status (and usually educational level) correlated with less overt hostility as a way of dealing with anger (Hampson et al. 1990). Families have the additional task of supporting children in the process of ethnic socialization. In multicultural societies where, in addition, many adolescents experience racism and discrimination, this is a formidable task. In a study of 60 American-born Japanese-American, African-American, and Mexican-American high-school students, some ethnic differences emerged (Phinney and Chavira 1995). African-American parents reported more

frequent discussions about prejudice with their children than Japanese-American or Hispanic-American parents. The Japanese-American and African-American parents emphasized adaptation to society more than the HispanicAmerican parents. The African-American parents discussed both achievement and social problems while the Japanese-American parents discussed mainly achievement problems. The Hispanic-Americans reported intermediate positions in both. In terms of the adolescents, 81.3 per cent of African-Americans, 45.9 per cent of MexicanAmericans, and 27.8 per cent of Japanese-Americans reported discriminatory experiences.

EDUCATIONAL AND VOCATIONAL INFLUENCES Social decisions by adolescents represent the effects of attaining the cognitive stage that enables them to be more reflective of their actions and assess their consequences, the integration of their identity and sense of self, and in Western industrialized societies a move towards an internal locus of control (Blum 1985). Educational performance in adolescence can affect later career development and thus enhance or restrict future options (Nurmi 1993). In addition, Osipow (1983) feels that some students often make occupational decisions about their future imposed on them by their specific educational system. Sociocultural explanations have been implicated in the differences of educational success between ethnic groups. In a recent study of over a thousand English-proficient adolescents from California, foreign-born Filipino and European students performed better than third-generation adolescents of the same ethnicity, whereas third-generation Latino students did better than their foreign-born counterparts (Fuligni 1997). A strong perception of parental, personal and peer emphasis on educational achievement was more commonly reported among foreignborn than among native-born adolescents. However, over 55 per cent of the first-generation sample consisted of only one ethnic group (Filipino). As in other reports, Asian children had the highest grades, and Latinos the lowest. The effects of culture, nevertheless, in the adolescent’s academic outcome are unclear. Popular explanations for differences among ethnic groups in academic achievement have included less emphasis on education in certain cultures, bias on examination questions, and poor self-esteem secondary to discrimination; however, these issues still remain controversial (Rowe et al. 1994). Support-seeking behavior has also been considered as different across groups. In young Caucasian-American college students, peer support was associated with academic commitment, whereas for African-Americans

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parental support was a stronger indicator of success (Malon et al. 1996).

CONCLUSION Adolescence is a period of development that affects children differentially in many parts of the world. The biological, cognitive, and social–emotional components of this stage are both complex and multi-factorial. The plurality and diversity of ‘normative’ expectations of this period are affected not only by their biological correlates but also by the complex sociocultural context in which they are embedded (Shrier et al. 1996). Adolescence both defines and is defined by biology, peers, family, community, and social supports and stresses. In spite of a paucity of cross-cultural research, partially due to the complex methodological issues that still need to be addressed, the data suggest that there are indeed cultural and contextual differences and similarities during this stage. Gender, age, and physical and cognitive attributes interact powerfully with cultural and societal values and expectations and, these in turn define the process, resolution, and future consequences of this period. The increased media and technological exposure to different cultures combined by the large migrations of culturally diverse groups pursuing economic opportunities or escaping political persecution, have emphasized the need to understand adolescence in a new light. Not only are there dynamic internal shifts but also increasingly major external shifts and demands from the environment. Finally, ethnic and cultural development in adolescence is increasingly influenced by exposure to multicultural peers and by society’s perception and evaluation of specific expected attributes.

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Blum, R. The adolescent dialectic: a developmental perspective on social decision-making. Psychiatric Annals 15(10): 614–618, 1985. Brown, B.B., Clasen, D.R., Eicher, S.A. Perception of peer pressure, peer conformity dispositions, and self-reported behavior among adolescents. Developmental Psychology 22: 521–530, 1986. Burkowski, W.M., Gauze, C., Hoza, B., et al. Differences and consistencies between same-sex and other sex peer relationships during early adolescence. Developmental Psychology 29: 255–263, 1993. Canino, I.A., Spurlock, J. Culturally Diverse Children and Adolescents: Assessment, Diagnosis, and Treatment. New York: Guilford Press, 1994. Chin, A.-P. Children of China: Voices from Recent Years. New York: Alfred A. Knopf, 1988. Chiu, L.H. Locus of control differences between American and Chinese adolescents. Journal of Social Psychology 128(3): 411–413, 1988. Davis, B.J., Voegtle, K.H. Culturally Competent Health Care of Adolescents: A Guide for Primary Care Providers. Chicago, Illinois: American Medical Association, 1994. de Anda, D. Bicultural socialization: factors affecting the minority experience. Social Work 29: 101–107, 1984. Erickson, E. Identity, Youth and Crisis. New York, W. Norton, 1968. Foulks, E.F. Culture and personality disorders. In Mezzich, J.E., Kleinman, A., Fabrega, H., et al. (eds), Culture and Psychiatric Diagnosis: A DSM Perspective. Washington, DC: American Psychiatric Press, 1996, pp. 243–252. Fuligni, A.J. The academic achievement of adolescents from immigrant families: the role of family background, attitudes, and behavior. Child Development 68: 351–363, 1997. Gavin, L.A., Furman, W. Age differences in adolescents’ perceptions of their peer groups. Developmental Psychology 25: 827–834, 1989. Giles, H., Johnson, P. The role of language in ethnic group relations. In Turner, J.C., Giles, H. (eds), Inter-group Behavior. Oxford: Blackwell, 1981. Goodman, M.E. Race Awareness in Young Children (revised edition). New York: Collier, 1964. Hampson, R.B., Beavers, W.R., Hulgus, Y. Cross-ethnic family differences: interactional assessment of White, Black, and Mexican-American families. Journal of Marital and Family Therapy 16: 307–319, 1990. Ho, M.K. Minority Children and Adolescents in Therapy. Newbury Park, CA: Sage Publications, 1992. Katz, P. The acquisition of racial attitudes in children. In Katz, P.A. (ed.), Towards the Elimination of Racism. New York: Pergamon Press, 1976, pp. 125–154. Keefe, S.E., Padilla, A.M. Chicano Ethnicity. Albuquerque, New Mexico: University of New Mexico Press, 1987. Lambert, W.E. The effects of bilingualism on the individual: cognitive and sociocultural consequences. In Hornby, P.A. (ed.), Bilingualism: Psychological,

170 Normal development Social and Educational Implications. New York: Academic Press, 1977, pp. 15–27. Malon, K.I., Teti, D.M., Corns, K.M., et al. Cultural specificity of support sources, correlates and contexts: three studies of African-American and Caucasian youth. American Journal of Community Psychology 24: 551–587, 1996. McGoldrick, M., Giordano, J. Overview: ethnicity and family therapy. In McGoldrick, M., Giordano, J., Pearce, J.K. (eds), Ethnicity and Family Therapy. New York: The Guilford Press, 1996, pp. 1–27. McGoldrick, M., Pearce, J.K., Giordano, J. (eds) Ethnicity and Family Therapy. New York: The Guilford Press, 1982. Norton, D. Black family life patterns: the development of self and cognitive development of Black children. In Johnson-Powell, G., Yamamoto, J., Romero, A., Morales, A. (eds), The Psychosocial Development of Minority Group Children. New York: Brunner Mazel, 1983, pp. 181–193. Nurmi, J.E. Adolescent development in an age-graded context: the role of personal beliefs, goals, and strategies in the tackling of developmental tasks and standards. International Journal of Behavioral Development 16: 169–189, 1993. Oetting, E.R., Beauvais, F. Orthogonal cultural identification theory: the cultural identification of minority adolescents. International Journal of Addiction 25(5A/6A): 655–685, 1990–1991. Osipow, S.H. Theories of Career Development. Englewood Cliffs, NJ: Prentice Hall, 1983. Padilla, A.M. Bicultural development: a theoretical and empirical examination. In Malgady, R.G., Rodriguez, O. (eds), Theoretical and Conceptual Issues in Hispanic Mental Health. Florida: Krieger Publishing. Co., 1994, pp. 19–51. Petersen, A.C., Crouter, A.C., Wilson, J. Heterosexual behavior and sexuality among normal young adolescents. In Levine, M.D., McAnarney, E.R. (eds), Early Adolescent Transitions. Lexington, MA: Lexington Books, 1988, pp. 123–137. Phinney, J.S., Rotheram, M.J. Children’s ethnic socialization: themes and implications. In Phinney, J.S., Rotheram, M.J. (eds), Children’s Ethnic Socialization: Pluralism and Development. Newbury Park, CA: Sage Publications, Inc., 1987, pp. 274–292. Phinney, J.S., Chavira, V. Parental ethnic socialization and adolescent coping with problems related to ethnicity. Journal of Research on Adolescence 5: 31–53, 1995. Porter, J.D.W. Black Child, White Child: The Development of Racial Attitudes. Cambridge, MA: Harvard University Press, 1971.

Pumariega, A.J., Glover, S., Holzer, C.E., Nguyen, H. Utilization of mental health service in a tri-ethnic sample of adolescents. Community Mental Health Journal 34(2): 145–156, 1998. Ramsey, P.G. Young children’s thinking about ethnic differences. In Phinney, J.S., Rotheram, M.J. (eds), Children’s Ethnic Socialization: Pluralism and Development. Newbury Park, CA: Sage Publications, Inc., 1987, pp. 56–72. Rogler, L.H., Cortez, D.E., Malgady, R.G. Acculturation and Mental Health status among Hispanics. American Psychologist 46: 585–597, 1991. Rosenthal, D.A. Ethnic development in adolescents. In Phinney, J.S., Rotheram, M.J. (eds), Children’s Ethnic Socialization: Pluralism and Development. Newbury Park, CA: Sage Publications, Inc., 1987, pp. 156–179. Rotheram, M.J., Phinney, J.S. Introduction: Definitions and Perspectives in the Study of Children’s Ethnic Socialization. In Phinney, J.S., Rotheram, M.J. (eds), Children’s Ethnic Socialization: Pluralism and Development. Newbury Park, CA: Sage Publications, Inc., 1987, pp. 10–28. Rotheram-Borus, M.J., Lightfoot, M., Moraes, A., Dopkins, S., LaCour, L. Developmental, ethnic, and gender differences in ethnic identity among adolescents. Journal of Adolescent Research 13(4): 487–507, 1998. Rowe, D.C., Vazsonyi, A.T., Flannery, D.J. No more than skin deep: ethnic and racial similarity in developmental process. Psychological Review 101: 396–413, 1994. Shrier, D.K., Hsu, C.-C., Yang, X. Cross cultural perspective on normal child and adolescent development: Chinese and American. In Mak, F.L., Nadelson, C.C. (eds), International Review of Psychiatry, Volume 2. Washington, DC: American Psychiatric Press, 1996, pp. 301–334. Siegel, J.M., Aneshensel, C.S., Taub, B., Cantwell, D.P., Driscoll, A.K. Adolescent depressed mood in a multi-ethnic sample. Journal of Youth and Adolescence 27(4): 413–427, 1998. Spencer, M.B., Dornbusch, S.M., Mont-Reynauld, R. Challenges in studying minority youth. In Feldman, S.S., Elliot, G.R. (eds), At the Threshold: The Developing Adolescent. Cambridge, MA: Harvard University Press, 1990, pp. 123–146. Spiegel, J. An ecological model of ethnic families. In McGoldrick, M., Pearce, J.K., Giordano, J. (eds), Ethnicity and Family Therapy. New York: The Guilford Press, 1982, pp. 31–51. US Bureau of the Census. Washington, DC: US Government Printing Office, 1991.

3.2 Cognitive development HUMBERTO QUINTANA

INTRODUCTION Cognition is a far-reaching and inclusive concept that refers to the mental activities involved in the acquisition, accumulation, processing, organization, and use of knowledge. The major processes incorporated under the term ‘cognition’ include detecting, interpreting, classifying, and remembering information, evaluating ideas, inferring principles and deducing rules, imagining possibilities, generating strategies, fantasizing and dreaming (Mussen et al. 1984; Vidyasagar 1996). Two different theoretical approaches to these questions are presented in this chapter. The first is Piaget’s influential theory, which focuses primarily on reasoning and problem solving. His theories give less attention to perception, memory, fantasy, and dreaming. The second, most commonly discussed theory is called the informationalprocessing approach; this theory focuses its attention on age changes in perception, memory, inference, evaluation, and the use of rules. However, before discussing these two approaches in cognitive development, it is important to consider two critical issues, or controversies, that dominate contemporary study of cognitive development. One of these problems results from the fact that it is still not possible to separate the consequences of maturation of the brain, on the one hand, from the consequences of active experience on the other (Erickson 1962). Many psychologists, for example, believe that the manipulation of objects and reciprocal interactions with people during the early years contributes significantly to cognitive development, and that some intellectual advances may be attributable primarily to changes in the central nervous system. For example, children in extremely isolated areas of the world who have no toys and live in a homogeneous environment with few cognitive challenges may be several years behind American children in developing some cognitive abilities (Kagan et al. 1979).

Another critical issue is the distinction between the knowledge and abilities that a child possesses, called ‘actual competency,’ and the appropriate use of that knowledge and skill to solve problems, which is called ‘performance.’ Children may possess knowledge and skills that they do not use even though the occasion calls for it. For example, although a person may forget the name of an acquaintance, we would not conclude that the person did not know the friend’s name or lacked a general ability to recall people’s names (Mussen et al. 1984). Children differ in their ‘potential competence’ to acquire various skills and domains of knowledge. But given the evidence, it seems wise to conceive of a child’s competence, actual and potential, as applying to limited domains rather than very broad ones (Brown et al. 1983). This chapter begins with a discussion of some fundamental concepts in Piaget’s Cognitive Theory – the Operations, Assimilation, Accommodation, and Equilibrium – and then turns to a discussion of the range, depth, and significance of these and other cognitive developments encountered from infancy through childhood into adolescence. Next, Piaget’s four stages of childhood development are reviewed, followed by an overview of informational-processing theory before focusing on adolescence and adolescent cognitive development. The final part of the chapter focuses on adolescent cognitive development and its consequences, as well as other issues referred to earlier in the chapter. The chapter concludes with a summary of adolescence, adolescent cognitive functioning, and the feelings associated with some of these cognitive developments.

PIAGET’S THEORY The fundamental concepts of Piaget’s theory deal exclusively with cognitive development, beginning with primitive reflexes and motor coordination of infancy and

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extending to the thinking and problem-solving of adolescence. Scientific and mathematical abilities are stressed: abstract and logical reasoning, generation of hypotheses, and organizing mental activities into more complex structures. Piaget was not concerned with motives, emotions, personality characteristics, or social behavior, although some psychologists have found his concepts useful in understanding these issues (Block 1982; Cowan 1978; Piaget 1954a, 1958). In Piaget’s theory, knowledge is assumed to have a specific goal or purpose: specifically, to aid the person in adapting to the environment. The child or adult does not receive information passively, and thoughts are not simply the products of direct teaching or imitation of others, nor is cognitive progress seen as primarily a product of maturation of the brain. In essence, knowledge is acquired and thought processes become more complex and efficient as a consequence of the maturing child’s interactions with the world (Piaget 1954a). Piaget’s central thesis is that the individual is active, curious, and inventive throughout the life cycle. Human beings seek contact and interaction with the environment, search out challenges, and – most importantly – interpret events. ‘It is the interpretation, not the event itself, which affects behavior’ (Ginsberg and Opper 1979, p. 67). Therefore, children and adults continually construct and reconstruct their knowledge of the world, trying to make sense of experience and attempting to organize their knowledge into more efficient and coherent structures (Piaget 1958; Ginsberg and Opper 1979).

The operations A central concept in Piaget’s theory is what he called ‘the operational structure’ or the ‘operation.’ Operations are ‘actions that the child performs mentally and which have the added property of being reversible’ (Ginsburg and Opper 1979). For example, a child plans a series of moves in Nintendo, checkers, or chess, and then cognitively retraces the beginning or earlier moves in the game; this is an operation. Similarly, the ability to perform many arithmetic problems and combine the quantities into single sets, also demonstrates the concept of operations. According to Piaget, the acquisition of the concept of operations in cognitive development is one of the core essentials in the development of intellectual growth in children (Mussen et al. 1984; Piaget 1977a, pp. 215–249).

Assimilation, accommodation, and equilibrium The abilities of the child to be able to progress from one stage of cognitive functioning to the next are called by Piaget ‘assimilation, accommodation, and equilibrium’ (Block 1982; Piaget 1958). Assimilation refers to ‘efforts

to deal with the environment by making it fit into the individual’s own existing structure by incorporating it’ (Donaldson 1978, p. 140). Thus, an idea or object is interpreted with respect to ideas or objects that the child has already previously acquired. For example, a child sees a train and may try to assimilate this to their idea of a car. However, the size, shape, and noises of this object do not allow for complete agreement with existing ideas, and assimilation is therefore not possible (Mussen et al. 1984; Nosphitz and King 1991a). Accommodation is ‘the individual’s tendency to change in response to environmental demands’ (Ginsberg and Opper 1979, p. 18), and refers to the ability of an individual to modify actions and ideas to fit new information, situations and objects. Whenever new knowledge is acquired, according to Piaget the child is in a state which he calls ‘equilibrium,’ or cognitive harmony (Piaget 1958). Essentially, Piaget assumes that all individuals attempt to achieve a state of balance in their various environmental interactions, and that whenever an individual’s balance or equilibrium is disturbed – such as by a new and interesting challenge – the process of assimilation and accommodation function to attempt to re-establish this balance. Assimilation, accommodation, and equilibrium are operative throughout the life of the child and throughout all of our lives, as attempts are made to adjust our behavior and ideas to changing circumstances and events. The amounts of assimilation or accommodation vary from activity to activity (Donaldson 1978). It is through the interactions with objects that children, by using the mechanisms of assimilation, accommodation, and equilibrium, can perceive enigmatic concepts or properties of the world that are around them and which may not be intrinsic in the objects themselves (Mussen et al. 1984; Piaget 1970). Piaget states that some of these operations and cognitive processes are universal in the world of people and objects, predominantly because it forces upon all children the same types of findings, thus resulting in acquisition of the same cognitive structures. Piaget further claims that because of everyday activities and collaborations that children have with other children, adults, and objects, it is these interactions utilizing the concepts of accommodation and equilibrium that induce the development of new mental organizations (Piaget 1969, 1972).

OVERVIEW OF PIAGET’S DEVELOPMENTAL STAGES The four major stages of development described in Piaget’s theory are:

•

The Sensorimotor Stage: from about birth to 18 months.

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• • •

The Pre-Operational Stage: from 18 months to 7 years. The Stage of Concrete Operations: from 7 years to adolescence. The Stage of Formal Operations (abstract operations): adolescence.

Each of these stages is often further subdivided, and Piaget very clearly attempts to present a developmental theory which contains stage sequences and overlapping. In Piaget’s theory, what moves a child from one stage to another or to the next stage, beyond the intellectual effort needed to resolve a cognitive incongruity, remains unclear in his theory, and this also remains unclear in our current-day knowledge. Regrettably, although Piaget spoke extensively about cognition, he had relatively little to say about the effects or about the influences of the environment on thinking (Erickson 1962; Flavell 1977).

Sensorimotor stage In the sensorimotor stage (0 to 18 months of age), there are six substages which have been identified by Piaget. In the first month of life, the infant exercises functions simply because they exist, such as grasping. In the next three to four months (from age 1 month to 41⁄2 months) of the infant’s life, new schemas are acquired which are usually centered on the infant’s own body, such as thumbsucking. Between 41⁄2 and 8–9 months of age, the infant tries to produce an effect upon the objects he sees or comes in contact with in the external environment, for example the famous rattle. Interestingly, recent studies have pointed to the cognitive development and behavior effects caused by very low birth weight in children many years later (Dezoate and MacArthur 1996). Between the ages of 8–9 and 11–111⁄2 months, the infant begins to become aware of the existence of unperceived or hidden objects, such as behind an obstacle, or in peek-a-boo games. At this time, the infant may begin to experience stranger anxiety. Also, the image of the object (care-giver) has begun to achieve some degree of permanence in the mind of the infant (object permanence or constancy). In the first half of the second year (between 11–12 and 18 months of age), the child explores more thoroughly his/her environment, objects, and spatial relationships. Towards the end of the second year (18 months to 2 years of age), the child shows some indications of reasoning: trial-and-error-type mental processes are replaced by trial and error in action, such as when a child uses one inanimate object to obtain another (Lewis 1982b,c; Piaget 1958). During this stage, words have emerged and language is first of all an accompaniment to action that comes from, or is based on, delayed limitations. Slowly a change occurs, and language becomes the verbal representation of previous actions. The word begins to function as a

sign, although at this stage the child’s language is still very private; the child does not at first use adult meanings, sentence structure, vocabulary and so on and cannot yet conceptualize and understand abstract concepts. It is not until the child is approximately seven or eight years of age that his/her private language gives way to the public verbal sign. At this age, verbal signs are used instead of images to signify what is used in thought, and mental imagery, symbolic play and language comprise what is called ‘semiotic function.’ Semiotic function, which is integrated between two and four years of age, means the ability to represent something (signified) by means of something else (the signifier) (Lewis 1982a, p. 32).

Pre-operational stage Occurring approximately between the ages of two and seven years, the ‘pre-operational stage’ demonstrates definite progress over the sensorimotor intelligence. Generally, this stage is subdivided into the stage of symbolic activity and the stage of decentration. The period between years 2 and 4 is marked by symbolic activity and make-believe play which represent the development of symbolic thought and language. Language now becomes increasingly important as the child learns to differentiate and distinguish between objects of the real world and the names or labels used to interpret or represent them. Therefore, the child is now able slowly to reason symbolically instead of acting as in the sensorimotor stage when he/she was limited to the chasing of concrete goals through actions alone (Kagan 1982). Although there are many advancements during this period, cognitive limitations to pre-operational thinking which exist during this period distinguish this period from the logical thought processes which will follow in the coming years. It is in the subsequent stages of cognitive development that concrete and eventually abstract thinking develop (Gillies and Light 1997; Piaget 1958). There are a number of major accomplishments which mark the pre-operational stage. The judgments of the child during this period are governed by his/her perceptions of objects, events, and experiences. However, children experience a number of limitations. They are not yet able to reason logically or to employ deductive reasoning, and cannot pay attention to more than one perceptual attribute or measure at any given time. Furthermore, although a child can recognize sequences and daily routines, they cannot fully understand the concept of time, such as a minute, an hour, a week, or month. These limitations often serve as a great source of frustration for many parents and care-givers (Donaldson 1978; Ginsberg and Opper 1979; Nosphitz and King 1991a; Piaget 1954a). During this cognitive stage of development, the preoperational child is often described as being ‘egocentric,’ and this is a period often referred to by many parents and

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others as the ‘naughty twos’ (Piaget 1977b, pp. 186–188). Piaget used this term to mean that the child experiences certain cognitive limitations of the pre-operational stage, mainly that the child is conceptionally unable to see events and experiences from any perspective other than his own. Children at this age and stage of cognition see themselves as the center of the universe and often feel that the world revolves around them. They are at the center of their own representational world. The child is generally unable to distinguish clearly between himself/ herself and the world, between that which is subjective, such as feelings and thoughts, and that which represents the objective external world which is reality. Piaget terms the type of reasoning which a child demonstrates during this period as ‘transductive’. In other words, the child during the pre-operational stage relates the particular to the particular in a manner which is not logical (Lewis 1982a, p. 33). Therefore, the child relates to events not in a cause-and-effect relationship but simply on the basis of their relationship in space and because of their temporal connections, continuity, or juxtaposition. Moreover, during this developmental stage, the child is neither concerned or bothered by logical contradictions and may often be seen attempting actions which go against logical expectations. The second substage of pre-operational thinking occurs from four to seven years of age, and is marked by an increased adjustment or accommodation to reality. There is a gradual and progressive decentering from the child’s own interest, perceptions, and viewpoints, and an increase in accommodation by the child to everyday reality (Piaget 1962). Decentering occurs predominantly in relation to the child’s increased involvement in the social environment (i.e., pre-school, school, group activities) (Piaget 1958). As the child becomes increasingly involved in social interactions, there is an increased demand for the child to use language. Peer interactions allow and sometimes force the child to compare his thinking with that of others; in so doing, the child may find that what his peers think is not necessarily the same as what he thinks. Therefore, the child begins to see himself and the environment, or the world around him, from other and different points of view.

Concrete operations The stage of concrete operations extends from seven to eleven years of age (and sometimes persists beyond twelve years) (Piaget 1952). At this stage, the child can examine two variables at once and masters what Piaget called the principle of conservation; not only for volume measurements or comparisons but also for number, class, and area. Different variations on this acquired capacity may occur at different ages. For example, conservation of objects occurs quite early, usually at the end

of the sensorimotor period. Quantity is conserved at six to eight years of age. As Piaget (1958) puts it, ‘It is more difficult to … equalize objects whose properties are less easy to dissociate from one’s own action, such as weight, than to apply the same operation to properties which can be objectified more readily, such as length.’ (Piaget 1958, p. 249). The above example regarding the unevenness in the development or emergence of certain logical operations was called by Piaget ‘decalage’ (Piaget 1958). For example, conservation does not appear all of a sudden in full bloom. Although children in the concrete stage have advanced beyond those at the pre-operational stage in reasoning, problem solving, and logic, their thinking is still restricted to the ‘here-and-now’ of concrete operations. At this stage, children conserve quantity and number and can order and classify real objects and things. However, they cannot reason about abstractions, hypothetical propositions, or imaginary events. Furthermore, although they can arrange a series of boxes in order of size, they have difficulty solving abstract verbal problems such as ‘Sam is bigger than John. Fred is shorter than John. Who is tallest?’ In short, the important development or advance in the concrete operational stage is that the child can apply basic logical principles to the domain concrete events, activities and events without allowing his or her perceptions to interfere. Increasingly, the child’s logical thought processes become more organized into more elaborate and integrated structure through which he or she systematically faces and responds to the environment and the world around them.

Formal operations The stage of formal operations, which is the most advanced stage of cognitive development, starts around the age of eleven to twelve years, but probably does not reach its point of equilibrium until the age of fourteen or fifteen, and extends through adulthood. This period is accentuated, or marked, by the youth’s ability to ‘… possibly manipulate ideas in themselves, and longer in merely manipulating objects.’ (Piaget 1969, p. 12). The individual uses a wider variety of cognitive operations and strategies in solving problems, is versatile and flexible in thought and reasoning, and can see things from a number of perspectives or points of view (Ginsberg and Opper 1979). The young adolescent can use hypothesis, make deductions, experiment, and reason from the particular to the general. The thinking of the adolescent is more complex than that of the pre-adolescent, and the range of their intellectual capabilities is much greater. As a result, they are no longer bound to environmental limitations (Elkind 1961).

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Among the differences between the formal operations stage and the concrete operations stage is that in the latter stage the child can make statements about the environment based on what his or her perception determines to be relationships between objects or classes of objects, whereas in the formal operations stage the adolescent can produce new statements by mixing previously arrived-at statements. Therefore, the young adolescent can make statements which are independent of specific content, and he can – and often does – apply this type of thinking to everyday experiences and information needing to be evaluated. Thus, as Piaget stated, among the most important property of formal operations ‘… is this reversal of direction between reality and possibility instead of deriving a rudimentary type of theory from the empirical data, as is done in concrete inferences, formal thought begins with a theoretical synthesis implying that certain relations are necessary and this proceeds in the opposite direction.’ (Elkind 1961; Nosphitz and King 1991b; Piaget 1958, p. 251). Among the most striking aspects of this stage is the development of the ability to reason about hypothetical problems – ‘what might be or could be’ – as well as to deal with real problems. Consequently, this also includes their having the ability to think of possibilities as well as facts. Unlike the concrete operational stage where the child mentally manipulates objects and events, in the stage of formal operations the youth manipulates ideas about hypothetical situations. Yet another important aspect of this formal operational stage of development is problem-solving and the systematic search for solutions. Faced with a new and challenging problem, the adolescent attempts to consider all possible ways of solving it and carefully checks the logic and effectiveness of each possibility. In formal operational thought, mental operations are organized into higher-order operations as a means by which to use abstract rules to solve a whole class of problems (Vidyasagar 1996). In addition, it is during this stage that individuals think about their own thoughts, evaluating them and searching for incongruities and errors in logic. Often, the examination of two or more seemingly incompatible beliefs or ideas causes the adolescent to look for ways of resolving the tension and frustration created by the inconsistency. Therefore, for the above reasons – the characteristics of formal operational thinking – the preoccupation of many adolescents may be seen to turn during this period to theoretical and profound matters of all kinds, such as philosophy, religion, and morality. They may examine everything and evaluate everything and may take on philosophical and political issues such as human rights and justice or equality. Piaget believes that preoccupation with thought is one of the principal manifestations of the stage of formal operations (Douvan and Addelson 1966; Elkind 1968).

Overview of information-processing approaches Although many of the cardinal concepts of Piaget’s theory are accepted by most psychologists (e.g., the interactional point of view that cognitive process depends on both maturation and active contact with the environment or world), many contemporary theorists and psychologists are critical of some aspects of Piaget’s theory (Lee 1996) and conclusions about the development of children’s abilities (Forsyth et al. 1996; Lee 1996). Hence, the following section provides an overview of an alternate approach that also examines the phenomenon of cognitive development. In the United States, many psychologists use an information-processing approach to understand how the child interprets, stores, retrieves, and evaluates information (this is in contrast to Piaget’s theories). This school of thought does not have a single, comprehensive theory guiding its research; rather, it focuses on understanding specific processes such as perception, memory, learning, evaluation of information, and the use of rules of cognition. First this group has an interest in how children obtain knowledge as they grow and mature, and how they are able to share and relate these facts to each other. Second, these psychologists are interested in many cognitive processes which are involved in cognitive change. Third, like Piaget, some information-process researchers are concerned with children’s ability to relate and operate on more units of information simultaneously with increasing age (Flavell 1977; Mussen et al. 1984). According to this group, the operations that arbitrate these developmental changes involve reinforcement, maturation of the central nervous system, and recurrent reorganization of children’s acquisition of knowledge. Reinforcement is based on the principle that the feedback that children receive from an effective or ineffective solution is accompanied by a reorganization of their knowledge and by subsequent changes in their problemsolving behavior (Douvan and Addelson 1966; Mussen et al. 1969, 1984). These theorists believe that it is helpful to regard cognitive processes and functioning as being composed of different processes which work on different levels or units of knowledge. Since each cognitive process is selectively associated with certain kinds of knowledge units, this group is split on different researchers who are examining these various units. Therefore, some of these researchers are investigating perception, others memory, others inference and problem solving, and still others are studying the use of rules in cognition (Dougher 1995). Cognitive development and function is currently a very active area of brain imaging research and techniques that include advanced methods in electroencephalography (EEG), nuclear magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS) and positron

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emission tomography (PET). These new techniques are very likely to provide many new questions and possibly also some answers in the very near future (Berman et al. 1997; Vidyasagar 1996).

FOCUSING ON COGNITIVE DEVELOPMENT IN ADOLESCENCE The mid to late adolescent period covers the ages of approximately thirteen to seventeen years in girls, and fourteen to nineteen years in boys. For boys and girls, the first encounter with pubertal changes is past, and the patterns of biological growth are becoming firmly established. Girls are usually slightly or well advanced in their development, the body contours are very near their adult fullness, maximum height has been achieved, and the menstrual cycle has achieved regularity. The development of the boys, which until now has been slightly behind that of the girls, has now begun to catch up and sometimes exceed that of girls. The boy goes through his growth spurt, his erections and nocturnal emissions have become an acceptable part of life, and the first disturbing confusion of puberty is resolving. The boys are experiencing the further advancing pubertal changes as their voices deepen and facial hair begins to grow (Nosphitz and King 1991b). The male and female genders have both become entirely fertile and each must therefore deal with the implications and ramifications of this conversion (Berman et al. 1997). Most commonly there has been a movement in a progressive heterosexual direction, though deviations from this may appear (and often already have appeared) at earlier developmental periods. Generally during this period, the youngster is interested in the opposite sex, but is not yet seeking a confirmed or lasting partnership with long-term involvement. During this period, biology retains enormous presence and sets the tone and conditions for further development in cognition, identity, and other areas (Varela 1997). The cognitive or intellectual growth at this time of life is amazing. Piagetian formal operations tends to take place at about eleven to twelve years of age. As the years advance, the process also continues, and by the midteens the youth is capable of an altogether new order of thinking, which is conspicuous in a variety of ways. For example, the youngster can look at a number of dissimilar items, abstract from them a common underlying principle, and form an overarching generalization that will embrace all the variances. Thus, children begin to possess the capacity to generalize from a specific set of information; this is a powerful ability in that it makes for much more effective problem-solving than was possible during latency or earlier years. During earlier years, youth used the concrete approach which addressed each

instance as a separate entity, thus making the ability to generalize much more difficult. Now, the youth can understand and discuss more general principles which govern classes of events, no matter how disparate they may be. Another advance during this period is the ability, or power, to draw fine distinctions. Yet another competence that emerges is the ability to address concepts as entities capable of study, comparison, and manipulation, of being loved and being hated. Despite these cognitive developments however, a recent three-year longitudinal study which examined risk behaviors concluded, like most models of health behavior, that health cognitions in adolescents predict risk behavior. In addition, the data demonstrated that increases in risk behaviors were accompanied by increases in the adolescent’s perceptions of vulnerability, and by a prevalent decrease in the influence of concerns about health and safety. Moreover, there seems to be a reciprocity between risk behaviors and related cognitions, and the authors suggest that adolescents – even though aware of the risk associated with their behavior – modify their thinking about taking risks in ways that facilitate continued participation in behaviors (Elkind 1967; Gerrard et al. 1996).

Cognitive development in adolescents The physiological and physical changes that occur in adolescence may tend to obscure the fact that there are simultaneously occurring cognitive developmental changes taking place. It has been stated that this period, adolescence, is ‘the period during which the capacity to acquire and to utilize knowledge reaches its peak efficiency’ (Mussen et al. 1969). This is evident by the scores on tests of mathematical reasoning and verbal ability which tend to peak in late adolescence and early adulthood, after which they begin to decline. Consequently, it has been found that mental test scores in adolescence are better predictors of adult functioning than those obtained at earlier ages. Therefore, some researchers believe that the level of intellectual functioning achieved in late adolescence or early adulthood, and to a major extent to which this capacity is developed, will determine the course of future of adult cognitive functioning. Cognitive functioning in adolescence involves both quantitative and qualitative functioning. Based on the earlier review of Piaget’s theory and his four stages of cognitive development, it should be recalled that the adolescent changes from the stage of concrete operations, which is prevalent during the middle and late childhood, to the stage of formal operations. Whilst the older pre-adolescent child is capable of relatively elementary deductive reasoning and of dealing with the principles of conservation and reversibility, class inclusion, and serialization, the degree of their reasoning

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ability remains quite limited when compared to the reasoning ability of the adolescent (Piaget 1969, pp. 22–26). As the adolescent enters the stage of formal operations, their cognitive capabilities increase in that they can reason – he/she can consider their own thoughts as answers to challenging questions or problems, but can consider many possible other alternatives and options. The adolescent, unlike the child, is capable of exploring and tapping many possible combinations and alternatives. Furthermore, the adolescent in the formal operational stage of cognitive thought is able to differentiate what is true from what is false – he/she can formulate hypotheses and test them in a logical manner (Tsutsumi 1996). It is also during this cognitive developmental stage that the adolescent can become more general and more separated from immediate abstract experience, something that the child is unable to do in either the preoperational or concrete stages of cognitive development. Thus, there is a movement from the concrete or literal meaning of an idea, concept, etc., and the figurative meaning that may be implied by these elements.

Consequences of adolescent cognitive development If the young individual does not develop the qualitative and quantitative adaptations in cognitive operation that usually take place in adolescence, he or she will be unable to deal adequately with the various intellectual demands placed upon them during this time of rapid growth and maturation. Furthermore, it is this very newly discovered ability for formal operational thought that results in the adolescent’s and young individual’s characteristic dismay with the world, his parents, and captivation with values and certain philosophical beliefs. In addition, this stage seems to account for many of the young individual’s excessive concerns with multiple social and emotional themes and self-involvement or self-centeredness which may often put them into conflict with other peers, their parents, their teachers, other adults, and society (Tsutumi 1996; Wells and Mathews 1996; Wetzel 1976). An additional consequence brought about by the adolescent’s entry and immersion in the formal operations stage of cognitive development is how this stage of development affects not only the way they relate and approach others, but also the way that the adolescent approaches himself (Varela 1997). The young individual becomes increasingly introspective, self-critical, judgmental, and analytical. If the adolescent does not develop these capacities for abstract thinking, hypothesis building and the ability to differentiate between truth or falsehood, many conflicts could be avoided, but also without the capacity for abstract thought, for conceptualization which provide alternative to reality the adolescent would

be fixed and limited in their future cognitive functional development and unable to overcome many of environmental or life challenges to be encountered in adolescence and young adulthood (Zelnic and Kantner 1980). Similarly, the development of moral principles, the development of future goals, and life plans that characterize adolescence, all depend in considerable measure on the cognitive maturation taking place in adolescence (Erickson 1962, pp. 261–263; Kolhberg 1969; Nosphitz and King 1991b). The adolescent’s immersion in the formal operations stage of development may best be summarized by Elkind: ‘… The adolescent is now able not only to grasp the immediate state of things but also the possible states they might or could assume. This new awareness of the discrepancy between how things are and how they might be – at home, at school, with themselves – probably underlines many of the recurrent adolescent feelings of depression and dissatisfaction. The awareness of the discrepancy between the actual and the possible also helps to make the adolescent a rebel. He is always comparing the possible with the actual and discovering that the actual is flagrantly wanting.’ (Elkind 1968, p. 152).

SUMMARY: ADOLESCENT COGNITIVE DEVELOPMENT AND OTHER ISSUES IN ADOLESCENCE Cognitive development in adolescence is delineated by a broadening spectrum of intellectual movement or activity, increased awareness, and a developing capacity for insight; indeed, adolescence was called by Piaget the ‘state of formal operations’ (Piaget 1969). Cognitive changes fundamentally include the beginning of the ability to comprehend abstract concepts and to reason from assumption or hypothesis. Egocentricism takes a unique meaning and form in adolescence in some forms of interactions (Piaget 1962); based on the false belief that others are as critical or loving of him/her, the adolescent constructs what Elkind calls an ‘imaginary audience.’ Therefore, the adolescent constantly feels shameful, self-critical and self admiring. Of course, their egocentricity interferes with their ability to differentiate between what they believe to be pleasing and what others actually appreciate or find appealing. Concurrently, the adolescent also considers his or her feelings as unique, and develops what Elkind called ‘personal fables.’ It is often these beliefs that adolescents have created about themselves that may cause them to become involved in risk-taking behavior that may have harmful consequences, including substance abuse, pregnancy, and trouble with the law. By age fifteen to sixteen years, the imaginary audience has gradually become a real audience through a process

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of repeated testing of, and against, reality. In addition, the adolescent discovers and learns to accept the fact that others have feelings similar to his or her own. Fountain (1961) described five qualities that differentiate adolescents from adults: 1 Adolescents show special intensity and volatility; and they seek emotional experiences. 2 Adolescents have a need for frequent and immediate gratification. The adolescent is likely to be unaware of the probable consequences of their actions, and misunderstands the feelings and behaviors of others. 3 The adolescent has a failure of self-criticism, failing to perceive contradiction, incongruity, and absurdity in himself/herself. 4 The adolescent’s awareness of the world about him/her is often completely different from that of the adult. 5 The adolescent is less likely or capable than the adult to concern himself/herself with people and events that do not involve him/her personally. Therefore, as the adolescent matures, the world begins to exist for him in its own right; he sees people having needs of their own, independently, and he no longer perceives them only as they relate to him. Thus, the adolescent becomes to varying degrees responsible for ‘his fellow man’ (Fountain 1961, p. 273).

REFERENCES Block, J. Assimilation, accommodation and the dynamics of personality development. Child Development 53: 281–295, 1982. Berman, K.F., Schmidt, P.J., Rubinow, D.R., Danaceau, M.A., Van Horn, J.D., Esposito, G., Ostrem, J.L., Weinberger, D.R. Modulation of cognition-specific cortical activity by gonadal steroids: a positron-emission tomography study in women. Proceedings of the National Academy of Sciences, USA 94: 8836–8841, 1997. Brown, A.L., Bransford, J.D., Ferrara, R.A., Campione, J.C. Learning, remembering and understanding. In Flavell, J.H., Markman, E.M. (eds), Cognitive Development. Hillsdale, NJ: Erlbaum, 1983. Cowan, P.A. Piaget with feeling. New York: Holt, Rinehart, and Winston, 1978. Dezoate, J.A., MacArthur, B.A. Cognitive development and behavior in very low birthweight twins at four years. Acta Genetica Medicina Gemellol (Roma) 45(3): 325–332, 1996. Dougher, M.J. A bigger picture: cause and cognition in relations to differing scientific frameworks. Journal of Behavior Therapy and Experimental Psychiatry 26(3): 215–219, 1995. Donaldson, M. Children’s minds. New York: Norton, 1978, p. 140.

Douvan, E., Addelson, J. The Adolescent Experience. New York: Wiley, 1966. Elkind, D. Children’s discovery of the conservatism of mass, weight, and volume. Journal of Genetic Psychology 98, 219–277, 1961. Elkind, D. Egocentrism in adolescence. Child Development 38(4): 1025–1034, 1967. Elkind, D. Cognitive development in adolescence. In Adams, J.F. (ed.), Understanding Adolescence. Boston: Allyn and Bacon, 1968, 128–158. Erickson, E.H. Childhood and Society, 2nd edition. New York: Norton, 1962. Flavell, J.H. Cognitive Development. Englewood Cliffs, NJ: Prentice-Hall, 1977. Flavell, J.H. On cognitive development. Child Development 53, 1–10, 1982. Forsyth, J.P., Lejuez, C.W., Hawkins, R.P., Eifert, G.H. Cognitive vs. contextual causation: different world views but perhaps not irreconcilable. Journal of Behavior Therapy and Experimental Psychiatry 27(4): 369–376, 1996. Fountain, G. Adolescents into adulthood: an inquiry. Journal of the American Psychoanalytic Association 9: 417–433, 1961. Gerrard, M., Gibbons, F.X., Benthin, A.C., Hessling, R.M. A longitudinal study of the reciprocal nature of risk behaviors and cognition in adolescents: what you do shapes what you think, and vice versa. Health Psychology 15(5): 334–354, 1996. Gillies, M., Light, P. Spatial cognition in language-impaired children. European Journal of Disorders in the Community 32 (2 Special No.): 159–166, 1997. Ginsberg, H., Opper, S. Piaget’s Theory of Intellectual Development. Engelwood Cliffs, N.J: Prentice-Hall, Inc., 1979, p. 18. Kagan, J. The Second Year: The Emergence of Self-Awareness. Cambridge, Mass: Harvard University Press, 1982. Kagan, J., Klein, R.E., Finley, G.E., Rogoff, B., Nolan, E. A cross-cultural study of cognitive development. Monographs of the Society for Research in Child Development 44(5): 1–77, 1979. Lee, C. Arguing with cognitivists. Journal of Behavior Therapy and Experimental Psychiatry of Australia 27(4): 357–361, 1996. Lewis, M. Cognitive development. In Clinical Aspects of Child Development. 2nd edition. Philadelphia: Lea & Febiger, 1982a, pp. 31–33. Lewis, M. Part II. Cross Sectional Perspectives. In Clinical Aspects of Child Development. 2nd edition. Philadelphia: Lea & Febiger, 1982b, pp. 121–262. Lewis, M. Adolescence. In Clinical Aspects of Child Development. 2nd edition. Philadelphia: Lea & Febiger, 1982c, pp. 263–304. Mussen, P.H., Conger, J.J., Kagan, J. Adolescence. In Child Development and Personality, 3rd edition. New York: Harper & Row, 1969, pp. 54, 103, 605–688.

Cognitive development 179 Mussen, P.H., Cogner, J.J., Kagan, J., Huston, A.C. Cognitive development. In Child Development and Personality, 6th edition. New York: Harper and Row, 1984, pp. 82, 224, 218–303, 461–506, and 508–523. Nosphitz, J.D., King, R.A. The Self: Stern’s Theory of Development, Chapter 9. In Pathways of Growth – Essentials of Child Psychiatry, Volume I, Normal Development. New York: John Wiley & Sons, 1991a, pp. 189–199. Nosphitz, J.D., King, R.A. Mid and Late Adolescence, Chapter 17. In Pathways of Growth – Essentials of Child Psychiatry, Volume I, Normal Development. New York: John Wiley & Sons, 1991b, pp. 391–420. Piaget, J. (with Alina Szeminska) The Child’s Conception of Number (translated by Gattegno, C., Hodson, F.M.) London: Routledge and Kegan Paul, 1952. Piaget, J. The Child’s Conception of Physical Causality (translation by Cook, M.). New York: Basic Books, 1954a. Piaget, J. The Construction of Reality in the Child. New York: Basic Books, 1954b. Piaget, J. The Growth of Logical Thinking. New York: Basic Books, 1958. Piaget, J. The intellectual development of the adolescent. In Caplan, G., Levoici, S. (eds), Adolescence, Psychosocial Perspectives. New York: Basic Books, 1969, pp. 22–26. Piaget, J. Intellectual evolution from adolescence to adulthood. Human Development 15: 1–12, 1972. Piaget, J. The origins of intelligence in children (translation Margaret Cook). In Gruber, H.E., Voneche, J.J. (eds), The Essential Piaget. New York: Basic Books, 1977, pp. 215–249. Piaget, J. Egocentric thought in the child. In Gruber, H.E., Voneche, J.J. (eds), The Essential Piaget. New York: Basic Books, 1977, pp. 186–188. Tsutsumi, S. Adolescents with developmental psychopathology in adulthood. Japan Psychiatric Clinical Neuroscience Journal 50(3): 101–107, 1996.

Varela, F.J. Patterns of life: intertwining identity and cognition. Brain Cognition 34(1): 74–87, 1997. Vidyasagar, T.R. Basic information processing and higher cognition: does the mammalian cerebral cortex deal with them at different hierarchical level? Clinical Experimental Pharmacology and Physiology 23(10–11): 908–912, 1996. Wells, A., Matthews, G. Modeling cognition in emotional disorder: the S-REF model. Behavior Research and Therapy 34(11–12): 881–888, 1996. Wetzel, K.R. Hopelessness, depression and suicide intent. Archives of Psychiatry 33: 1069–1073, 1976. Zelnic, M., Kantner, J.F. Sexual activity, contraception use, and pregnancy among metropolitan-area teenagers: 1971–1979. Family Planning Perspectives 12: 230–237, 1980.

Suggested reading This chapter reviews cognitive development mainly from the Piagetian perspective. For later perspectives, the reader may find the following material helpful. Anthony, B.J. Cognitive Development in Adolescence, Chapter 9. In Handbook of Child and Adolescent Psychiatry, Volume 3: Adolescence – Development and Syndromes. New York: John Wiley & Sons Inc., 1997, pp. 65–78. Seress, L. Neuronal connections, cell formation and cell migration in the perinatal human hippocampal dentate gyrus. Cesk-Fysiol. 47(2): 42–50, 1998. Lerner, P.M. Rorschach assessment of cognitive impairment from an object relations perspective. Bulletin of the Menninger Clinic 60(3): 351–365, 1996. Yates, T. Theories of cognitive development. In Lewis, M. (ed.), Child and Adolescent Psychiatry – A Comprehensive Textbook, 3rd edition. Philadelphia: Lippincott Williams & Wilkins, 2002, Chapter 12, pp. 172–196.

3.3 Adolescent moral development ROY LUBIT AND STEPHEN B. BILLICK

INTRODUCTION Moral development is a crucial aspect of adolescence. Moral beliefs are a central aspect of an individual’s personality, and have a profound impact on the choices people make: how we treat others, whether we obey laws and customs, and even which work and avocations we pursue. One’s moral compass not only affects whether an individual engages in activities that can lead to prison, but also affects choices about engaging in pro-social activities and whether one is thoughtful or selfish in relationships. To understand the belief systems and behavior of adolescents, it is necessary to understand their moral development. Therefore, understanding how moral development occurs, and how to foster it when it is not going well, is a crucial issue for doing therapy with adolescents. One of the first great works on the moral development of children was Rousseau’s Emile. There are two underlying themes in Emile. First, education is key to the child’s moral development. To foster moral independence in the adult we need to pay attention to the way that every activity in the child’s life shapes the child’s beliefs. Children should learn through direct experience rather than through lectures or books, since people rebel against the dictates of others, but are willing to accept the nature of things and the limits of nature. Second, Rousseau believed that human beings are naturally good. In the state of nature, people have compassion for others and their desires remain within their means. Society, however, leads to pride and a desire for fame and power. A proper education, however, can antidote these problematic effects of society and bring out people’s natural goodness. More recently, our understanding of the complexity of moral development has been forged by the evidence-based

research of Piaget, Kohlberg, Gilligan, the domain theorists such as Turiel, and the work of Stilwell and her collaborators. Morality can be seen as having two major components. First, morality entails a set of standards or prohibitions; for example, we should not lie, we should not steal, and we should not harm others. Morality also entails a positive concern for the welfare of others, and a sense of responsibility to take action to help others (Damon 1988). Moral development is a gradual process that occurs throughout our lifetime. Our moral philosophy evolves as a result of a number of factors. Most important are our cognitive development, family/peer/social influences, life experiences, and education.

SOCIAL LEARNING THEORY Researchers in social learning, such as Bandura, hold that modeling plays a key role in the development of an individual’s behavior and beliefs. In modeling, an individual observes a given behavior or way of interacting and then consciously or unconsciously seeks to behave in a similar way. According to social learning theory, people’s behavior is affected by direct reinforcement (being rewarded or punished for a behavior), by vicarious reinforcement (seeing others rewarded or punished for a given behavior), and by self-imposed standards (Bandura 1977). Moral development arises from being rewarded or punished for a given behavior, by seeing others rewarded or punished for the behavior, and by what we are instructed is right or wrong by authority figures, and how we observe role models behave. Role models who are seen as powerful and consistent in their standards and actions will have a particularly powerful impact on the developing morality of the child (Wolf and Cheyne

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1972; Mischel and Grusec 1966; Mischel and Liebert 1966). According to the behavioral perspective of learning theorists children develop positive and negative attitudes toward a given behavior based both upon being taught it is wrong, and shown it is wrong by the example of role models. Social learning theorists, in contrast to the cognitive developmental theorists, are not concerned with how the child thinks about and processes ideas about the behavior. Also in contrast, Freud believed that the superego developed from resolution of the Oedipus Complex and internalization of the father, behaviorists see the conscience arising from anxiety associated with punishment for wrong doing (Aronfreed 1968, 1976; Parke 1967; Parke and Walters 1967).

PIAGET The cognitive developmental researchers (most notably Piaget, Kohlberg, and Gilligan) did not believe that moral judgment was formed simply as a result of the effect of rewards, punishment and praise (as social learning theorists believed), or as the result of internalization of adults (as psychoanalytic theorists hold). Rather, as the child develops cognitively he or she is able to develop an increasingly elaborate construction of the world as a result of interaction with others. Several concepts were central to Piaget’s thinking. First, the child reconstructs what is experienced, rather than simply absorbing or reproducing what is seen. Like putting together the pieces of a complex puzzle, the child sorts out and interprets his interactions with others to develop a sense of right and wrong. Second, as children’s cognitive abilities grow they are able to handle more variables and more complex models of the world. Development progresses from unilateral respect for authority to mutual respect, from fixed belief and categorical rules toward maintaining social relationships and cooperation, from concern about the impact on us of obeying rules toward concern for justice, from fixed adherence to our own perspective toward concern for the viewpoints of others, from focus on the outcomes of actions toward concern for intentionality, from focus on revenge to focus on reform of the wrongdoer, from punishment as imminent in a situation to punishment as separate from wrongdoing, and from rules as being rigid and universally applicable to different places legitimately having different rules (Turiel 1998). Piaget believed that both cognitive development and the experience of interacting with peers were responsible for the development of moral reasoning. Interacting with peers helps children to see others’ points of view, to decrease the profound dependence on adults which exists in early childhood, and

provides an opportunity to actively create rules to fit reallife situations. Piaget proposed a four-stage theory of moral development (Piaget 1932). At two years of age, as the child transitions from the stage of sensory motor development1 to pre-operational thinking,2 we see considerable symbolic play. The child makes up his or her own rules, and changes them at will. At around five years of age, the child enters the stage of concrete operations. This is marked by the emergence of unilateral respect. During this stage rules are experienced as external to oneself and one’s conscience, as handed down from above. Piaget used the term ‘heteronomous’ to refer to justice based on respect for the commands of a superior. (Autonomous refers to selfgoverned, and heteronomous refers to government from the outside; Piaget 1965.) During this stage, rules are seen as sacred and permanent. The ‘moral realism’ of this stage – the view that moral principles have an objective foundation, and are not based on subjective human convention – consists of various components including objective responsibility and immanent justice. In ‘objective responsibility,’ intentions do not matter, only effects. In ‘immanent justice,’ punishment is seen as inevitable following a wrongful act. Around age eight years, as concrete operations3 develop, the child begins to develop a sense of mutual respect with peers. Now, rules are ways of regulating agreements, ensuring cooperation, and are useful to all. Autonomous morality begins replacing heteronomous morality. By autonomous, Piaget meant ‘that the subject participates in the elaboration of norms instead of receiving them ready-made as happens in the case of the norms of unilateral respect that lie behind heteronomous morality.’ Rules are now seen as man-made and changeable. Social reciprocity and desire for cooperation with peers replace adult constraints as the basis for obeying moral strictures. At around age eleven years, as formal operations (the period of abstract thinking) develop, the child begins to be able to construct new rules to deal with potential situations. This is the ‘ideological’ mode of moral reasoning. 1

Sensory motor development lasts from birth to age two years; during this time the child is primarily interested in the outward characteristics of objects and in manipulating objects. 2 The pre-operational stage lasts from age two to six years; this is a prelogical stage in which magical thinking predominates. Children are unable to handle two variables at once, such as height and width. As a result, they believe that whatever bottle has a higher level of water has more water, and ignore the width of the bottle. 3 The period of concrete operations is a period of logical thinking and the ability to manipulate multiple variables. A child realizes that as water is poured between bottles of different shapes, the amount of water does not change although the height of the water is different in the different containers.

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Research has shown that young children do not blindly accept authority as Piaget states. Rather, they have conceptions of morality from other sources, particularly when there is an issue of harming another. For example, young children do not accept parental directives to steal or cause harm to others. Moreover, children consider commands by non-authority figures to stop fighting as more legitimate than a command from an authority figure that they be allowed to continue fighting. Children will give priority to authority figures over non-authority figures in terms of game rules and turn-taking (Laupa et al. 1995; Turiel 1998, pp. 903–904).

KOHLBERG Kohlberg continued the structural-developmental approach of Piaget. (The structural-developmental approach sees children progressing through stages in which they are able to see the world in increasingly complex ways.) Kohlberg did not believe that morality was primarily imposed on children (as social learning theorists believe) nor based on anxiety and guilt as Freud argued. Rather, children are ‘moral philosopher(s).’ (Kohlberg 1968). Children think through their social experiences. Altruism and sympathy for others significantly affect their thinking (Turiel 1998, p. 867). Kohlberg was interested in the reasons that children used for deciding what was moral. He created a test referred to as the Heinz dilemma. He presented children with moral dilemmas and then asked what they would do and why. He told a story of a man whose wife was dying and a druggist who had medicine that could save her. The man could not obtain the money to buy the medication, which the druggist sells for ten times more than it costs him to make. Therefore, the man steals the medication. Kohlberg then asked children to give their thoughts on the morality of potential options. Their reaction to the story provided a window into their inner world and beliefs. Kohlberg differed from Piaget in several important ways. Most important, he said that there are several stages of autonomous moral development, and described these stages. This advance over Piaget’s work evolved because Kohlberg presented children with serious, complex adult dilemmas, such as the Heinz dilemma discussed above, soldiers in combat, air raid personnel during an enemy attack, etc. Another important difference is that while Piaget saw a gradual increase in autonomous thinking as heteronomous thinking declined, Kohlberg saw a more abrupt transition, consistent with structural-developmental theory. As a result of his studies, Kohlberg divided the process of moral development into three levels, each divided into two stages. Moral Level One, found in pre-school

children, is pre-conventional morality. This corresponds to Piaget’s heteronomous morality. Moral behavior is seen through a lens focused solely on the effect of an action on oneself, that is, will one be punished or will one obtain a gain. In addition, at this stage children do not see others’ perspectives and do not care about intentions. Stage one is the period of ‘punishment and obedience orientation.’ Children’s ideas on what is right and what is wrong depend upon what is punished. It is ‘okay’ to do something if one does not get caught. Authorities are respected without question. Others’ needs are not considered in making moral decisions. Stage two of Level One is the period of ‘instrumental relativist orientation.’ Children are still overwhelmingly focused on their own needs, but they now understand that people have different needs and that this leads to conflicts. Children are willing to obey rules in order to obtain a reward. The concepts of fairness, equal exchange and keeping agreements are used as rationale for moral decisions. Schoolage children generally function on moral Level One. Moreover, juvenile delinquents are often children who have remained on this level rather than moving on to moral Level Two (Gibbs 1987; Turiel 1998, p. 867). During the period of moral Level Two, conventional morality, children develop a concern for role obligations, conceptions of the good person, and respect for societally based rules and authority. Children are concerned with fairness and motives, and are able to empathize with the position of another. These stages are may begin as early as age nine years and are generally seen in adolescence and adulthood. Stage three (the beginning of moral Level Two) is the period of ‘interpersonal concordance or ‘good boy–nice girl’ orientation.’ In stage three, the individual attempts to live up to others’ expectations and to show concern for others in order to be seen as being good, and not simply to repay a debt to an individual as in stage two (the end of moral Level One). Societal expectations such as keeping agreements and living by the golden rule often take precedence over short-term concrete interests. This requires an ability to abstract. Stage four (the end of moral Level Two) is the period of ‘law and order orientation.’ Being good now means contributing to society or the group. One obeys rules in order to maintain the social order. The social order takes precedence over individual interests and interpersonal relationships. In stage four, one believes that one should follow the rules because they are the rules. The issue is no longer what will happen to you, a debt to an individual, or how people will see you. The issue is now a sense of there being right and wrong ways of behaving that exist apart from how you are affected by the reaction of others to your behavior. At this time there is concern with the world beyond one’s personal connections. One should be a good citizen, support society’s laws, and be responsible to all of society (Turiel 1998, p. 867). Most adolescents and adults function on the level of conventional morality.

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Moral Level Three, post-conventional morality, requires higher levels of abstract reasoning and education. It is generally not reached before the latter part of college. Moreover, most adults never reach the level of postconventional morality. Stage five (the beginning of moral Level Three) is the period of ‘social-contract legalistic orientation.’ The individual becomes aware that rules and values differ by group. Certain values are seen as generally accepted, and there is a focus on equality and mutual obligation. Judgments are based on concern for contractual arrangements, procedural arrangements and differentiated concepts of justice and rights. The individual is aware of moral conflicts and has difficulty integrating moral, legal and societal perspectives. This is the period of Lockian ethics (Locke 1690). Stage six (the end of moral Level Three) is that of ‘universal ethical principles.’ Morality involves the voluntary acceptance of abstract moral principles (Turiel 1998, p. 867). Law and agreements may be subordinated to principles such as justice and equality. This is the period of Kantian ethics (Kant 1785/1969). Kohlberg believed that moral development came as a result of cognitive development and interaction with others. Specifically, moral development is fostered by challenging discussions, listening to others, weighing the differences, critiquing others, and attempting to resolve differences by challenging one’s own assumptions (Blatt and Kohlberg 1975; Berkowitz et al. 1980). There are several notable differences between the work of Kohlberg and Piaget. While Piaget felt that young children at the heteronomous level respected rules and authority, Kohlberg felt that young children were concerned about power, sanctions and instrumental needs. Concern for rules and authority, according to Kohlberg, does not come until adolescence and the stage of conventional morality. Moreover, while Piaget felt that mutual respect and concepts of justice and rights (postconventional level) came during late childhood or early adolescence, Kohlberg felt it generally only came during adult years (Turiel 1998, p. 867). Many concerns have been voiced with Kohlberg’s work. Perhaps most importantly, Kohlberg believed that his stages were universal, i.e., common across cultures. Many have criticized this. Some research shows that there may be significant similarities across the first three or four stages, but fewer over the last stages (Turiel 1998, p. 867; Snarey 1985). In particular, Shweder criticizes Kohlberg for stating that stages five and six, which entail ‘society as a social contract’ and the ‘individual as possessing natural and inalienable rights prior to or outside society’, are universal rather than culture specific (Shweder 1982). A second concern with Kohlberg is that he underestimated young children’s moral abilities. While Kohlberg predicted that moral principles emerged in adolescence, empirical research has shown that concern for fairness,

justice, and equality emerge much earlier, often by seven and eight years of age, as Piaget believed. Kohlberg felt that young children’s morality was based on sanctions, rather than on an understanding of generalizable moral principles. But, more sophisticated tests than those employed by Kohlberg have shown that children are sensitive to key issues of morality, such as distributive justice. Whereas pre-schoolers focus on their own needs, elementary school children think about merit; older children think about just desert and reciprocity; and by age ten or eleven years children become aware of competing claims and the need for compromise (Turiel 1998, pp. 901–902; Damon 1977, 1980, 1988). A third problem concerns the cross-cultural limitations of Kohlberg’s levels (Hoffman 1970). Kohlberg sought to develop a universally applicable model, but different cultures often have different rules as to what is appropriate. Fourth, Kohlberg’s work is too global. For example, Kohlberg asserted that justice is the essential factor in human social life and that social relations and social institutions are organized primarily around our conceptions of justice (Kohlberg 1971). In recent years domain-specific models have replaced Kohlberg’s view of individuals having a given way of thinking across all domains of life. (Domain models hold that one should separate convention from morality when studying morality; Turiel 1998.) Fifth, Kohlberg’s research dealt with dramatic, once-in-a-lifetime events and not everyday moral issues that confront us in our social lives (e.g., issues of fairness, justice, equality, and rights). Sixth, Kohlberg’s post-conventional stages (five and six) do not well meet structural-developmental criteria for real stages (Gibbs 1977; Hogan 1970). Seventh and finally, Kohlberg minimized the role of the family. Reacting against the psychoanalytic perspective that early family experiences are central to moral development, Kohlberg (1969) writes that: ‘(1) Family participation is not unique or critically necessary for moral development and (2) the dimensions on which it stimulates moral development are primarily general dimensions by which other primary groups stimulate moral development, i.e., the dimensions of creation of role-taking opportunities.’

DIFFERENCES BETWEEN MEN AND WOMEN Gilligan was not the first to express the belief that the moral development of girls was different from that of boys. Many years earlier, Freud wrote that ‘I cannot escape the notion (though I hesitate to give it expression) that for women the level of what is ethically normal is different from what it is in men. Their superego is never so inexorable, so impersonal, so independent of its emotional origins as we require it to be in men.’ (Freud 1925/1959).

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Moreover, Piaget, writing about school-age girls, asserted that ‘the legal sense is far less developed in little girls than in boys’ (Piaget 1932, p. 69). He also noted that girls were more willing to subordinate rules to cooperation and mutual agreement, and are ‘more tolerant and more easily reconciled to innovations.’ (Piaget 1932, p. 75). Although Piaget felt that girls were less focused on legal issues, he did not assert that they were less morally advanced, since he saw girls as more oriented toward tolerance, innovation and cooperation. Piaget believed that the advanced level of autonomous morality entailed concerns for mutuality, reciprocity and cooperation, while the more primitive heteronomous morality of younger children was marked by intolerance and lack of innovation (Turiel 1998, p. 883). Gilligan was a student of Kohlberg, and stayed within the stage theory paradigm. Gilligan objected to the implication of Kohlberg’s model that women were less advanced morally than men, because they were less rule driven. Rather, Gilligan argued that women had a different set of moral strictures, and were more concerned by relationships and caring for others. Gilligan believed that there are two lines of moral development. The morality of justice concerns treating others fairly; it focuses on rules, rights, autonomy, equality and reciprocity. In contrast, the morality of care concerns fulfilling responsibilities and taking care of people in need. The morality of justice is based on images of the self as autonomous and detached from social networks, while the morality of care sees oneself as part of a social system (Turiel 1998, pp. 881–882; Gilligan 1977, 1982). Another difference between Gilligan and Piaget and Kohlberg is that in Gilligan’s stage theory, changes in the sense of self, rather than changes in cognitive abilities, lead to progression through stages. In Gilligan’s pre-conventional stage, the goal is individual survival. In time, the individual transitions from selfishness to responsibility to others. During the conventional stage, issues of responsibility, such as caring for dependent individuals and self-sacrifice, are seen as goodness. One moves on to the last stage with the realization that one is also a person and that complete self-sacrifice is not the ultimate good. During the post-conventional period individuals see themselves as interdependent with others, the principle of non-violence becomes important, and caring for others is seen as benefiting others and oneself. To a significant degree, Gilligan was arguing against the work of her mentor Kohlberg, which she understood as stating that men were at a higher stage of moral development than women. Kohlberg had argued that college age women were at stage 3, in which moral judgments focused on interpersonal considerations. Kohlberg placed men, however, at stage 4 which focused on maintenance of rules, authority and the social order. There are strong reasons to challenge Kohlberg’s findings. Research

by Walker, controlling for educational and occupational levels, did not show the difference Kohlberg found (Walker 1984, 1991). Moreover, other studies show that most people use both the morality of care and the morality of justice, and that justice is used more than care. Research has also shown, however, that women use care more than men and that men use justice more than women (Haste and Baddeley 1991). Some research suggests that girls may be more sensitive to the emotional states of others than are boys (Zahn-Waxler and Kochanska 1990). One explanation for the alleged differences in moral development between boys and girls is that they face different challenges in identify formation. Both little boys and little girls are generally cared for by their mother. Girls identify with their mother, who is their primary caretaker. Boys, however, identify with their fathers whose power and authority are prominent in their eyes, rather than care taking. As a result, in girls the experience of inequality with their primary identification figure (the mother) is less powerful than for boys. Girls’ experience of inequality with their primary identification figure is mollified by their ongoing nurturing attachment to their mothers (Gilligan and Wiggins 1987). One could also postulate that differences in moral outlook between men and women have to do with their place in society. In most Western societies, women are rewarded for caring for and nurturing others, while men are encouraged to be competitive and to excel at careers and thereby provide material goods for their families.

DOMAIN THEORY One of the most important developments in the study of moral development during the past two decades has been domain theory. Turiel and others have argued that a significant problem with research on moral development has been the failure to separate moral issues from social–organizational issues of convention and from the psychological domain. Each area forms its own domain. Children deal differently with issues that fall into different domains. The moral domain concerns justice, the rights of people, welfare, and hurting others. The domain of conventions concerns regulations serving social coordination, such as what we wear and how it is appropriate to treat guests. Moral beliefs are relatively universally held, for example that it is wrong to kill, rape, steal, or hurt others without reason. Domain theorists argue that to follow convention one needs culture-specific knowledge, whereas one does not need culture-specific knowledge to know what is moral (Turiel 1983; Turiel et al. 1987; Tisak 1995; Smetana 1995; Laupa et al. 1995).

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Research has shown that four- and five-year-old children can differentiate conventional and moral issues and respond differently to them. By age nine or ten, children understand the difference concerning both familiar and unfamiliar issues (Turiel 1998, pp. 905–906). For example, even young children will reject commands which are morally unacceptable, albeit given by someone who is otherwise a legitimate authority. An example would be an adult telling a child that he can continue to fight or to hit someone. Similarly, research on adolescents has found that they do not reject parental authority on issues of morality or convention. Rather, they reject parental authority on issues in the psychological domain, the personal realm (Smetana 1988a,b, 1989). Research on children’s response to authority (whether they see it as legitimate) shows three factors which are important. These include the type of command, the attributes of the authority figure, and the social context. The type of command includes which domain the issue falls under (morality, convention, personal) and whether or not it is morally acceptable. Attributes of the authority figure refers to their position within a social context and their knowledge. The social context entails whether one is at school, at home, or elsewhere. Obedience to authority hangs on a different set of issues. First, children are concerned with whether the command is likely to solve the issue at hand. A child will follow a command from a knowledgeable person unless he believes it will not yield the right outcome. Second, children will follow the commands of someone who is able to inflict punishment. The ability to punish depends upon their social position in a context. Third, children are likely to follow instructions given by someone without authority if the command serves a moral purpose, such as avoiding harm (Laupa and Turiel 1986, 1993; Laupa et al. 1995).

STILWELL Over the past two decades Barbara Stilwell has developed a detailed model of the development of moral functioning (Stilwell and Galvin 1985; Stilwell et al. 1991, 1994, 1996, 1997, 1998). The model was empirically derived from interviews with normal and disturbed children.

External conscience stage During the external conscience stage (younger than seven years) children are dependent on their parents and other authority figures for moral rules. Parental disapproval results in a drop in the child’s mood. The child wishes to undo the mistake that led to disapproval. Reparation entails making a quick apology and promising to do differently in the future. Emotional equilibrium returns in a matter of minutes.

Brain or heart conscience By age seven to eleven years, children see rules as arising from experience and stored in the heart or brain. This is a transitional stage in which rules become internalized. Nevertheless, external authority remains the ultimate source of moral knowledge.

Personified conscience (heart/mind) By late childhood (ages eleven to thirteen years), rules are now internalized and both rules and emotions are part of the moral domain. There is a desire to respond to the feelings of others, as well as to follow the rules. This creates conflicts at times. Rules are now seen as being affected by the relationships that exist between people. These require people to formulate their own rules. As the conscience becomes internalized, concern develops for intentions and private thoughts, and not simply actions. Moreover, adults are no longer seen as automatically right. External authority, however, remains the ultimate moral authority. Parents’ authority is now seen as coming from their wisdom and experience, rather than from their ability to punish.

Confused conscience By mid adolescence (ages fourteen to sixteen years), conflict arises between the impact of the ideas of adults on the one hand, and those of peers and the popular culture on the other. This creates confusion and instability in ideas, emotional responses, and behavior. The individual also needs to reconcile the need to get along with people day by day, and the ideal rule. There is confusion about the ultimate source of moral authority. Moral dilemmas stimulate the search for rules to govern situations and relationships. During this stage teenagers fluctuate between idealizing and devaluing parental values.

Integrated conscience The late adolescent (aged sixteen or seventeen years and beyond) begins to appreciate that rules cannot automatically be applied in any given situation. Situations are too complex. A greater acceptance of gray, as opposed to black and white, develops. The existence of both good and evil within the self is accepted. Greater benevolence and optimism arise. Multiple sources of moral knowledge exist, and the final decision is made by the individual. The need for hierarchy and the future of the individual in helping to set societal rules is appreciated. The individual becomes less affected by peer pressure and shows concern for the greater community. Late adolescents are able to both value and disagree with parental

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values rather than swinging between idealization and devaluation. According to Stilwell, there are various ways in which moral development can be abnormal. Delay entails slowed progression through the stages, and can arise from genetic or prenatal environmental problems causing intellectual deficits or a maladaptive temperament. Deviancy, values or behavior well outside society’s norms arises from disruptions in attachment, neglectful parenting and abuse. Anxiety plays an important role in the development of moral behavior. In the early years anxiety can be helpful in inhibited impulses. In later years, however, children need to overcome anxiety at times in order to go against the wishes of the group and engage in morally appropriate behavior. Anxiety can get in the way of the need to balance moral issues and to engage in the social relationships and experiences needed for moral development. Temperamental issues can also affect moral development. A child who is impulsive and disinhibited, and is then met with harsh parenting, may become angry with the world (or at least all authority figures), feel wronged by all he or she interacts with, fail to learn to take any responsibility for events, and develop a righteously indignant attitude.

ROLE OF EMOTIONS Originally, behaviorists and psychoanalytic thinkers focused on the role of guilt and anxiety in developing moral behavior. More recent researchers, however, have drawn attention to the roles of positive emotions and affiliative bonds (Dunn et al. 1995; Hoffman 1984, 1991a,b; Kochanska 1993, 1994). There is significant research showing that young children are interested in the well-being of others and therefore engage in sharing and altruism (Turiel 1998, pp. 874–875). These findings are in contradiction with theories that hold that children will behave selfishly, unless forced not to do so, before they have internalized parental and societal values. Kagan (1984) argues that the average person develops their moral beliefs based on feelings. The community’s affective reaction to a given behavior leads to the child’s development of moral sense. Similarly, Hoffman sees morality evolving from empathy and he sees changes in a child’s moral development and conceptions of morality evolving from development of one’s capacity for empathy (Hoffman 1984, 1991a,b). Wilson (1993) argues that for most people, as opposed to intellectuals, moral behavior evolves from emotions and habit. ‘Much of the time our inclination toward fair play or our sympathy for the plight of others are immediate and instinctive, a reflex of our emotions more than an act of our intellect.’ Moreover, Wilson goes on to argue

that evolution has selected for affiliative behavior. Sympathy, fairness, self-control and duty are central to our moral life and arise from our evolution and genetic make-up.

WHY SUCH DIFFERENT PERCEPTIONS? What people hold to be the basis of moral thinking depends to a large extent on what part of moral thinking they are trying to explain. If one wishes to understand the beginnings of a conscience, then psychoanalytic thinking and social learning theory hold value. If one wants to understand why certain things are prescribed and certain things proscribed, then social learning theory and the structural developmentalists (Piaget and Kohlberg) have important things to say. When one goes from wondering about the basic formation of concern for right and wrong to understanding the complexity of arguments which are both the foundation for and the rationalization for particular rules, then Kohlberg and Piaget are very valuable. When one moves on to understand how children deal with specific situations, then the insights of domain theorists become invaluable. Although contradictions exist between the different schools, in many ways they are complementary, build on the foundation laid by others and seek to explain new questions.

PSYCHOANALYTIC THEORY OF SUPEREGO DEVELOPMENT Many adolescent psychotherapists use a psychoanalytic framework to understand their patients. Psychoanalytic theory holds that resolution of the Oedipus complex (according to which children have a special attachment to the parent of the opposite sex and subsequently have rivalry and hostility toward the parent of the same sex) leads to the formation of the superego. (Psychoanalytic thinking holds that there are three parts to the psyche: the ego, the id and the superego. The superego concerns the internalized restrictions on what behavior is appropriate and what is not.) The healthy adolescent internalizes the parent he or she wished to replace during the Oedipal phase (Freud 1930) and relinquishes the fantasy of removing that parent and becoming the romantic object of the other parent (Ritvo and Solnit 1960; Holder 1982). Living up to the ego ideal (i.e. the individual’s ideal aspirations) begins to take precedence over parental approval and disapproval (Milrod 1990). Internalization of the parent and superego formation leads to a change from concern for parental approval to concern for one’s own standards. ‘With his abandonment of the Oedipus complex a child must … renounce the intense object-cathexes

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[emotional investment] which he has deposited with his parents, and it is a compensation for this loss of objects that there is such a strong intensification of the identifications with his parents which have probably long been present in his ego.’ Freud believed that the superego underwent change over time as the child interacted with other authority figures. ‘In the course of development the super-ego also takes on the influence of those who have stepped into the place of parents-educators, teachers, people chose as ideal models. Normally it departs more and more from the original parental figures; it becomes, so to say, more impersonal. Nor must it be forgotten that a child has a different estimate of its parents at different periods of its life. At the time at which the Oedipus complex gives place to the super-ego they are something quite magnificent; but later they lose much of this.’ (Freud 1933). During adolescence, the ego evaluates the superego’s precepts and changes occur. No longer are parental rules automatically accepted. The adolescent looks at the world, sees problems and hypocrisy, and remakes the superego to deal with the world as he or she sees it. Ego psychologists (psychoanalytic thinkers who believe that the development of the ego is particularly important in human behavior) believe that environmental factors have an important impact on a child’s ego development. Jane Loevinger argues that children who advance from the conformist to the autonomous level become more tolerant, objective, and introspective. Adolescents who are in the conformist stage fail to examine the rules of authority figures, and are guided by the need for peer approval, and desire for status and material possession. Adolescents at the autonomous level are less impulsive, less selfish and less parochial (Loevinger 1976).4

CURRENT AND FUTURE RESEARCH A major debate in the field of children’s moral development concerns the degree to which moral development is universal rather than culture specific. Cultural psychologists do not believe in the presence of general psychological processes. They argue that thoughts, meanings, emotions, and behaviors differ across cultures and therefore they focus on culturally constructed meanings (Shweder and Sullivan 1993; Turiel 1998, pp. 868–869). Evolutionary psychology, on the other hand, argues that

4 Loevinger argues that personality development proceeds through a succession of stages: Conformist (obedience to external social rules); Conscientious-Conformist (separation of norms and goals; realization that acts affect others); Conscientious (self-evaluated standards); Individualistic (process of acting more important than outcome); Autonomous (respect for individuality; tolerance for ambiguity); and Integrated (resolution of inner conflicts).

evolution and genetics have led to significant similarities in social relationships throughout humankind. ‘Altruism, compassion, empathy, love, conscience, the sense of justice – all these things, the things that hold society together, the things that allow our species to think so highly of itself, can now confidently be said to have a firm genetic basis.’ (Wright 1994; Turiel 1998, pp. 868–869). An area needing further research concerns a more detailed understanding of the development of moral prohibitions. Research within the domain perspective has shown that young children will reject the commands of authority figures when asked to do things which violate morality. Where does this early moral sense come from? Does it come from previously developed mental schema formed by accepting rules of authority figures, for example that hurting others is wrong? Does it come from innate empathy for others? Studying variations across cultures may be particularly useful in doing research in this area. More research is also needed on how to foster the development of a moral code later in life. Specifically, what can one do with a juvenile delinquent who never progressed past Kohlberg’s stage 2? When individuals believe that it is acceptable to hurt others in order to further their own parochial interests is this (1) because there is an innate or early developmentally induced failure to empathize with others; (2) from learning that others are less human than you (Social Darwinism) and therefore it is acceptable to take from others; (3) from learning that hurting others is acceptable from seeing role models do it; or (4) does it arise from psychic numbing (a term coined by Lifton 1991)? Further research is also needed concerning what society and schools can do to better foster moral development. Is the home situation overwhelmingly powerful? Can schools and other institutions have a major impact? If so, when are interventions most cost effective?

PARENTING AND MORAL DEVELOPMENT Researchers have studied a variety of factors affecting the development of a moral compass in children. Some researchers have divided disciplinary practices into three categories: 1 Power assertion involves physical punishment, deprivation of privileges and threats. 2 Love withdrawal involves demonstrations of disapproval. 3 Induction entails providing explanations, including concern for the well-being of others. Research has shown that development of a moral conscience (demonstrated by experiencing guilt, willingness to confess misdeeds, seeing acts as wrong, and developing the ability to resist temptation) is most effectively

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brought about by induction (Turiel 1998, pp. 877–878). Induction both focuses attention on the victim, rather than on the perspective of the child, and creates an optimal level of arousal. Too little anxiety and the child will not be motivated to pay attention; too much anxiety and the child will be too fearful to process the situation (Weiner 1998). Authoritarian parents exercise high levels of control over their children, along with limited amounts of warmth and communication. Authoritative parents, in contrast, also exercise high levels of control, but they couple it with high clarity of communication, warmth, and nurturance. Permissive parents are inconsistent in their control and communication (Damon 1988; Weiner 1998, p. 69). Power-assertive parents may interfere with children learning any perspective but that of the parents. The child’s attention, in the situation of authoritarian parents, goes neither to the victim nor to the consequences of their own behavior. Instead, the child focuses attention on the threatening parent and feels like a victim. Morality becomes external and arbitrary. The high level of arousal created will interfere with the child’s ability to attend to the reasoning provided (Weiner 1998, p. 70). Excessive power assertion leads to compliance without internalization of the behavior since there is no voluntary component. In the opposite circumstance, excess permissiveness will lead to increased noncompliance (Maccoby 1983). Similarly, it has been found that authoritative forms of parenting are more effective than either authoritarian or permissive forms (Baumrind 1973, 1989; Maccoby and Martin 1983). Children are more responsive to adult instructions when adults discuss fairness and how the welfare of others is affected, rather than simply pointing out the behavioral norm that should be obeyed. Research concerning sharing, hitting and stealing have found this to be the case (Killen 1991; Nucci 1984; Eisenberg-Berg and Geisheker 1979). However, induction may not be universally effective. Kochanska (1991) found that induction was primarily effective in fostering the development of conscience in children who were vulnerable to anxiety and who were not impulsive. Temperament has considerable impact on a child’s development of a conscience. Children who are uninhibited may not respond to mild sanctions and in general respond less favorably to sanctions than children who are behaviorally inhibited. In general, parents who are flexible in their choice of disciplinary techniques are more likely bring up children who have a strong moral orientation (Grusec and Goodnow 1994). Flexibility decreases the likelihood that the child will see the parents’ actions as arbitrary, and increases the likelihood that they will be seen as an appropriate response to the situation. This increases the likelihood that the child will experience the message as self-generated and internalize it (Weiner 1998). Nurturing, protective parents are more likely to have children with

flexible and adaptive superegos that permit them to be open to new influences rather than rigidly adhering to parental ideas (Sarnoff 1976). When encouraging children to engage in prosocial behaviors it is important to use the minimal level of reward and coercion. If the reward or punishment is excessively salient, the behavior will not last once punishment or reward is withdrawn. For the behavior to be internalized it needs to come, as much as possible, from inside the child and therefore lead to a change in selfattributions (Eisenberg 1987; Damon 1988; Fabes et al. 1989). There are a number of things that parents can do that will foster the moral development of their children. Discussion of real-life moral dilemmas, but not of hypothetical dilemmas, fostered moral development two years later. Parents should ask for the child’s opinion, paraphrase it and ask clarifying questions. Parents should avoid criticizing or directly challenging the child’s opinions. Lecturing the child is also not helpful (Walker and Taylor 1991). Non-parental factors are also important in the development of a moral orientation. These include a more positive relationship with siblings and having a good emotional understanding at a young age (Dunn et al. 1995). Peer interactions are also important. Children learn about cooperation and social rules by creating and using them with peers (Damon 1988; Turiel 1998, p. 899). Conflicts can help children to see others’ points of view and the rights of others (Killen and Nucci 1995). Interactions with peers help children to learn about discussion, compromise, and debate. For some children, poor cooperation may not arise from failure to learn the rules, but from failure to learn when discourse is needed (Weiner 1998, pp. 47–76). Children need the emotional capacity to tolerate the tension involved in conflict, as well as a belief in reciprocity, in order to sustain an argument for long enough to be able to recognize, and learn from, others’ perspectives (Haan 1985). Piaget and Kohlberg believed that interaction with peers whose moral reasoning is more advanced can raise an adolescent’s level of moral reasoning. Moreover, Kohlberg suggested that parents should discuss moral issues at home and encourage children to consider others’ perspectives (Baryam et al. 1983). The development of a strong conscience is not, however, the only goal for many parents. Parents may want children to develop flexibility, initiative, negotiation skills and thinking skills (Grusec and Goodnow 1994).

ADOLESCENT MORALITY Adolescents are often seen not only as self-preoccupied, but as selfish and self-centered. Research, however,

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presents a different picture. Adolescents regularly perform community service, show empathy toward others, and believe that it is important to help others – and particularly people that one is close to (Killen and Turiel 1998; Eisenberg 1990; Eisenberg et al. 1995).

CLINICAL IMPLICATIONS Assessing a child’s moral development should be part of the mental status examination. The child’s moral development has considerable impact on the child’s functioning, and is helpful in understanding both internalizing and externalizing problems. A rigid superego predisposes to anxiety and depression. Arrested or deviant moral development often underlies behavior problems and problems in social interaction. In order to assess a child’s level of moral development, clinicians should gather information from a variety of sources including teachers, parents, and the child. The therapist will want to know how the child functions in different settings. Crucial questions include the child’s ability to empathize with others, their sense of obligation to others’ welfare, use of emotions to regulate moral behavior, development of a hierarchy of moral values, the presence of rules supporting the values, a sense of responsibility to pursue moral values, how the child complies with rules, his sense of responsibility versus externalization of blame, the emotional reaction to his or her own wrongdoing, reparative actions in following wrongdoing, the child’s reactions to the distress of others, prosocial actions the child takes to help others, how the parents respond to wrongdoing, and how the child responds to the parents’ interventions. A crucial question is whether the child’s violations concern issues of morality, violations of societal conventions, or struggles with parents concerning personal issues. Moral violations are certainly of greater concern. It is also important to assess if the child’s deficits are primarily in the area of the ability to experience empathy and guilt, or in the area of being able to fill the appropriate role and behave as desired in a given situation. In the interview with the child the clinician will want to focus on a variety of issues, including the child’s understanding of and emotional reaction to the behavior which has led others to have concerns, the depth of understanding of and empathic connection with friends, the child’s understanding of social causality and knowledge of how to keep friends. Information on how temperament and learning disabilities may play a role is also important. The parents’ expectations for the child, their emotional reaction to the child, and their actions in relation to the child are also important (Weiner 1998). A variety of interventions is generally needed. Parent guidance is important to help parents be consistent, but

not harsh, in their discipline in the areas in which they should have control, and to give the child more freedom in the areas in which they should step back. Use of behavioral techniques such as time-outs, contracts and point systems is helpful. Some parents will need specific guidelines, while others need only a general discussion of principles. Training in authoritative and inductive techniques of discipline is very important. The negative impact of excessive arousal and inadequate arousal should be discussed. It is sometimes important to increase the child’s time in supervised activities with peers. Children should be involved in discussions of behavioral interventions and development of contract and point systems so that they own the activity and are most likely to internalize the new behavioral guidelines (Weiner 1998).

REFERENCES Aronfreed, J. Conduct and Conscience: the socialization of internalized control over behavior. New York: Academic Press, 1968. Aronfreed, J. Moral development from the standpoint of a general psychological theory. In Lickona, T. (ed.), Moral Development and Behavior: Theory, research, and social issues. New York: Holdt, Rinehart and Winston, 1976, pp. 54–69. Bandura, A. Social Learning Theory. Englewood Cliffs: Prentice-Hall, 1977, pp. 119–120. Baryam, M., Reimer, J., Kohlberg, L. Development of moral reasoning at the kibbutz. In Kohlberg, L. (ed.), Recent Research in Moral Development. New York: Holt, Rinehart and Winston, 1983. Baumrind, D. The development of instrumental competence through socialization. In Pick, A.D. (ed.), Minnesota Symposia on Child Psychology. Volume 7. Minneapolis: University of Minnesota Press, 1973, pp. 3–46. Baumrind, D. Rearing competent children. In Damon, W. (ed.), Child Development Today and Tomorrow. San Francisco: Jossey-Bass, 1989, pp. 349–378. Berkowitz, M.W., Gibbs, J.C., Broughton, J.M. Structure and process: an experimental inquiry into the ‘what’ and ‘how’ of moral judgment development. In Proceedings of the Eighth Annual International Conference on Piagetian Theory and its Implications for the Helping Professions. Los Angeles: University of Southern California Press, 1980. Blatt, M., Kohlberg, L. The effects of classroom discussion upon children’s level of moral judgment. Journal of Moral Education 4: 129–161, 1975. Damon, W. The social world of the child. San Francisco: Jossey-Bass, 1977. Damon, W. Patterns of change in children’s social reasoning: a two-year longitudinal study. Child Development 51: 1010–1017, 1980.

190 Normal development Damon, W. The moral child: Nurturing children’s natural moral growth. New York: Free Press, 1988. Dunn, J., Brown, J.R., Maguire, M. The development of children’s moral sensibility: individual differences and emotion understanding. Developmental Psychology 31: 649–659, 1995. Eisenberg, N. Self attributions, social interactions, and moral development. In Kurtines, W., Gewirtz, J. (eds), Moral development through social interaction. New York: Wiley & Sons, 1987, pp. 20–40. Eisenberg, N. Prosocial development in early and mid-adolescence. In Montemayor, R., Adams, G.R., Gullotta, T.P. (eds), From childhood to adolescence: A transitional period. Beverly Hills, CA: Sage, 1990, pp. 240–268. Eisenberg, N., Carlo, G., Murphy, B., Van Court, V.N. Prosocial development in late adolescence: a longitudinal study. Child Development 66: 1179–1197, 1995. Eisenberg-Berg, N., Geisheker, E. Content of preachings and power of the model/preacher: the effect on children’s generosity. Developmental Psychology 15: 168–175, 1979. Fabes, R., Fultz, J., Eisenberg, N., May-Plumlee, T., Christopher, F. Effects of rewards on children’s prosocial motivation. Developmental Psychology 25: 509–515, 1989. Freud, S. Three contributions to the theory of sex. (1930) Freud, S. Three contributions to the theory of sex. New York: E. P. Dutton & Co., Inc., 1962. Freud, S. Some psychological consequences of the anatomical distinction between the sexes. In Freud, S. (ed.), Collected papers. New York: Basic Books, 1925/1959, pp. 186–197. Freud, S. New introductory lectures on psycho-analysis. Standard edition, Volume 22. 1933. Reprinted 1964, London: Hogarth Press. Gibbs, J. Social proceses in delinquency: the need to facilitate empathy as well as sociomoral reasoning. In Kurtines, W., Gewirtz, J. (eds), Moral development through social interaction. New York: John Wiley & Sons, 1987, pp. 301–322. Gibbs, J. Kohlberg’s stages of moral judgment: a constructive critique. Harvard Educational Review 47: 43–61, 1977. Gilligan, C. In a different voice: women’s conceptions of self and of morality. Harvard Educational Review 47: 481–517, 1977. Gilligan, C. In a different voice: Psychological theory and women’s development. Cambridge, MA: Harvard University Press, 1982. Gilligan, C., Wiggins, G. The origins of morality in early childhood relationships. In Kagan. J., Lamb, S. (eds), The emergence of morality in young children. Chicago: University of Chicago Press, 1987, pp. 277–305.

Grusec, J., Goodnow, J. Impact of parental discipline methods on the child’s internalization of values: a reconceptualization of current points of view. Developmental Psychology 30: 4–19, 1994. Haan, N. Processes of moral development: cognitive or social disequilibrium. Developmental Psychology 21: 996–1006, 1985. Haste, H., Baddeley, J. Moral theory and culture: the case of gender. In Kurtines, W.M., Gewirtz, J.L. (eds), Handbook of moral behavior and development: Volume 2 Research. Hillsdale, NJ: Erlbaum, 1991, pp. 229–249. Hoffman, M. Moral development. In Mussen, P. (ed.), Carmichael’s manual of child psychology. New York: John Wiley & Sons, Inc., 1970. Hoffman, M.L. Empathy, its limitations and its role in comprehensive moral theory. In Kurtines, W.M., Gewirtz, J.L. (eds), Morality, moral behavior, and moral development: Basic issues in theory and research. New York: John Wiley, 1984, pp. 283–302. Hoffman, M.L. Empathy, social cognition, and moral action. In Kurtines, W.M., Gewirtz, J.L. (eds), Handbook of moral behavior and development: Volume 1. Theory. Hillsdale, NJ: Erlbaum, 1991a, pp. 275–301. Hoffman, M.L. Commentary on: Toward and integration of Kohlberg’s and Hoffman’s moral development theories. Human Development 34: 105–110, 1991b. Hogan, R. A dimension of moral judgment. Journal of Consulting and Clinical Psychology 35: 205–212, 1970. Holder, A. Preoedipal contributions to the formation of the superego. Psychoanalytic Study of the Child 37: 245–272, 1982. Kagan, J. The nature of the child. New York: Basic Books, 1984. Kant, I. Foundations of the metaphysics of morals (Lewis White Beck, Translation). Indianapolis: Bobbs-Merrill, 1785/1959. Killen, M. Social and moral development in early childhood. In Kurtines, W.M., Gewirtz, J.L (eds), Handbook of moral behavior and development: Volume 2 Research. Hillsdale, NJ: Erlbaum, 1991, pp. 115–138. Killen, M., Nucci, L.P. Morality, autonomy, and social conflict. In Killen, M., Hart, D. (eds), Morality in everyday life: Developmental perspectives. Cambridge, UK: Cambridge University Press, 1995, pp. 52–86. Killen, M., Turiel, E. Adolescents’ and young adults’ evaluations of helping and sacrificing for others. Journal of Research on Adolescence 8: 355–375, 1998. Kochanska, G. Socialization and temperament in the development of guilt and conscience. Child Development 62: 1379–1392, 1991. Kochanska, G. Toward a synthesis of parental socialization and child temperament in early development of conscience. Child Development 64: 325–247, 1993.

Adolescent moral development 191 Kochanska, G. Beyond cognition: expanding the search for the early roots of internalization and conscience. Developmental Psychology 30, 1994. Kohlberg, L. The child as moral philosopher. Psychology Today 2: 25–30, 1968. Kohlberg, L. Stage and sequence: the cognitive developmental approach to socialization. In Goslin, D.A. (ed.), Handbook of socialization theory and research. Chicago: Rand McNally, 1969, p. 399. Kohlberg, L. From is to ought: how to commit the naturalistic fallacy and get away with it in the study of moral development. In Mischel, T. (ed.), Cognitive development and epistemology. New York: Academic Press, 1971. Laupa, M., Turiel, E. Children’s conceptions of adult and peer authority, Child Development 57: 405–412, 1986. Laupa, M., Turiel, E. Authority reasoning and social contexts. Journal of Educational Psychology 85: 191–197, 1993. Laupa, M., Turiel, E., Cowan, P.A. Obedience to authority in children and adults. In Killen, M., Strayer, J. (eds), Morality in everyday life: Developmental perspectives. Cambridge, UK: Cambridge University Press, 1995, pp. 131–165. Laupa, M., Turiel, E., Cowan, P.A. Obedience to authority in children and adults. In Killen, M., Hart, D. (eds), Morality in Everyday Life: Developmental Perspectives. New York: Cambridge University Press, 1995. Locke, J. Two Treatises of Government, 1690. Reprinted 1988: Cambridge University Press. Loevinger, J. Ego Development: Conceptions and Theories. San Francisco: Jossey-Bass, 1976. Maccoby, E. Let’s not overattribute to the attribution process. In Higgins, E.T., Ruble, D., Hartup, W. (eds), Social cognition and social development. Cambridge, UK: Cambridge University Press, 1983, pp. 213–217. Maccoby, E.E., Martin, J.A. Socialization in the context of the family: parent–child interaction. In Mussen, P., Hetherington, E.M. (eds), Socialization, personality, and social development: Volume 4. Handbook of Child Psychology. New York: John Wiley, 1983, pp. 1–102. Milrod, D. The ego idea. The Psychoanalytic Study of the Child 45: 43–60, 1990. Mischel, W., Grusec, J. Determinants of the rehearsal and transmission of neutral and aversive behaviors. Journal of Personality and Social Psychology 3: 197–205, 1966. Mischel, W., Liebert, R. Effects of discrepancies between observed and imposed reward criteria on their acquisition and transmission. Journal of Personality and Social Psychology 3: 45–53, 1966. Nucci, L.P. Evaluating teachers as social agents: students’ ratings of domain appropriate and domain inappropriate teacher responses to transgressions. American Educational Research Journal 21: 367–378, 1984.

Parke, R.D., Walters, R.M. Some factors influencing the efficacy of punishment training for inducing response inhibition. Monographs of the Society for Research in Child Development 32, 1967. Piaget, J. The moral judgment of the child. London: Routledge & Kegan Paul, 1932. Piaget, J. The moral judgment of the child. New York: Harcourt Brace, 1932. Piaget, J. Sociological studies. London: Routledge, 1960/1995. Piaget, J. The moral judgment of the child. New York: Free Press, 1965. Ritvo, W., Solnit, A. The relationship of early ego identifications to superego formation. International Journal of Psychoanalysis 41: 295–300, 1960. Sarnoff, C. Latency. New York: Jason Aronson, 1976. Shweder, R.A. Liberalism as destiny. Contemporary Psychology 27: 421–424, 1982. Shweder, R.A., Sullivan, M.A. Cultural psychology: who needs it? Annual Review of Psychology 44: 497–523, 1993. Smetana, J.G. Adolescents’ and parents’ conceptions of parental authority. Child Development 59: 321–335, 1988a. Smetana, J.G. Concepts of self and social convention: adolescents’ and parents’ reasoning and hypothetical and actual family conflicts. In Gunnar, M.R., Collins, W.A. (eds), Proceedings, 21st Minnesota Symposium on Child Psychology: Development during the transition to adolescence. Hillsdale, NJ: Lawrence Erlbaum, 1988b, pp. 79–122. Smetana, J.G. Adolescents’ and parents’ reasoning about actual family conflict. Child Development 60: 1052–1067, 1989. Smetana, J.G. Morality in context: abstractions, ambiguities, and applications. In Vasta, R. (ed.), Annals of Child Development. Volume 10. London: Jessica Kingsley, 1995 pp. 83–130. Snarey, J. Cross-cultural universality of social-moral development: a critical review of Kohlbergian research. Psychological Bulletin 97: 202–232, 1985. Stilwell, B.M., Galvin, M.R. Conceptualization of conscience in 11–12 year olds. Journal of the American Academy of Child and Adolescent Psychiatry 24: 630–636, 1985. Stilwell, B., Galvin, M., Kopta, S.M. Conceptualization of conscience in normal children and adolescents, ages 5–17. Journal of the American Academy of Child and Adolescent Psychiatry 30: 16–21, 1991. Stilwell, B., Galvin, M., Klopta, S.M., Norton, J. Moral-emotional responsiveness: a two factor domain of conscience functioning. Journal of the American Academy of Child and Adolescent Psychiatry 33: 130–139, 1994. Stilwell, B.M., Galvin, M., Kopta, S.M., Padett, R.J. Moral valuation: a third domain of conscience

192 Normal development functioning. Journal of the American Academy of Child and Adolescent Psychiatry 35: 230–239, 1996. Stilwell, B.M., Galvin, M., Kopta, S.M., Padgett, R.J., Holt, J.W. Moralization of attachment: a fourth domain of conscience functioning. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1140–1147, 1997. Stilwell, B.M., Galvin, M.R., Kopta, S.M., Padgett, R.J. Moral volition: the fifth and final domain leading to an integrated theory of conscience understanding. Journal of the American Academy of Child and Adolescent Psychiatry 37: 202–210, 1998. Tisak, M.S. Domains of social reasoning and beyond. In Vista, R. (ed.), Annals of child development. Volume 11. London: Jessica Kingsley, 1995, pp. 95–130. Turiel, E. The Development of Social Knowledge: Morality and convention. Cambridge, UK: Cambridge University Press, 1983. Turiel, E. The development of morality. In: Damon, W., Eisenberg, N. (eds), Handbook of Child Psychology. John Wiley, & Sons, Inc., 1998. Turiel, E., Killen, M., Helwig, C.C. Morality: its structure, functions and vagaries. In Kagan, J., Lamb, S. (eds), The emergence of moral concepts in young children. Chicago: University of Chicago Press, 1987, pp. 155–244.

Walker, L.J. Sex differences in the development of moral reasoning: a critical review. Child Development 55: 677–691, 1984. Walker, L.J. Sex differences in moral reasoning. In Kurtines, W.M., Gewirtz, J.L. (eds), Handbook of moral behavior and development. Volume 2. Research. Hillsdale, NJ: Erlbaum, 1991, pp. 333–364. Walker, L., Taylor, J. Family interactions and the development of moral reasoning. Child Development 62: 264–283, 1991. Weiner, A.S. Moral development. In Noshpitz, J.D., Bemporad, J.R. (eds), Handbook of Child and Adolescent Psychiatry: The Grade School Years: Development and Syndromes. Volume 2. John Wiley & Sons, Inc., 1998, pp. 47–77. Wilson, J.Q. The Moral Sense. New York: The Free Press, 1993, pp. 7–8. Wolf, T., Cheyne, J. Persistence of effects of live behavioral, televised behavioral, and live verbal models of resistance to deviation. Child Development 43: 1429–1436, 1972. Wright, R. The moral animal: The new science of evolutionary psychology. New York: Pantheon Books, 1994. Zahn-Waxler, C., Kochanska, G. The origins of guilt. In Dienstier, R., Thompson, R. (eds), Nebraska syposium on motivation 1988: Socioemotional development. Lincoln: University of Nebraska Press, 1990, pp. 183–258.

3.4 Adolescent interpersonal relationships CHRISTOPHER J. KRATOCHVIL AND MARTIN J. HARRINGTON

INTRODUCTION Expanding relationships are an integral part of adolescent development. During adolescence, relationships extend beyond the family and increasingly involve the larger social world (Offer et al. 1996). This expansion of the social network generally includes a transition from parents to peers as providers of companionship and intimacy (Buhrmester and Furman 1987), although parental relationships generally remain meaningful. While relationships with adults outside of the family may account for some of the time lost by parents, peers absorb the majority of this time. Adolescents have been found to spend twice as much time with their peers as do children (Csikszentmihalyi and Larson 1984). As adolescents develop physically as well as emotionally, they generally begin to date and experiment with their awakening sexuality. For most adolescents, this is a time to develop a sexual identity and practice intimacy in preparation for adulthood, but for all too many it also means an adolescent pregnancy and premature parenthood. The successful negotiation of a variety of interpersonal relationships is an important developmental task of adolescence.

RELATIONSHIPS WITH PARENTS Adolescence is a time of changing relations between teenagers and their parents. The goal for the adolescent and parent is to accomplish separation and independence, leading to a consolidated identity. Devaluation, distancing, and authority conflict are essential steps in developing a separate identity during adolescence. Relationships between adolescents and their parents are described as positive most of the time (Kandel and Lesser 1969; Sorenson 1973; Niles 1979). Few adolescents report a high level of conflict between themselves and

parents (Offer and Sabshin 1984). Most relationships between adolescents and their parents remain intact and meaningful. According to Sheppard et al. (1985), ‘the peer group, contrary to what is commonly believed, has little or no influence as long as the family remains strong. Peers take over only when the family abdicates.’ Adolescents often select a peer group that has values and beliefs similar to those of their parents, provided that the level of conflict between the adolescent and parent is tolerable. Closeness in the family balanced with encouraging individuality and autonomy is crucial to the formation of an adolescent’s identity (Campbell et al. 1984; Cooper et al. 1984). Noller (1994) describes adolescent relationships with parents during three stages: early, middle, and late adolescence. Early adolescents, aged from ten to thirteen years, remain dependent upon parental values and beliefs, and defer most value judgments to authority figures. Impulsive acting out is their beginning step to distancing themselves from their parents. These adolescents are described as having simple cognitive constructs with ‘black or white’ thinking along with an egocentric thought style termed the ‘imaginary audience’ (Jani S 1997). The narcissistic sense that ‘all eyes are upon me!’ describes the ‘imaginary audience’. The horror of a thirteen-year-old being seen in public with her parents by peers demonstrates the parental devaluation and distancing at this stage. Middle adolescence (ages thirteen to sixteen years) is characterized by interacting with parents armed with newly attained knowledge, values, and beliefs. The adolescent will conform to various rules, roles and values to maintain and meet expectations of a variety of individuals. They also display a strong respect for individuality. Acceptance by peers becomes a stronger driving force furthering devaluation, distancing and authority conflict with parents. A middle-stage teenager may reject some parental beliefs and accept an alternative style in dress and attitude. The teenager may continue to accept other

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parental beliefs however, rarely rejecting all parental values. Late adolescents, aged between sixteen and nineteen years, compare parental values and beliefs to the teen’s higher authority or universal truths. The adolescent’s ideals may be 180 degrees from those of his parents. This conflict with authority is tempered by a respect for the autonomy and individuality of others. The conflict of values is a formidable challenge for parents. If they do not support the adolescent’s values, the parents can appear morally bankrupt to the teenager. If they attempt to force their values upon the teenager, the relationship can be in continual conflict. Devaluing, distancing, and authority conflict are required for the teenager and parent to successfully complete the journey of adolescence. The inadequate or excessive response to these components by the teen or parent can derail the separation and individuation of the adolescent. The successful completion of adolescence by child and parent transports the relationship to a new level.

RELATIONSHIPS WITH ADULTS OUTSIDE THE FAMILY Relationships with parents and peers are easily perceived as ‘important’ to adolescents as well as to researchers who have studied adolescents. Adults from outside the family can form ‘important’ relationships with adolescents, although this appears to be a different type of relationship than the adolescent forms with his parents or peers. Studies of relationships between adolescents and non-kin adults describe the relations as less emotionally supportive and more laden with instrumental aid. Instrumental aid includes teaching, guiding, serving as a role model, and challenging the adolescent (Darling et al. 1994). Darling et al.’s study of US and Japanese college students reported that instrumental aid was the consistent interactional style between the students and adults outside the family. The relationship was also described as less supportive and much less antagonistic. The emphasis appeared to be on explicit socializing functions and engaging youth in challenging as well as goal-directed joint activities (Darling et al. 1994). These findings do not suggest affect is absent, however. An emotional relationship often follows the interaction between the adolescent and non-kin adult.

RELATIONSHIPS BETWEEN ADOLESCENTS Peer relationships in adolescence are an influential force in the development of identity, autonomy and social maturity. Peer influence increases at the onset of adolescence

(Douvan and Adelson 1966), and peers spend more time together than they did at earlier stages of development (Larson 1983). Research suggests that peer pressure is high during early and middle adolescence, and appreciably less during preadolescence and late adolescence (Steinberg and Silverberg 1986). These data are not to suggest that relationships with parents diminish in influence, however. Indeed, the teenager’s relationships with parents and peers complement each other in the socialization of the adolescent (Youniss 1980; Sebald 1986). Two areas of study in peer relationships during adolescence are those involving friendships and crowds. Friendships appear essential to the development of social maturity. The literature describes most adolescents as having one or two ‘best friends’ and a number of ‘close friends’, varying on how these friends are identified and distinguished by the particular study (Crockett et al. 1984). Reciprocity, co-construction, and consensual validation originate in peer friendships rather than in relationships with adults (Youniss and Haynie 1992). Reciprocity refers to the ability of teenagers to relate to each other in a positive, negative, or neutral manner. Co-construction refers to the steps through which friends interact and define their own reality by arguing, discussing, negotiating, and conceding. Consensual validation refers to the critical feedback, information and support present in these relationships. Friendships are an interactive relationship offering growth opportunities for the adolescent. Friendships differ between the genders during adolescence. The literature describes girls as reporting a greater sharing of personal information, issues, thoughts, and emotions in comparison to boys (Bigelow and LaGaipa 1980; Blyth and Foster-Clark 1987; Dimond and Muntz 1967). Girls have a higher level of intimacy in their samesex friendships due to these differences in self-disclosure (Reisman 1985; Sharabany et al. 1981), although both girls and boys have been found to perceive an increase in intimacy with age (Hunter and Youniss 1982; Blyth and Foster-Clark 1987). In general, the sexes appear to pass through adolescence with marked differences regarding close friendships. Crowds refer to collections of adolescents identified by interests, attitudes, abilities, and/or personal characteristics they have in common (Brown et al. 1994). Adolescents utilize crowds to provide models for a variety of peer relationships. Crowds can offer structure, predictability and a sense of control over these interactions. Proximity, permeability, and desirability are all factors in an adolescent’s selection of a crowd (Brown et al. 1994). These group structures have a dynamic quality, changing in their characteristics over the course of adolescence. An adolescent’s need for belonging to a crowd declines in importance with age as autonomy and identity increase during late adolescence (Coleman 1974; Brown et al. 1986). The crowd is a powerful component which

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adolescents must navigate in order to have meaningful peer relationships.

DATING Early romantic experiences are felt to play a crucial role in the development of identity and intimacy (Erikson 1968). The early adolescents’ crises regarding their identities, who they are and where they are going, are later followed by the adolescents’ crises regarding becoming intimate with friends as well as sexual partners. The intimacy of these relationships is significantly less frightening if the identity crisis has been resolved (Kaplan et al. 1994). In this framework, dating is seen as an opportunity to test various roles and to develop a sense of who the adolescent is sexually, while practicing intimacy with others. Several decades ago, Skipper and Nass (1966) outlined what they saw as four potential primary functions of dating: recreation (providing entertainment and immediate pleasure); socialization (an opportunity to get to know and learn how to interact with the opposite sex); status achievement (raising prestige in one’s peer group by dating highly desirable people); and courtship (an opportunity to select a marriage partner). Rice (1984) and McCabe (1984) later added three additional reasons for dating: sexual experimentation; companionship; and intimacy. Adolescents may be motivated by one or more of these functions as their personal reason for dating, although their partner may have a completely different impetus. For example, one may be in the relationship because of a desire for a sexual experience (recreation), whereas the other is looking for peer acceptance (status achievement). One possible reason many of the relationships during this ‘practicing stage’ are so short-lived is that the two adolescents may be mismatched in their reasons for dating. Another possibility is that the adolescent’s goals are ‘low level,’ such as status or recreation, which are not conducive to developing a long-term relationship (Paul and White 1990). Roscoe et al. (1987) reviewed the functions of dating developmentally, comparing early (6th grade), middle (11th grade), and late (college level) adolescents. These authors found that early and middle adolescents were more apt to hold an egocentric orientation towards dating. The focus of the teens was on immediate gratification, ranking recreation as most important, followed by intimacy, and then status. The early adolescents placed more stock in the superficial features of their date and weighted others’ approval more heavily than did older adolescents. Late adolescents were more likely to focus on reciprocity in their dating relationships, ranking intimacy, companionship, socialization, and then recreation as important factors.

Dating plays a significant role as a forum for the sexual expression of the adolescent. Factors influencing the sexual expression include rapid physiological changes, social and cultural pressures, as well as the individual’s personal quest to become a mature person (McCabe 1984). Udry and Billy (1987) reported that these specific factors might be different for adolescent males and females. Initiation of sexual behaviors and intercourse in early adolescent males were more likely to be influenced by the effects of androgens and less by social controls. Early adolescent females were similarly found to be significantly influenced in their sexual motivation and noncoital sexual behaviors by androgens, but their coital behaviors were primarily differentiated by social control processes. Throughout the late 1960s, 1970s and early 1980s, several studies indicated an increasing permissiveness in premarital sexual attitudes and behaviors (Roche and Ramsbey 1993). Recent data, however, indicate that this trend of increasing sexual activity in teenagers may be ending. The 1995 National Survey of Family Growth found that approximately 50 per cent of adolescent females aged fifteen to nineteen years reported ever having intercourse, compared with 55 per cent in 1990 and 53 per cent in 1988 (Abma et al. 1997). The survey also assessed sexual activity by age, with 22 per cent of females having sex by age fifteen years, rising to 75 per cent by age nineteen years. The 1988 National Survey of Young Men indicated that, by age fifteen years, one-third of males have had sex, and 86 per cent by age nineteen (Sonenstein et al. 1989). Issues of intimacy and dating can be particularly difficult for gay or lesbian adolescents (Savin-Williams 1994). As Savin-Williams points out, the first struggle regarding finding a partner is coming out to oneself. Resolving one’s sexual identity is often a process for these youths, just beginning in early adolescence and ‘increasing exponentially’ throughout young adulthood (Savin-Williams 1990). A second issue is the harassment by peers and family, verbal as well as physical, as a consequence of same-sex dating. The third impediment suggested is the lack of social recognition and ‘celebration’ seen in heterosexual dating. It is not surprising that many bisexual, gay, and lesbian adolescents date heterosexually to avoid stigma and discrimination (Savin-Williams 1994).

ADOLESCENTS AND THEIR OWN CHILDREN Adolescent mothers While still struggling in an often-dependent relationship with their own parents, many girls are faced with the additional tasks of caring for and developing a relationship with their newborn child. Each year in the United States, over one million adolescent girls become pregnant

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(Jaffee and Dryoos 1980), and two-thirds carry their pregnancy to term (Balwin 1983). Although the trend of increasing adolescent pregnancy rates peaked in 1991 and has since begun to decline, teenage pregnancy remains a significant problem (Kaufmann et al. 1998). Developmental tasks of pregnancy, motherhood, and often marriage are superimposed on the usual tasks of adolescence. These tasks, when combined with socioeconomic and psychological factors, can lead to a stressed relationship between the teenage mother and her child. Although it is difficult to specify whether it is the adolescent’s age alone, the psychosocial stressors inherent in being a parent from this age group, or a combination of factors, younger maternal age does appear to be associated with less favorable mothering behaviors (McAnarney et al. 1986; Coley and Chase-Lansdale 1998). Younger adolescents appear to be particularly at risk for inappropriate interactions with their children. A study of thirty adolescent mothers and their nine- to twelve-month-old children showed the younger adolescents to display less acceptance, accessibility, sensitivity, cooperation, and more negative verbal communications than older adolescent mothers (McAnarney et al. 1986). Other findings included diminished reinforcement of vocalization as well as lessened responsiveness of the child to maternal vocalizations. Buchholz and Korn-Bursztyn (1993) found that older mothers are more likely to interact verbally with their children than adolescents are. When compared to adolescent mothers, non-adolescent mothers appear to have a more positive affect toward their infants and a more interactional teaching style (Levine et al. 1985). According to Levine et al. these factors in combination are thought to partially explain consistent cognitive defects in the children of adolescent mothers.

Adolescent fathers Although much has been written about the relationships between adolescent mothers and their children, very little has focused on the adolescent father. What is known about this relationship is that its presence or absence can have a very significant impact on the child as well as the mother of the child (Buchholz and Korn-Bursztyn 1993). A consistent relationship with the father has shown positive effects on the child’s social and cognitive development (Robinson 1988), while providing the mother with an important source of support (Buchholz and KornBursztyn 1993). The social and emotional support provided by the child’s father, combined with other family support, leads to more effective parenting by the adolescent mother (Cox and Bithoney 1995). Despite the common perception that adolescent fathers have limited or no contact with their children, several studies have shown consistent paternal contact and support (Furstenberg 1976; Robinson 1988). One study of

55 inner-city adolescent mothers reported that 81 per cent of fathers were providing some assistance with the baby (Zuckerman et al. 1979). Weekly visits by new young fathers occurred in about one-half of those followed, and daily visits in about one-fourth (Coley and Chase-Lansdale 1998). Identified predictors of at least monthly contact during the first twenty-four months of the child’s life in another study included: attending at least one prenatal visit; visiting the infant in the hospital; and acceptance by the mother’s family (Cox and Bithoney 1995). Confronting parenthood and adolescence simultaneously is a difficult task for the adolescent with significant implications for the child.

CONCLUSION Adolescence is a period of expanding relationships with parents, adults outside the family, other teenagers, and at times with their own children. Interactions with parents involve devaluation, distancing and authority conflict as normal steps toward individuation. Relations with nonkin adults focus on instrumental aid. Peer relationships contain opportunities for friendships, affiliations with crowds, and dating with varying levels of intimacy. Adolescent motherhood poses substantial difficulties, but the teenage father’s presence is often a positive element in this challenging relationship. Adolescence offers a diversity of interpersonal relationships in preparation for entry into adulthood.

REFERENCES Abma, J.C., Chandra, A., Mosher, M.D., et al. Fertility, family planning, and women’s health: new data from the 1995 National Survey of Family Growth. Vital Health Statistics 23(19): 1–114, 1997. Balwin, W. Trends in adolescent contraception, pregnancy and child bearing. In McArne, E.R. (ed.), Premature Adolescent Pregnancy and Parenthood. New York: Grunes and Stratton, 1983, pp. 3–19. Bigelow, B.J., LaGaipa, J.J. The development of friendship values and choice. In Foot, H.C., Chapman, A.J., Smith, J.R. (eds), Friendship and Social Relations in Children. New York: Wiley, 1980, pp. 15–44. Blyth, D.A., Foster-Clark, F.S. Gender differences in perceived intimacy with different members of adolescent social networks. Sex Roles 17: 689–718, 1987. Brown, B.B., Eicher, S.A., Petrie, S. The importance of peer group affiliation in adolescence. Journal of Adolescence 9: 73–96, 1986. Brown, B.B., Mory, M.S., Kinney, E. Casting adolescent crowds in a relational perspective: caricature, channel,

Adolescent interpersonal relationships 197 and context. In Montemayor, R., Adams, G.R., Gullota, T.P. (eds), Personal Relationships During Adolescence, Volume 6. Thousand Oaks, California: Sage Publications, 1994, pp. 123–167. Buchholz, E., Korn-Bursztyn, C. Children of adolescent mothers: are they at risk for abuse? Adolescence 28: 361–382, 1993. Buhrmester, D., Furman, W. The development of companionship and intimacy. Child Development 58: 1101–1113, 1987. Campbell, E., Adams, G.R., Dobson, W.R. Family correlates of identity formation in late adolescents: a study of predictive utility of connectedness and individuality in family relations. Journal of Youth and Adolescence 13: 509–525, 1984. Coleman, J.C. Relationships in Adolescence. Boston: Routledge & Kegan, 1974. Coley, R.L., Chase-Lansdale, P.L. Adolescent pregnancy and parenthood. Recent evidence and future directions. American Psychologist 53: 152–166, 1998. Cooper, C.R., Grotevan, H.D., Condon, S.M. Family support and conflict: both foster adolescent identity and role-taking skills. In Grotevan, H.D., Cooper, C.R. (eds), Adolescent Development in the Family: New Directions For Child Development. San Francisco: Jossey-Bass, 1984, pp. 43–59. Cox, J., Bithoney, W. Fathers of children born to adolescent mothers. Predictors of contact with their children at 2 years. Archives of Pediatric and Adolescent Medicine 149: 962–966, 1995. Crockett, L., Losoff, M., Peterson, A.C. Perceptions of the peer group and friendship in early adolescence. Journal of Early Adolescence 4: 155–181, 1984. Csikszentmihalyi, M., Larson, R. Being Adolescent: Conflict and Growth in the Teenage Years. New York: Basic Books, 1984. Darling, N., Hamilton, S., Niego, S. Adolescents’ relations with adults outside the family. In Montemayor, R., Adams, G., Gullota, T. (eds), Personal Relationships During Adolescence, Volume 6. Thousand Oaks, California: Sage Publications, 1994, pp. 216–235. Dimond, A.D., Muntz, R.S. Ordinal position of birth and self-disclosure in high school students. Psychology Reports 21: 829–833, 1967. Douvan, E., Adelson, J. The Adolescent Experience. New York: Wiley and Sons Ltd., 1966. Erikson, E.H. Identity: Youth and Crisis. New York: Norton, 1968. Furstenberg, F.F. Unplanned Parenthood: The Social Consequences of Teenage Childbearing. New York: The Free Press, 1976. Hunter, F.T., Youniss, J. Changes in the function of three relations during adolescence. Developmental Psychology 18: 806–811, 1982. Jaffee, S.M., Dryoos, J.G. Fertility control services for adolescents: access and utilization. In Adolescent

Pregnancy and Childbearing. US Department of Health and Human Services, 1980. Jani, S. Changing relationships with parents. In Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3: Adolescence: Development and Syndromes. New York: John Wiley & Sons, 1997, pp. 87–111. Kaplan, H., Sadock, B., Grebb, J. Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences, Clinical Psychiatry, 7th edition. Baltimore: Williams & Wilkins, 1994. Kandel, D.B., Lesser, G.S. Parent-adolescent relationships and adolescent independence in the US and Denmark. Journal of Marriage and the Family 31: 348–358, 1969. Kaufmann, R.B., Spitz, A.M., Strauss, L.T., et al. The decline in US teen pregnancy rates, 1990–1995. Pediatrics 102: 1141–1147, 1998. Larson, R.N. Adolescents’ daily experience with family and friends: contrasting opportunity systems. Journal of Marriage and Family 45: 739–750, 1983. Levine, L., Garcia Coll, C.T., Oh, W. Determinants of mother–infant interaction in adolescent mothers. Pediatrics 75: 23–29, 1985. McAnarney, E.R., Lawrence, R.A., Ricciuti, H.N., et al. Interactions of adolescent mothers and their 1-year-old children. Pediatrics 78: 585–590, 1986. McCabe, M.P. Toward a theory of adolescent dating. Adolescence 19: 159–170, 1984. Niles, F.S. The adolescent girl’s perception of parents and peers. Adolescence XIV: 591–597, 1979. Noller, P. Relationships with parents in adolescence: process and outcome. In Montemayor, R., Adams, G., Gollota, T. (eds), Personal Relationships During Adolescence, Volume 6. Thousand Oaks, California: Sage Publications, 1994, pp. 37–77. Offer, D., Sabshin, M. Normality and the Life Cycle. New York, Basic Books, 1984. Offer, D., Schonert-Reichl, K.A., Boxer, A.M. Normal adolescent development: empirical research findings. In Lewis, M. (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook. Baltimore: Williams & Wilkins, 1996, pp. 278–290. Paul, E.L., White, K.M. The development of intimate relationships in late adolescence. Adolescence 25: 375–400, 1990. Reisman, J.M. Friendship and its implications for mental health or social competence. Journal of Early Adolescence 5: 383–391, 1985. Rice, F.P. The Adolescent: Development, Relations, and Culture, 4th edition. Boston: Allyn and Bacon, 1984. Robinson, B.E. Teenage Fathers. Lexington, MA: D.C. Health, 1988. Roche, J.P., Ramsbey, T.W. Premarital sexuality: a five-year follow-up study of attitudes and behavior by dating stage. Adolescence 28: 67–80, 1993.

198 Normal development Roscoe, B., Diana, M.S., Brooks, R.H. Early, middle, and late adolescent’s views on dating and factors influencing partner selection. Adolescence 22: 231–245, 1987. Savin-Williams, R.C. Gay and lesbian youth: Expressions of identity. Washington, DC: Hemisphere, 1990. Savin-Williams, R.C. Dating those you can’t love and loving those you can’t date. In Montemayor, R., Adams, G., Gullotta, P. (eds), Personal Relationships During Adolescence. Thousand Oaks, California: Sage Publications, 1994, pp. 196–215. Sebald, H. Adolescents’ shifting orientation toward parents and peers: a curvilinear trend over recent decades. Journal of Marriage and Family 48: 5–13, 1986. Sharabany, R., Gershoni, R., Hofman, J.E. Girlfriend, boyfriend: age and sex differences in intimate friendship. Developmental Psychology 17: 800–808, 1981. Sheppard, M.A., Wright, D., Goodstadt, M.S. Peer pressure and drug use – exploding the myth. Adolescence 20: 949–958, 1985. Skipper, J.K., Nass, G. Dating behavior: a framework for analysis and an illustration. Journal of Marriage and the Family 28: 412–420, 1966.

Sonenstein, F.L., Pleck, J.H., Ku, L.C. Sexual activity, condom use, and AIDS awareness among adolescent males. Family Planning Perspectives 21: 152–158, 1989. Sorenson, R.C. Adolescent Sexuality in Contemporary America. New York: World Press, 1973. Steinberg, L., Silverberg, S.B. The vicissitudes of autonomy in early adolescence. Child Development 57: 841–851, 1986. Udry, J.R., Billy, J.O.G. Initiation of coitus in early adolescence. American Sociological Review 53: 709–722, 1987. Youniss, J. Parents and Peers in Social Development: A Sullivan–Piaget Perspective. Chicago: University of Chicago Press, 1980. Youniss, J., Haynie, D. Friendship in adolescence. Developmental and Behavioral Pediatrics 1: 59–66, 1992. Zuckerman, B., Winsmore, G., Alpert, J.J. A study of attitudes and support systems of inner city adolescent mothers. Journal of Pediatrics 95: 122–125, 1979.

SECTION

4

Assessment of the adolescent EDITED BY GARY J. GOSSELIN

Introduction Gary J. Gosselin

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4.1 The clinical interview of the adolescent Gary J. Gosselin and Yiu Kee Ng

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4.2 Family assessment Richard A. Oberfield

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4.3 Psychosocial assessment Gary J. Gosselin and Yiu Kee Ng

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4.4 Medical assessment Elizabeth Kay Spencer

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4.5 Biological assessment Brian J. Klee

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4.6 Psychological assessment Alan S. Elliot and Enrique Gular

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4.7 Cultural assessment Phill V. Halamandaris and Tanya R. Anderson

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4.8 Educational assessment Edward A. Mainzer

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4.9 Assessment and treatment planning Glenn S. Hirsch and Richard Gallagher

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Introduction GARY J. GOSSELIN

This section on assessment was developed to meet the needs of trainees gaining their first clinical exposure to assessment practices in the field of adolescent psychiatry. It is by no means an exhaustive coverage of current assessment practice, and it is not meant to be one. Rather, it is intended to be a conceptual introduction and practical overview of the process of clinical assessment. The editors and authors of this volume were instructed to ‘assume no prior knowledge’ of adolescent psychiatry on the part of the reader. Given the space limitations of this section, certain compromises on content had to be made to highlight areas of special importance and relevance to clinical work with adolescents. Such compromises were made at the expense of topic areas that usually

receive coverage in general psychiatry training programs and the general psychiatry literature. To benefit most from this section, the reader should possess a basic knowledge of the elements of the mental status examination and diagnostic categories. Also, the reader should be thinking about assessment practice from a developmental perspective. It can be argued reasonably that the text chapters on development and diagnostic categories should be read as conceptual foundations and background for this section. Experienced practitioners and readers seeking more detailed and advanced coverage of assessment topics are encouraged to refer to the references and recommended readings section of each chapter.

4.1 The clinical interview of the adolescent GARY J. GOSSELIN AND YIU KEE NG

The clinical interview of the adolescent requires the interviewer to draw upon an array of techniques and strategies to complete multiple tasks. During the interview, the clinician must build rapport with the adolescent, establish the context of the clinical encounter, collect sufficient data to arrive at a diagnosis, organize observations and inform the adolescent and his parents about the purposes and details of the clinical assessment process. The information derived from the interview must then be integrated with data obtained from other sources, such as teacher reports, parent interviews, family meetings, document reviews, test results and diagnostic studies.

INTERVIEW FORMATS Researchers on adolescence generally agree that no single assessment instrument or interview protocol exists that offers optimal sensitivity, specificity and validity across all settings and diagnoses. Also, they have discussed the limited utility of using interview data, or any one source of information, to assign clinical diagnoses (Achenbach 1995; Verhulst and Koot 1992; Malone et al. 1995; Verhulst et al. 1997). A range of interview formats and approaches can be used. Format selection is usually based on the interviewer’s training, orientation, the purpose of the interview, and the limitations that exist in a given practice setting. Structured interviews are widely used for research purposes but are generally considered to have limited utility for everyday clinical use owing to the amount of time required to administer the interview and the lack of flexibility afforded to the interview situation when a structured interview is conducted. The advantages of structured interview approaches include their systematic nature, their thorough coverage of diagnostic areas and, in some situations, their established test characteristics.

Training in the administration of structured interview formats is usually required. Well-known examples of structured interviews include the Diagnostic Interview Schedule for Children (DISC) and the Diagnostic Interview for Children and Adolescents (DICA). Semi-structured interview formats offer the combined advantages of thorough screening coverage and flexibility of administration. Organized semi-structured question sequences enhance systematic coverage of vital topic areas while affording the interviewer more flexibility than the set protocols of structured approaches. Semi-structured formats may range from diagnosis-specific interviews such as the Yale Brown Obsessive Compulsive Scale (YBOCS) to general diagnostic screening tools such as the Child and Adolescent Psychiatric Assessment (CAPA) and the Young Adult Psychiatric Assessment (YAPA). Disadvantages of semi-structured instruments include their lack of established test characteristics and the need for specific training related to performance of some interview tasks. Examples of clinically useful semi-structured question sequences are available in the psychiatric literature (Bird and Kestenbaum 1988; Angold et al. 1995). A suitably flexible, yet systematic interview approach begins with open-ended screening questions to cover relevant diagnostic areas. If these screening questions should yield positive responses, or if collateral reports have raised diagnostic possibilities, a series of more specific question sequences is asked to gather more detailed information. In this approach the interviewer screens all potential areas of diagnostic concern and asks more focused probe questions based on cues provided by the patient as the interview progresses. This approach provides an opportunity to digress from structured approaches to questioning as the need arises and lets the clinician tailor the flow of the interview to fit the dynamics of a changing clinical situation. For example, during an interview segment focused on the review of school interests, an adolescent spontaneously

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mentioned that he knew of a classmate who had talked about committing suicide. The interviewer shifted the focus of the interview from the initial intended flow of questioning about the review of school history. Openended questions were used to explore the adolescent’s feelings, attitudes and responses to the situation. The adolescent’s relationship with the classmate was discussed and his opinions about suicide and death were elicited. He was asked if he had been able to speak with other people, such as his parents or teachers, about the situation. The interviewer then closed this segment of the interview by using a sequence of probe questions to assess risk factors associated with suicide. During this interaction, the interviewer made note of the need to follow up on content areas related to suicide risk (i.e., a review of mood symptoms, substance use, impulse control, etc.). By attending to the adolescent’s inclination to speak about a key content area (suicide) at a specific point in the interview, rapport was fostered and the risk of underreporting by the adolescent was reduced.

INTERVIEW CONTENT AREAS During the interview the clinician systematically screens, makes observations and organizes data obtained along multiple dimensions according to developmental principles. Positive responses to screening questions or the detection of signs and symptoms that raise suspicion of possible clinical problems serve as indications to pursue more detailed inquiries via probe questions into relevant areas. Although there is no set content for all clinical situations, a comprehensive clinical interview, or series of interviews, will cover the following content areas:

• • • • • • • • • • •

Reason for seeking evaluation History of present illness Symptom review and screening based on DSM-IV criteria A review of prior mental health assessments and treatments Medical review of systems and medical history Mental status examination Developmental status School functioning Ethnicity and culture Sources of support in the home, school and community Emotional adjustment – Attitudes toward relationships with parents and family – Signs of movement toward a sense of individual identity – Awareness of sources of self-esteem – Ability to identify and speak about feelings – Attitudes and feelings about love, intimacy, and sexuality

•

•

•

•

– Reactions to puberty – Awareness of their passage from childhood to adult life Moral and spiritual attributes – Religious affiliations and spiritual beliefs – Sense of personal responsibility for behavior – Personal values and convictions – Appreciation of the concepts of right and wrong Social adaptation – Peer relations – Dating activities – Social skills – Capacity for empathy – Conflict resolution strategies Health beliefs and specific risk behaviors – Drug use, drinking and tobacco use – Automobile safety – Exposure to violence – Suicidality and self-injurious behaviors – Criminal activity – Access to firearms – Sexual behaviors Associated strengths – Job skills and career aspirations – Academic interests and achievements – Hobbies – Involvement in constructive leisure activities – Availability of adult role models.

INTEGRATING INTERVIEW DATA AND COLLATERAL INFORMATION Interview data alone are often insufficient for the purposes of assessment, diagnosis, and treatment. Collateral sources of information should be sought whenever feasible. Of course, there is no single approach or combination of collateral information sources that will be adequate for every assessment situation, and the sources of information will be selected to fit the unique needs of a given clinical situation. For example, paper-and-pencil tasks will have limited utility when the clients being served lack basic literacy skills. Such sources of information might include questionnaires and symptom checklists such as the Child Behavior Checklist/4-18 (CBCL) (Achenbach 1991a) or the Behavioral Assessment System for Children (BASC) (Reynolds and Kamphaus 1992). Also, there are often indications to obtain collateral information from parent interviews, family interviews, contacts with schools or social agencies, psychological testing and document reviews. When available, information from these sources should be checked for consistency with information obtained in the interview. At times, it can be helpful to review information obtained from other sources with the

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adolescent to elicit his direct reactions and to attempt to clarify any apparent inconsistencies. All assessment information can be affected by the distortions of subjective reporting and careful validity checks should be attempted whenever possible. The limitations of independent sources of information must be remembered, particularly when working with older adolescents who spend much of their time outside the scope of direct adult observation. The clinician should also remain mindful that information appearing to emanate from multiple sources of information might actually originate from a single source, adding no corroborative value to the assessment process. The following example illustrates the importance of collateral contacts to reduce the effects of redundant and inaccurate information.

Case example A student at a local high school wrote a poem about death. Her teacher, after reviewing the poem, feared that the student was suicidal and, according to the school policy and procedure, referred the student to the busy guidance office of the school. A guidance counselor, who did not know the student and had no rapport with her, conducted a brief interview. During this brief exchange with the guidance counselor, the student denied that she wanted to die or to harm herself. The guidance counselor decided, based on his brief interview with the student, that there was no evidence of suicide risk. After conferring with the vice principal about the matter, a decision was made to ‘be on the safe side’ and have the guidance counselor seek phone consultation with a local clinic about the student’s need to have a psychiatric evaluation. During the initial phase of the phone contact, the guidance counselor emphasized that he did not think that the student was suicidal (based solely on the student’s statements made to him) and that he did not think there was any need for a psychiatric evaluation. The clinician conducting the phone screening determined that the busy guidance counselor had conducted only a brief interview and did not seem know the student well. The clinician asked to speak directly with the teacher who received the poem. On the phone, the teacher stated that she had been alarmed by the morbid tone of the student’s poem, which seemed unusual for any of her students. She also said that the student had looked tired and withdrawn for several weeks and that all attempts to engage the student in discussion during the school year had been unsuccessful. The teacher also reported that in a recent conference, the student’s parents had reported that they were unaware of any problems but that the student did not spend much time with them at home. A decision was made to evaluate the student that day at the clinic. She was found to be

quite depressed, at risk for suicide and in need of immediate treatment. In this case, the second source of corroborative information was the classroom teacher and not the guidance counselor, who merely echoed the statements made by an uncooperative student. If the clinician had accepted the guidance counselor’s report at face value without contacting the classroom teacher, the suicide risk and an opportunity for a timely intervention would have been missed.

INITIAL CONTACTS AND THE REFERRAL PROCESS The clinical context is likely to determine the nature of the initial contact and what activities are to be pursued and completed prior to meeting with the adolescent. Clinical judgment will determine how to tailor the evaluation to suit the purposes at hand. For example, referral circumstances and appropriate preliminary clinical approaches will differ between a comprehensive elective outpatient evaluation and a referral for a problemfocused emergency room evaluation that could lead to hospitalization. In most cases, parents, guardians or other concerned adults initiate a contact for a psychiatric evaluation of an adolescent. At this point, preliminary screening questions will be used to determine the appropriateness of the referral and the potential acuity of the clinical situation. If parents are initiating the referral, the clinician should ask the parents if they have discussed the matter with their adolescent and what was said during that discussion. Parents may need guidance on how to speak with the adolescent about their reasons for seeking an evaluation. In non-emergency situations it can be helpful to include the adolescent in the scheduling of appointments. If an adolescent is not present at the time of the initial contact, an invitation can be extended to have him call the office on his own to schedule or confirm an appointment and to follow up with preliminary questions he might have about a pending initial appointment. Sometimes it is useful to have older adolescents schedule and make the initial contact on their own. No matter what the initial contact approach will be, it should be emphasized that a time will be allotted for the adolescent to meet alone with the clinician. During the initial contact, instructions can be given to parents about clinical questionnaires, forms or materials that a clinician prefers to have completed and returned for review prior to the first office encounter. Printed materials might include an orientation to the assessment process and an introduction to the unique confidentiality conditions that apply to the psychiatric assessment of

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an adolescent. When feasible, checklists such as the Youth Self-Report (YSR) can be provided to the adolescent and the CBCL (Achenbach 1991a) can be forwarded to the parents for completion and review prior to the initial interview. Such a strategy can help to focus the assessment process and make more efficient use of interview time. Clinicians may use several strategies to conduct the initial office visit. The adolescent can be seen alone, the parents can be seen alone, or the parents and adolescent can be seen together. In each situation the clinician must balance the adolescent’s desire for privacy with the need to keep parents informed. Failure to find the right balance of involvement between the adolescent’s privacy interests and parents’ right to know about their child’s treatment will limit cooperation and jeopardize the assessment process. When an adolescent is going to be seen without his parents present, the rationale for doing so should be explained to the parents, and the consents necessary to proceed should be obtained. In such cases, the parents can be told that it is a common clinical practice in adolescent healthcare to meet with adolescents alone for at least a portion of the clinical contact. If an adolescent initially chooses not to be seen alone, the option to meet alone with the clinician should be held open to them throughout the assessment. When working with younger adolescents it may be most useful to meet with the parents alone to obtain history and to help the parents prepare their adolescent for the first office visit. Most clinical assessments necessitate seeing adolescents together with their parents at some point during the assessment process. Some clinicians prefer to schedule a portion of the first visit to meet with the adolescent and parents together to outline confidentiality matters and describe the details of the assessment process. It should be stated that the assessment findings will be discussed with the parents and the adolescent at the conclusion of the assessment process. A special variation of the initial contact involves emergency situations. In emergencies, parents, guardians, supervising adults or adolescents may need specific information on gaining rapid access to mental health services. Clinicians should be prepared to expedite the referral process and offer succinct instructions on the location of clinical services and how to obtain support from community agencies and resources to enact safe transport to a clinical site for an emergency evaluation. No concessions should be made to compromise safety during emergency situations.

CONFIDENTIALITY In assessments, the confidentiality limits between adolescents and their parents are unique and should be clarified

at the start of the process and refreshed as needed. The adolescent should be told that during the assessment he will be invited to speak with the clinician under conditions of limited privacy. If the adolescent chooses to meet alone with the clinician, a promise of full confidentiality should not be made. In most instances, the evaluation findings and treatment recommendations will be reviewed with the adolescent’s parents at the end of the assessment. It is also helpful to state that time will be set aside for the adolescent and the clinician to prepare for any planned information sharing with parents. Also, a clear message should be given that dangerous conditions will be addressed directly with the adolescent and his parents. The reactions to this information should be assessed. The need to share information and recommendations is presented at the beginning of the evaluations and again as needed to refresh the adolescent’s awareness of the limits of confidentiality as the assessment proceeds. When adolescents react negatively to the outlining of confidentiality limits, the clinician can discuss possible approaches to preserve some degree of privacy for the adolescent. A discussion of strategies to present sensitive personal topics to the parents might dispel an adolescent’s initial reservations about speaking with the interviewer. A query such as, ‘How would you like to tell your parents about this?’ might help the adolescent to take a more active role in any disclosure process. As the end of the assessment process draws near, a discussion is held between the clinician and the adolescent to plan the presentation of findings and recommendations to the adolescent’s parents. Prior to the meeting with the parents it can be useful to summarize the findings and present the recommendations in an individual session with the adolescent. Some clinicians prefer to incorporate this approach throughout the course of the assessment as a way to prevent any surprises at the close of the assessment process.

COMMUNICATION BARRIERS Teenagers might have various special communication needs that are often missed or misdiagnosed. If an adolescent appears to be uncooperative with the interview process, the clinician must conduct screening to detect potential barriers to communication, such as primary language or cultural differences, speech and language disabilities, developmental disabilities or sensory impairments. An initial approach with the uncommunicative patient should include a preliminary estimation of the patient’s developmental level. An early adolescent might feel more comfortable and be better able to engage in the interview process if he is given the option to use toys, games or art materials that are kept in the interview

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room. Tactical adjustments may need to be made in a clinician’s usual approach during an encounter with an uncommunicative adolescent. A reticent patient may be willing to provide more information in written form via questionnaires such as the Youth Self-Report (Achenbach 1991b) that are commonly available. It is not unusual to encounter significant ‘warming up periods’ when working with adolescents. At times, the ice might be broken by chatting about non-clinical topics in order to become acquainted before moving into areas of clinical inquiry.

PROBLEMS AND PITFALLS Most adolescents do not seek clinical services independently. Often, an adult is involved in making the first contact for assessment services. Under these circumstances adolescents frequently have initial negative reactions to the interview situation, either because they disagree with the decision to seek an evaluation or because they feel deceived and misinformed about the nature of the clinical encounter. Such situations arise despite clinicians’ or parents’ best efforts to prepare an adolescent for the clinical encounter. In these difficult circumstances, it is necessary to address the adolescent’s feelings directly and ask about specific events that contributed to any feelings of distrust. It should be acknowledged if the adolescent has been misinformed and errors of information should be corrected as soon as possible. At these junctures, instructions such as ‘trust me’ are useless. It is much more tenable to take the position that trust is earned over time through information sharing and that opportunities for clarification and questions will be provided through the course of the assessment. Self-disclosure and shame can be powerful influences on the dynamics of the interview process. Unlike adult patients seeking evaluations on their own, many adolescents have not made the choice to seek services and are not prepared to delve into their problems during the clinical interview. Many teens may not be able to tolerate focused inquiry of the presenting problem and may require a ‘warming-up period’ of conversation about acquaintances, general interests or favorite activities. Interaction might be enhanced and initial resistances overcome by acknowledging visual cues such as manner of dress, choice of reading materials or possession of personal articles that might be associated with a special interest. Some adolescents might be encouraged to take an active role in the encounter by talking about areas of specialized skill or knowledge. Some adolescents might explore the interviewer’s potential responses by presenting their problems in displacement as observations about other people (i.e., ‘There is this kid in my class who has this problem.’). In most situations it is advisable to respect the adolescent’s inclination to proceed in this manner.

Adolescents might approach the clinical encounter with a determination to establish and maintain the position that there is ‘nothing wrong with me.’ A viable responses to such a position draws on the likelihood that most teens have strengths and sources of self-esteem that can be tapped into for therapeutic advantage. For example, ‘The purpose of this assessment is to get to know you as a complete person, to understand what is going right in your life too, not just what is going wrong. Of course, if there are things that are troubling you, it is important for us to be able to talk about them. It is the only way for us to work together to help you feel better.’ An uncommunicative patient might respond when problems are reframed in interpersonal terms with a statement such as, ‘What is going on with your parents and you?’ If his family or school places an adolescent in the role of symptom bearer, the clinician can try to provide the adolescent with some distance from the symptom bearer’s role while aligning with his capacity to observe his circumstances and condition. A statement such as, ‘Your parents have told me some things about you but it is very important for me to hear about things from you directly. I can’t think of anyone who would know you better, can you?’ might suffice to start a discussion. How the interviewer approaches such a response will vary based on the severity of the presenting signs and symptoms and the amount of reliable information available about the clinical circumstances and active problems. While a clinician should make every effort to avoid conflict in such situations, tactful and gentle clarification can be sought when presented with apparent discrepancies between the adolescent’s personal account and information derived from other sources. An adolescent’s denial of obvious dangerous behavior might be indicative of severe psychopathology requiring more robust inquiry from other sources of information. Attempts by the clinician to build rapport by emulating teenage mannerisms, speech or dress and any tendency to act too familiar should be avoided. Such tactics are easily seen as transparent and inauthentic ploys that are likely to diminish the clinician’s credibility with the adolescent. Clinicians must remain patient, calm flexible and persistent when attempting to interview a reticent youth.

CLOSING THE INTERVIEW The interview ends by summarizing what has occurred and sharing clinical impressions with the adolescent. If additional interviews, special procedures or testing are required, the rationale for pursuing each additional procedure should be explained. The clinician should discuss with the adolescent, and the parents, how to handle

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indicated collateral contacts with schools or agencies. In many instances, consideration may need to be given to contacts required between a clinician and an insurance company case reviewer for managed care purposes. In the summing-up phase of the interview process, an opportunity for final questions and explanations is offered to the adolescent. And finally, a strategy to present the assessment findings and recommendations to the adolescent’s parents is discussed. The clinician and adolescent collaborate to develop an approach to the session with the parents and the adolescent is invited to attend that meeting and encouraged to take an active role in the presentation of findings.

REFERENCES Achenbach, T.M. Manual for the Child Behavior Checklist/ 4-18 and 1991 Profile. Burlington: University of Vermont, 1991a. Achenbach, T.M. Manual for the Youth Self-Report and 1991 Profile. Burlington: University of Vermont, 1991b. Achenbach, T.M. Developmental issues in assessment, taxonomy, and diagnosis of child and adolescent psychopathology. In Cicchetti, D., Cohen, D. (eds), Developmental Psychopathology, Volume 1. New York: Wiley Interscience, 1995, pp. 57–80. Angold, A., Prendergast, M., Cox, A., et al. The child and adolescent psychiatric assessment (CAPA). Psychological Medicine 25: 739–753, 1995. Bird, H., Kestenbaum, C.J. A semi-structured approach to clinical assessment. In Handbook of Clinical Assessment of Children and Adolescents. New York: New York University Press, 1988, pp. 19–30. Malone, E.M., Szanto, K., Corbitt, E.M., et al. Clinical assessment versus research methods in the assessment of suicidal behavior. American Journal of Psychiatry 152: 1601–1607, 1995. Reynolds, W., Kamphaus, R.W. Behavioral Assessment System for Children Manual. Circle Pines, Minnesota: American Guidance Service, 1992. Verhulst, F.C., Koot, H.M. Child Psychiatric Epidemiology: Concepts, Methods and Findings. Newbury Park, California: Sage Publications, Inc., 1992. Verhulst, F.C., van der Ende, M.S., Ferdinand, R.F., et al. The prevalence of DSM IIIR diagnoses in a national sample of Dutch adolescents. Archives of General Psychiatry 54: 329–336, 1997.

Suggested reading Angold, A. Clinical interviewing with children and adolescents. In Rutter, M., Taylor, E., Hersov, L. (eds), Child and Adolescent Psychiatry Modern Approaches. Bath, UK: Bath Press, 1994, pp. 51–63. Barkley, R.A. Child behavior rating scales and checklists. In Rutter, M., Tuma, A.H., Lann, I.S. (eds), Assessment and Diagnosis in Child Psychopathology. New York: Guilford Press, 1988, pp. 113–155. Cohen, R.L. Special considerations in the examination of adolescents. In Noshpitz, J.D. (ed.), Basic Handbook of Child Psychiatry, Volume 1. New York: Basic Books, 1979, pp. 547–550. Esman, A.H. (ed.) The Psychology of Adolescence. New York: International Universities Press, 1975. Edelbrock, C., Costello, A.J. Structured psychiatric interviews for children. In Rutter, M., Tuma, A.H., Lann, I.S. (eds), Assessment and Diagnosis in Child Psychopathology. New York: Guilford Press, 1988, pp. 87–111. Flaherty, L.T., Sarles, R.M. (eds) Adolescence: development and syndromes. In Handbook of Child and Adolescent Development, Volume 3. New York: John Wiley & Sons, 1997. King, R.A. Practice parameters for the psychiatric assessment of children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1386–1402, 1995. King, R.A., Schowalter, J.E. The clinical interview of the adolescent. In Wiener, J.M. (ed.), Textbook of Child and Adolescent Psychiatry. Washington, DC: American Psychiatric Press, 1997, pp. 89–94. Lewis, M. Psychiatric Assessment of infants, children, and adolescents. In Lewis, M. (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook, 2nd edition. Baltimore, MD: Williams & Wilkins, 1996, pp. 440–456. Meeks, J.E., Bernet, W. The Fragile Alliance: An Orientation to the Psychiatric Treatment of the Adolescent, 4th edition. Malabar, Florida: Robert S. Kreiger, 1990. Offer, D., Schonert Reiche, K.A. Debunking the myths of adolescence: findings from recent research. Journal of the American Academy of Child and Adolescent Psychiatry 31: 1003–1014, 1992.

4.2 Family assessment RICHARD A. OBERFIELD

INTRODUCTION The diagnostic assessment of the family of an adolescent is an essential, often underutilized, part of the overall assessment process in child and adolescent psychiatry. The family interview offers the clinician a glimpse of the usual context surrounding the symptomatic member, de-emphasizes the possible scapegoat role of the youngster, and sheds light on the developmental stage of the family. Evaluating the entire family, in addition, clarifies the various roles the members have adopted in order to cope with developmental stresses. Family interviewing also provides valuable clues regarding treatment, regardless of whether family therapy will be recommended. The family assessment augments the individual assessment of the adolescent by providing opportunities to gather history from parents and to conduct conjoint interviews with two or more family members. It is vital to keep in mind that intrapsychic and interpersonal dynamics are not mutually exclusive, and that these dynamic forces coexist and interrelate to produce the psychological strengths of the adolescent as well as the pathological elements. The method of introducing the family assessment will be discussed in detail after a review of the major models of normative family functioning and of the family life cycle framework.

MODELS OF FAMILY FUNCTION Various models and typologies of normative family functioning have been described in the field of family therapy. No single model has gained general acceptance. The major clinical and research models will be briefly described as a key to understanding both normative and pathological family functioning.

McMaster model This model was developed by a group led by Nathan Epstein and his colleagues at McMaster University during the 1970s. Epstein outlined three developmental tasks throughout a family’s life cycle: basic needs, including those of food, shelter, and financial security; developmental tasks, or predictable problems inherent in the life cycle of the family; and crisis-related or ‘hazardous’ life events which are unexpected, such as illness, accidents and geographic displacement. The model is based on the assumption that family components are interrelated. In this manner, no individual component can be comprehended outside of the family context. In addition, the family’s structure and function – and in particular its interactional sequences – are crucial determinants of each member’s behavior. The model is based on a problemoriented systems framework across the broad area of biological, psychological, and social levels (Epstein et al. 1982).

The Beavers model This model utilizes direct observation of family interaction, as opposed to self-reports or checklists. The model is based on a two-dimensional grid with ratings of whole family competence and adaptability around a task, as well as the family’s interactional style. This model is frequently used as an assessment instrument at the outset of family treatment as well as a prospective monitoring and outcome instrument during treatment (Beavers 1982).

Olson circumplex model This model of family functioning measures features of cohesion, adaptability, and communication within the group. The specific working description of the family

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based on this model has yielded clinical rating scales (e.g., FACES: the Family Adaptability and Cohesion Evaluation Scale) which have been successfully utilized in clinical as well as research settings (Olson et al. 1983).

Family paradigm model (Reiss) This model utilizes a laboratory and a card-sorting task in order to ascertain the functioning of the family. The three specific areas of family function which this model explores include configuration, coordination, and closure. Data are elicited about the way in which the family deals with the outside world, and differences have been delineated among families who have members suffering from psychotic or antisocial disorders (Reiss 1981).

members are challenged to accommodate to these changes. The primary task for the family at this point is to redefine the parent–child relationship, especially regarding issues related to autonomy, control, and individual responsibility. Common presenting problems include acting-out on the part of the adolescent, who may actually be ambivalent about attaining new freedom and responsibility. The family’s own attempts at resolution of issues of autonomy and trust, as well as the eventual departure of the adolescent from the home, may be veiled within complex presenting symptoms which emerge during the assessment.

GENERAL GUIDELINES FAMILY DEVELOPMENTAL LIFE CYCLE In recent years, the life cycle of the family has become quite prominent in descriptions of family functioning. It is very useful during the assessment of the family to ascertain the current life cycle stage of the group and its members. The family’s life cycle unfolds in an analogous manner to that of an individual. There are numerous variations of the family life cycle related to changing family structures, but the successive and sequential staging remains similar across various types of family. Life cycle transitions are classically the points at which the family may have difficulty and individuals emerge with symptoms. These transitional problems usually relate to the regulation of intimacy and personal distance within the family. The typical description of the family life cycle includes five major stages: the early married couple; the family with young children; the family with adolescents; the gradual departure of children; and the family in later life, often referred to as the ‘empty nest.’ The emergence of children into adolescence can be challenging to the family, as the young person attempts to balance the competing demands of autonomy and allegiance to peers, while simultaneously maintaining affiliation to the family. As has been stated, ‘...regardless of how they are referred, or whether they welcome or resist the referral, families tend to arrive feeling confused, angry and out of control, and present problems that reflect the family’s inability to deal with the tasks of adolescence… . Unable to make the necessary shifts that facilitate growth, they often repeat dysfunctional patterns that eventually lead to symptomatic behavior in adolescents.’ (Garcia Preto 1989). As the children undergo the physical and psychological changes associated with adolescent development, the usual structural patterns which have evolved between the parents and children are altered and all the family

As was previously noted, the purpose of the family assessment interview is to place the presenting problems and symptoms of the identified patient in a coherent context. Although this concept may be quite reasonable from the perspective of the clinician, the parents may present significant resistance to the idea of the entire family being seen in a conjoint meeting. From the time of the first phone call, the therapist must find a balance between maintaining control of the evaluation and establishing a working alliance with the other family members, particularly the parents. The parents are often reluctant to involve siblings of the adolescent, as they are concerned that the well-functioning brothers and sisters may be ‘contaminated’ by exposure to the problems surrounding the identified patient. The parents’ wish to not expose the other children may be related to their guilt about the patient’s problems, and their wish to maintain the idea that they have other well-functioning children. The therapist might respond to this question by replying that the other children are most likely exposed to family dynamics and heated discussions at home. It may be added that the other siblings may have valuable input into the process including views of their own about the difficulties of the identified patient. This often reassures them about keeping the clinical focus on the patient. Another rationale regarding the other children is to underline the preventive aspect of the process: the family treatment may avert future problems with other siblings. If resistance on the part of the parent persists, rather than attempting to counter the resistance it is usually best to initiate the first session with the members deemed most important by the parents, and then attempt to have others attend later sessions after a trusting relationship has been established. It is usually best to state during the initial phone contact that during the first meeting, the clinician will be interested in interviewing both the parents and the adolescent together and alone. Some

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clinicians prefer to suggest a definite structure for the first meeting, and others tend to allow the parents to decide how to best plan the meeting, as they have the most familiarity with the patient. In arranging the initial interview, the clinician might ask ‘Since you know your son/daughter’s reactions better than I do, do you think it would work best if we start together or if I see him/her alone first?’ If the family prefers the clinician to begin with the patient individually, it is of utmost importance to establish from the outset the guidelines of confidentiality. In this way, the youngster will understand that the clinician will not be communicating privileged information to the parents after the interview. As is true of individual psychiatric evaluation and psychotherapy with adolescents, it is vital to establish the limits and exceptions of the confidentiality agreement, for example relating to illegal or dangerous activities. Another problem which might arise in the early stages of contact with the family is the issue of the noncustodial parent. If the custodial parent has consented to treatment, the clinician must decide how important it is to engage the other parent in the assessment process. There may be much resistance on the part of one parent to the psychiatric and family assessment, which may relate to ongoing court issues, financial issues, or continuing bitter conflict between the parents. It is usually helpful to elicit the opinion of the adolescent regarding involvement of both parents in the evaluation and treatment.

THE FIRST INTERVIEW Most clinicians and theoreticians in the family therapy field agree that the initial diagnostic interview with the family is pivotal in terms of establishing an ongoing relationship. Many family/systems writers in the field have presented practical guidelines for conducting the first interview (Haley 1976). For psychiatrists of adolescents, it is crucial to establish rapport with the symptomatic adolescent during the initial interviews. Most beginning clinicians are not certain about whether to meet separately with the young person before meeting with the parents and the rest of the family. Generally, most experienced clinicians take the cue about this from the family; if the adolescent would prefer to meet individually at first with the clinician, this usually is arranged. It is important during such a meeting to establish the limits of confidentiality in relation to other members of the family. If, however, the adolescent feels strongly about not being singled out as ‘the problem’ and would prefer to begin as part of a family group, this request is usually honored. If the clinician adopts this sequence, it can be explained to the young person that separate sessions, as needed, will be arranged during the evaluation process.

When an initial family session is arranged, it is useful for the clinician to observe, if possible, the family’s behavior in the waiting area. The family usually conducts itself in a more spontaneous and open manner before entering the consulting office. It is instructive to note the degree of physical proximity of the members, the presence or absence of conversation, the level of tension, and any attempts by the parents to set limits on the children before entering the office. The seating arrangement in the office, if chosen by the family, can be extremely revealing of interpersonal dynamics. It is therefore advisable to allow the members to seat themselves and not be directed where to sit by the clinician. An adolescent who places him/herself far from other family members may be feeling alienated and isolated. A youngster who sits between parents may be poorly differentiated or involved in some inappropriate manner with the marital relationship. The youngster who sits very near the new clinician may be attempting to reach out and form an attachment to a neutral outsider. The parent who sits furthest away from the therapist may be the most challenging to engage, and may possess an alienated position in relation to the rest of the family. Regarding the course of verbal exchange during the session, it is most beneficial to allow the family to tell its own story in its own manner. At the same time, the clinician should not allow the ‘identified patient’ to be severely ‘scapegoated’ by the group, and the family’s reaction to the therapist’s interceding here is critical to assess. Early in the beginning interview it can be helpful to try to engage each person in the room, by asking them about their work, hobbies, or favorite pastimes. Eventually, the clinician should inquire about the presenting problems in an open-ended manner, such as ‘I know a bit about the problems, but would like to find out more. Who would like to start?’ In this manner, one soon may ascertain if the parents and children are in general agreement about the problems and what alliances exist in the family. The clinician needs to be active and directive during the session in order to keep general control of the flow of the meeting. If a strong-minded member is able to dominate and is not gently challenged or interrupted by the clinician, the family members may feel that the therapist is not really in charge of the process. It is also important during the first session that the clinician not allow the atmosphere to become too intense or heated. It has been stated by many veteran clinicians in the field that the primary goal of the first session is to have the family return for a second time. It is best to identify the difficult areas in a scanning manner, to be revisited in greater detail later in the course of treatment. If a particular issue leads to great emotional intensity during the first session, the various family members may feel that they cannot endure this on a regular basis. Nathan Ackerman, one of the pioneers of the family therapy field, referred to the opening type of mild but

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pointed questioning of the family patterns around the identified patient as ‘tickling the defenses’ (Ackerman 1966). By this term, he meant gently assessing the family members’ tolerance of alternative suggestions regarding the genesis or maintenance of problems. For example, if a family with three children presents their fifteen-year-old daughter as uncooperative, difficult and divisive, the evaluating clinician might ask the parents at some point, ‘Are there any problems in the family that do not involve her? Are you at all concerned about the other children and how they are doing? How does everyone else get along with one another?’ There is usually a wide range of responses to these questions. The family which is rather inflexibly focused on the adolescent will generally respond to such inquiries by referring back to the patient with much blame and apparent frustration. This type of response enables the clinician to understand the rigidity of the family’s system, and the amount of resistance one can expect to encounter in order to forge change in pattern and behavior. Alternately, a response such as ‘We all have some trouble getting along together, besides the issues with her’ would be an indication that the family members may be willing to examine interpersonal issues beyond the identified patient. The evaluator must keep in mind that the family has a strong ‘homeostatic’ tendency to revert to usual patterns, and the clinician must refrain from too actively challenging the system during the first interview. It is usually most practical to engage the family through the problems of the identified patient during the early portion of the first session. For example, a doctor was interviewing a new family. The presenting issue was the patient’s complaint of gastrointestinal distress which was deemed to be of psychosomatic origin. Further into the interview, there appeared various indicators of serious marital pathology, after which the trainee excused the children from the consultation room and proceeded to address the marital dysfunction. The parents’ anxiety increased dramatically, and the family did not return to treatment. The doctor may well have been correct in suspecting the particular dynamics of this family, but because the interventions were too rapid, the family’s ‘homeostat’ was alerted and the members could not tolerate such rapid and aggressive investigation of their situation. Clinicians often exclude young children from family interviews because of concerns that they will be behaviorally challenging, may become bored, and would not have much to contribute to the process. Many authors, including Zilbach (1989), Satir (1967), and Whitaker and Keith (1981) have strongly maintained that the exclusion of young children will deprive the clinician of valuable input. Younger children – particularly those under five or six years of age – may surprise everyone with a very direct and meaningful comment, or they may act out a crucial

family scene during play in the session. In order to best profit from the presence of young children in the room, the therapist should provide some standard play materials such as drawing paper and crayons, representational dolls and animals. A special and meaningful bond between the adolescent and a younger sibling may be highlighted in the treatment room when young children are included in the family interview. For example, a fourteen-year-old adolescent was referred for aggressive and, at times, violent and threatening behavior toward his siblings. During the first family evaluation session, the parents were asked by the clinician about discipline for the teenager. There was a pause and hesitation, during which the five-year-old brother, who apparently had been focused exclusively on toys and drawings, stated, in a low voice, ‘They beat him.’ The clinician clarified this topic via thorough and careful questioning regarding child abuse.

OBSERVATIONS Communication It is important to separate the content from the process of communication in the sessions. There may be repetitive sequences of conversation which are dysfunctional. It may later be important to point out these relatively fixed and repetitive communication patterns. The clinician should ascertain if the chief complaints are coherent and comprehensible or rather unfocused and rambling. If it is difficult to elicit a coherent sense of what is wrong, it may indicate that there are chaotic and severely dysfunctional communication patterns in the family which will need to be addressed.

Changes desired by members A thought-provoking and often fruitful question to ask in the family session relates to changes desired by each member. The clinician might ask ‘If you had the power to change one thing in this family, what would that be?’ This question often challenges the members to go beyond the obvious problems and to consider deeper changes to be desired. The responses of children to such a question are frequently illuminating regarding family dynamics. During a family session of a single-parent household, when asked this question, the six-year-old sister replied that she wished her mom could find a rich man to marry so that she could quit working and be home more with her and her older sister. The older sister, the identified patient, responded with, ‘Who wants her around more anyway, since all she does is nag me to do stuff.’ This led to an in-depth discussion of the issue of the lack of positive family time spent together.

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Genogram The genogram in family assessment has been described as follows: ‘Genograms are graphic pictures of the family history and pattern, showing the basic structure, family demographics, functioning and relationships. They are a shorthand used to depict the family patterns at a glance.’ (McGoldrick and Gerson 1989). Adolescents as well as young children are often engaged by the visual and active nature of the task of developing a genogram and family history. The children are often fascinated to learn about events of which they have had little knowledge, and possibly family ‘secrets’ as well. A family history of psychiatric or physical illness as well as recurrent relationship patterns are sometimes more readily engaged through use of the genogram than otherwise. Discretion must always be used in allowing ‘family skeletons’ and secrets to be discussed.

Description of typical day and layout of the home It is very helpful for the clinician to inquire about the physical environment of the family on an everyday basis. Data about shared and private space are useful in determining the degree of enmeshment or autonomous functioning in the family group. For example, a poor inner-city family may, due to lack of sleeping space, have the adolescent sharing a bedroom with a younger sibling of the opposite sex, which could interfere with the sense of privacy which is critical to teenagers. On the other hand, a family environment where each member is physically quite distant from the other members may indicate a lack of engagement within the family and would need to be further explored (Karpel and Strauss 1983). After discussing the family’s portrayal of their home, the clinician should ask about a ‘typical day’ in the life of the family. It should be observed which individuals answer the question and whether the members can agree with one another on the typical day’s events. The family may spontaneously discuss how their time together used to be, and contrast it with their more recent problemladen home life. The adolescent patient’s role in the daily activities is crucial to delineate. For example, a fifteenyear-old who is functioning in the role of parent when the single-parent mother is working will give a very different rendition of a day’s activities than an adolescent who continues to be treated like a school-age child. It is quite useful to find out about eating behavior and meals. Does the family ever sit down together and share a meal, or is each member fending for him or herself separately? Does the adolescent patient separate from the rest of the family at these times? What do the parents do to attempt to re-engage the patient, if anything? Careful exploration here may reveal a family which subtly

encourages the young person to remain at home, rather than expanding socially through more involvement with school and peer activities.

Rules and regulations It is advisable for the clinician to get a sense of both the written and unwritten rules and regulations which guide family interaction. This would include material about what is necessary for the family to live together, and how they implement these basic assumptions. Generally, it is helpful to avoid professional terms or jargon in gathering this kind of information, and to inquire in a straightforward and low-key manner. For example, when inquiring about the parents’ ability to limit the identified patient as well as the other children, a productive series of questions would be, ‘All families have a variety of rules and regulations of behavior, such as bedtimes, curfew, chores, and so on.’ What are some of the rules and expectations in this family? Do the rules differ for each child according to age? Who is the main enforcer of the rules and limits? Follow-up questions might address the consequences of noncompliance. It is usually best to avoid ‘why’ questions, as they tend to elicit more defensive responses. This line of questioning can flow smoothly into a discussion of discipline in the home. Is one parent the ‘strict one’ and the other more relaxed about rules? Is one parent undercutting the other’s authority and is the adolescent confused as a result?

Alliances and coalitions It is critical to inquire about the dyadic alliances within the family, although this topic may result in a substantial amount of resistance. An indirect way of attaining this information is to ask with whom does the individual spend the most time. Another helpful question is ‘Who supports whom in this family?’ Are there alliances across generations, for instance involving parents or grandparents? Are the alliances shifting or fairly rigidly in place? Is there an opportunity for new alliances to form during stress times?

Managing disagreements It is often difficult to get a family to discuss how they function during times of stress, as the members may be very defensive in their responses. Gentle questioning is helpful here, in order to not overwhelm the family members. Do the disagreements always end in bitter arguments? Does the ‘identified patient’ usually get involved in any nearby dispute and makes it worse? Do controversies get discussed or do they persist and continue to affect

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the individuals? Can the family reasonably discuss the emotional and behavioral issues of the index patient? If a family is unable to tolerate this type of questioning about emotional interaction, they may collectively defend themselves by resorting to laughter and humor, disruptive behavior in the session or hostility to the interviewer.

Roles in family Family members often have consciously or unconsciously assigned roles which they feel obliged to fulfill. The more typical roles include the scapegoat, the ‘lazy one,’ the rescuer, the provocative one or the peacemaker. It is important to ascertain how rigid the ‘role assignment’ is. Is a member permitted to switch roles occasionally? What are the consequences? A sixteen-year-old girl who was known as the ‘selfish one’ attempted to assist with extra chores around the house. Her father praised her, but the mother mockingly suggested that this was only ‘for show’ because the girl wanted some privilege in return. She quickly reverted to old established patterns of misbehavior and ‘selfishness.’

Previous crises in the family The evaluating clinician should inquire about past difficulties which the family has experienced. These difficulties may relate to health status of members, employment changes, economic setbacks, dislocation or relocation, or emotional/behavioral problems with one or more members. It is important to ascertain the structure and function of the family during these past challenging situations. Were certain members overfunctioning in relation to the others? Did the extended family become involved and, if so, how? Who was the ‘identified patient’ in past crises? What was the role of the current ‘identified patient’ in the past turmoil? Has the ‘identified patient’ changed or been relatively stable over time? It is helpful to find out if the previous problems were related to those currently being presented.

a strong mutual bond but were compelled by the family system to play out these diverting hostile scenes.

SEEING SUBGROUPS It may be useful to see groups within the family to elicit different types of information and data. Generally, the parents are seen as a couple early in the comprehensive evaluation in order to gather history and ascertain how they function as a marital couple. If siblings are seen for separate visits, it is important to be equitable about private time in order to maintain a working relationship with each member. It is frequently quite informative and revealing to have the siblings together in an assessment session. It is important to ascertain that the parents will not be too threatened by this meeting, and to exercise sound clinical judgment as to its timing. An identified patient can often present differently when seen as part of a sibling subgroup rather than in the context of the entire family. At times, some previously undisclosed yet vital information will emerge during a subgroup meeting. It is helpful to inquire about why the issue was not previously brought up and about any feared consequences of disclosure. Obviously, it is vital to keep track of lines of confidentiality when dealing with this type of information, as well as carefully planning if and when to raise the issue with the larger group.

OBSTACLES TO ASSESSMENT The clinician needs to be mindful that certain common obstacles will emerge during the family assessment. These include a dominating member, an agitated member, a challenging member, or an uncooperative adolescent as the identified patient. It is vital for the practitioner to deal in a diplomatic and delicate manner with these situations, allowing all involved parties to ‘save face’ while encouraging appropriate participation in the group discussion.

Problem-solving style The family’s usual response to problems should be explored. It is helpful to ascertain if there is usually a scapegoat to be blamed. Is the family decision-making capability impeded by obsessive rumination and preoccupation? Are impulsive or rash decisions arrived at which have negative consequences? For example, a middle-class family with poor communication usually dealt with unpleasant family issues through diversion of attention to the teenage brothers who were verbally and physically abusive with one another. Beneath their apparent hostility, they had established

CLOSING THE ASSESSMENT It is vital for the family to have a sense of closure at the conclusion of the family assessment, and for the clinician to develop a comprehensive formulation which will serve as the basis for the feedback to the family of the rationale for the treatment plan. The family formulation should meaningfully address the question of the relationship between the presenting set of symptoms of the adolescent patient and the systemic context of the family. A careful review of the family’s

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structure, roles, boundaries and communication patterns should be undertaken. Additionally, one must consider the developmental stage of the family in the life cycle and the associated current stressors. A historical context, explicated perhaps through use of the genogram during the assessment, is vital as well, in order to gauge how the family has coped with similar problems and stressors in the past. The clinician, in constructing the formulation, should be able to differentiate among normal stage-related difficulties, pathological reactions to developmental stressors and chronic unresolved problems in the family. Furthermore, an in-depth understanding of each member’s respective psychological needs and individual dynamics is critical in constructing a useful formulation. Regarding the communication of the formulation to the family, it is usually best to accomplish this in the context of discussing the treatment plan with the family. In selected situations, it is advisable to give feedback to the parent(s) separately from the adolescent, which will help to allow the final feedback session including the adolescent present to proceed smoothly.

THE TREATMENT PLAN The treatment recommendations are a vital and often neglected part of the assessment of the adolescent and the family. The clinician must first decide which are the most significant interpersonal issues in the family system, in contrast to those which are mainly individual problems of the adolescent or another family member. The strengths of the family and individual members should also be actively considered when the clinician attempts to sum up the evaluation. A clinician may have an accurate understanding of the functioning of the family, but the members may not be psychologically ready to hear and integrate the information. Practitioners may offer too much information about areas which should await further therapeutic consideration. It is of vital importance to focus on the strengths and resources of the family group, as well as addressing the problematic areas. The individual members are less inclined to react in a defensive manner if explanations about family problems involve the functioning of the entire group, as opposed to one or several members. After the clinician carefully decides whether one or more members in the family would benefit from individual psychotherapy, this feedback must be given to the family in a manner most likely to avoid defensive reactions. Often, a separate meeting with the parent(s) is helpful in order to have a productive feedback session with the entire family which includes these points. If individual psychotherapy is suggested, the clinician must decide whether to perform the psychotherapy or,

as is most often the case, to refer to an outside therapist. If another therapist becomes involved, it is advantageous for the individual therapist to communicate frequently with the family therapist, within the arranged guidelines of confidentiality.

REFERENCES Ackerman, N. Toward an integrative therapy of the family. American Journal of Psychiatry 114: 727–733, 1958. Beavers, W.R. Healthy, midrange and severely dysfunctional families. In Walsh, F. (ed.), Normal Family Processes. New York: Guilford Press, 1982, pp. 45–66. Epstein, N.B., Bishop, D.S., Baldwin, L.M. McMaster model of family functioning: a view of the normal family. In Walsh, F. (ed.), Normal Family Processes. New York: Guilford Press, 1982, pp. 115–141. Garcia Preto, N. Transformation of the family system in adolescence. In Carter, B., McGoldrick, M. (eds), The Changing Family Life Cycle: A Framework for Family Therapy, 2nd edition. Needham Heights, Massachussets: Allyn and Bacon, 1989, p. 271. Haley, J. Problem Solving Therapy. San Francisco, CA: Jossey Bass, 1976. Karpel, M., Strauss, E. Family Evaluation. New York: Gardner Press, 1983, pp. 137–153. McGoldrick, M., Gerson, R. Genograms and the family life cycle. In Carter, B., McGoldrick, M. (eds), The Changing Family Life Cycle: A Framework for Family Therapy, 2nd edition. Needham Heights, Massachussets: Allyn and Bacon, 1989, pp. 164–186. Olson, D.H., Russell, C.R., Sprenkle, D.H. Circumplex model of marital and family systems. VI: Theoretical update. Family Process 22: 69–83, 1983. Reiss, D.J. The Family’s Construction of Reality. Cambridge, Massachussets: Harvard University Press, 1981. Satir, V.M. Conjoint Family Therapy. Palo Alto, CA: Science and Behavior Books, l967. Whitaker, C.A., Keith, D.V. Symbolic-experiential family therapy. In Gurman, A.S., Kniskern, D.P. (eds), Handbook of Family Therapy. New York: Brunner/Mazel, 1981. Zilbach, J. The family life cycle: a framework for understanding children in family therapy. In Combrinck-Graham, L. (ed.), Children in Family Contexts: Perspectives on Treatment. New York: Guilford Press, 1989.

Suggested reading Aponte, H. The open door: a structural approach to a family with an anorectic child. Family Process 12: 1–44, 1973. Combrinck-Graham, L. Adolescent sexuality in the family life cycle. In Family Transitions. New York: Guilford Press, 1979, pp. 67–68.

214 Assessment of the adolescent Combrinck-Graham, L. Family models of childhood psychopathology. In Children in Family Contexts. New York: Guilford Press, 1989, Chapter 4. Davidson, B., Quinn, W.H., Josesephson, A.M. Assessment of the family: systemic and developmental perspectives. Child and Adolescent Psychiatric Clinics of North America 10: 415–429, 2001. McPherson, S.R. Stages in the family therapy of adolescents. Family Process 13: 77–94, 1974. Minuchin, S. Families and Family Therapy. Cambridge: Harvard University Press, 1974. Serrano, A. A child-centered family diagnostic interview. In Noshpitz, J. (ed.), Basic Handbook of Child Psychiatry. New York: Basic Books, 1979, pp. 624–630.

Sprenger, D.L., Josephson, A.M. Integration of pharmacotherapy and family therapy in the treatment of children and adolescents, Journal of the American Academy of Child and Adolescent Psychiatry 37: 887–889, 1998. Tseng, W., McDermott, J.F. Triaxial family classification, a proposal. Journal of the American Academy of Child and Adolescent Psychiatry 18: 22–43, 1979. Wachtel, E. The family psyche over three generations: the genogram revisited. Journal of Marital and Family Therapy 8: 335–343, 1982. Weber, T. Family interview. Family Process 24: 357–364, 1985.

4.3 Psychosocial assessment GARY J. GOSSELIN AND YIU KEE NG

INTRODUCTION During adolescence, individuals expand their scope of interests, activities and relations beyond their immediate families while learning to navigate within a social matrix of growing complexity. Adolescents and their families receive support and are exposed to stress during their interactions with a network of social systems. The purpose of psychosocial assessment is to identify and characterize the social factors that affect an adolescent’s growth and development. These social factors might include strengths, resources, risks, and deficits. Studies indicate that social factors mediate adolescent developmental outcomes and should be assessed during clinical evaluations (Kolvin et al. 1988; Rutter 1979; Werner and Smith 1977, 1982, 1992).

their duties and responsibilities should be increased in a developmentally appropriate manner. There should be opportunities for the adolescent to exercise responsibility in the activities of daily living such as personal grooming, shopping, money management, cleaning, meal preparation and clothing maintenance. The effects of the adolescent being placed in a caretaking role for others in the home should be reviewed. Living quarters should be arranged to meet the adolescent’s developmental needs for privacy. Basic needs should be met, including heating, plumbing, and the provision of food. Cleanliness and crowding should be assessed. The routines of the primary residence should allow a time and place for the adolescent to complete homework. Relocations and factors contributing to change of residence should be reviewed.

The school STRATEGIES AND APPROACHES Assessment data should be derived from multiple sources over time to enhance accuracy. Data can be gathered by making site visits to schools, sports events, neighborhoods, church functions and residences to gain a detailed appreciation of an adolescent’s social environments. Contact with non-clinical personnel in the community can add new, and at times markedly different, perspectives on a patient from environments beyond the clinical encounter. Such approaches also afford the clinician an opportunity to discover potential resources that might be accessed to bolster psychosocial protection or reduce risk in a case.

ASSESSMENT AREAS The primary residence The adolescent’s role in the functioning of the primary residence should be examined. As adolescents mature,

School plays a substantial role in the socialization of adolescents. The school environment should be checked for a range of available extra-curricular activities and afterschool programs. Also, there should be venues for parental involvement and the presence of positive adult role models among faculty and staff. The availability of counseling services and school-based health personnel might be an added plus for students by providing access to health services and health-related information.

The community Adolescents are vulnerable to high-risk behaviors during periods when they are unsupervised by adults. The afternoon and evening hours spent in the community following the school day are frequently unsupervised and hold much potential for risk-related behaviors. The location and activities of adolescents during this period should be investigated. Community organizations and afterschool youth programs might be available as resources to families during these crucial hours.

216 Assessment of the adolescent

Social characteristics of neighborhoods, such as the presence of adults willing to supervise children informally at the neighborhood level, have been shown to protect youth from violence (Sampson et al. 1997). The presence of informal and formal adult leadership in a community provides positive role models outside the immediate family that can provide support and illustrate adaptive patterns of social involvement.

Economic conditions Economic factors exert direct effects on adolescents and their families. Developmental risks can be associated with diverse economic conditions ranging from affluence to poverty. Poverty is associated with crime, violence, homelessness, unemployment, poor healthcare, poor housing, single-parent families, limited career and educational opportunities and decreased access to social resources (McLoyd et al. 1997). Associations between low socioeconomic status and higher rates of psychopathology have been demonstrated (Hollingshead and Redlich 1958; Achenbach 1991; McLoyd 1990). Adolescents from impoverished backgrounds appear to be particularly vulnerable to poor self-image, delinquency and depression (Sarigiani et al. 1990; Elliott and Huizinga 1983; Gibbs 1986; Lempers et al. 1989). A growing number of homeless, runaway teenagers are appearing on city streets, and the clinician should be familiar with services and support networks for this population. In rural communities the lack of social, medical, and mental health services combines with a high prevalence of poverty and isolation to place adolescents at risk for poor developmental outcomes. It is particularly important to appreciate any recent economic transitions that might serve as sources of support or stress to a community, family, or adolescent.

Peer relations Peer relations foster the maturing adolescent’s ability to reach beyond the immediate family to form new friendships, establish intimate relationships, and participate in larger social groups. Successful involvement in adolescent peer relations has been postulated to enhance adaptive developmental processes (Waters and Sroufe 1983). Participation in peer relations requires the adolescent to appreciate increasingly sophisticated social norms, to gain the capacity for empathy, to be able to negotiate interpersonal differences, and to find effective approaches to resolve conflicts. In order to master these higher-level social functions, an adolescent must be able to use and interpret the nuances of facial expression, body language, spoken communication, and gestures. Persons with developmental disabilities will be at particular risk in this area.

Adolescent relational patterns may differ according to gender (Gilligan 1990; Surrey 1991; Baker Miller 1991). Gender differences may exert distinct influences on identity formation and the experience of love, intimacy, sexuality, and friendship. When approached sensitively, a discussion focusing on peers’ attitudes and values regarding love, sexuality, intimacy, romance, family relations, friendships and rivalries can reveal much about an adolescent’s interpersonal relationships. Cultural norms affect adolescent peer relations in all societies by imposing standards of social behavior and regulating access to peers. Conditions of group involvement, such as gang membership, should be considered. Involvement with friends, romantic interests or sexual partners can be reviewed. Exclusions from age-appropriate peer relations should be identified and characterized. Adolescents who are rejected by their peers have been shown to suffer from a variety of behavioral and psychological problems (East et al. 1987). Potential reasons for exclusion by peers may include withdrawal, aggression, domineering behavior and severe developmental, mental or physical disabilities (French and Waas 1985).

Religion Studies on the effects of religion and spirituality on adolescent behavior and development have produced mixed results. Comparisons among studies have been limited owing to the differing methodologies employed. Participation in organized religions has been found to exert positive effects on adolescents by enhancing their ties to family and community while encouraging altruism and prosocial behavior (Benson et al. 1986). Participation in organized religions has been negatively correlated with adolescent substance abuse (Donahue and Benson 1995). The tendency to be devout and observant of religious custom has been shown to differentiate between early and late initiators of sexual intercourse (Benson et al. 1989; Miller and Dyk 1993). The importance of religious beliefs in coping with serious illnesses has been described in the literature on adolescents diagnosed with cancer (Tebbi et al. 1987). Several investigators have postulated that religious adolescents had more personal and family involvement through the network of support found in religious organizations (Barbarin and Chester 1984). Youth groups affiliated with religious organizations can be a source of friends, adult role models and supervised, structured activities. Differences in religious approaches may exert differential effects on adolescent behavior. Religions characterized by restrictive limits, controls and discipline might be correlated with adolescent antisocial behavior. Coercive forms of parental disciplinary practices have been reported in religions with restrictive standards and rules (Forliti and Benson 1986). Benson et al. (1997) caution the

Psychosocial assessment 217

clinician to be aware that authoritarian religious beliefs can be associated with psychological and developmental dysfunction. Attempts to correlate religiousness to mental health have been limited by the presence of possible confounding factors such as familial psychopathology and parental conflict. Most of the studies investigating the effects of religion have focused on mainstream populations and may not be applicable to diverse populations (Benson et al. 1997).

distortions in body image and eating disorders (Nattiv et al. 1994). Youths can be subjected to significant stress if coaches and parents overemphasize winning and competition at the expense of balanced participation and enjoyment. Various psychiatric disorders have been associated with sports-related stress and athletic injuries (Katz Stryker et al. 1997). The use of performanceenhancing drugs such as anabolic steroids can exert adverse effects on physical and mental health (Bahrke et al. 1998)

Leisure activities

Media

When reviewing leisure activities, the clinician should consider a youth’s ability to utilize unstructured or unsupervised time. Hobbies and interests should be reviewed to identify preferences and skills. The clinician should check on a youth’s participation in organized leisure activities such as after-school programs, sports teams or activity clubs that provide access to peers and adult role models while promoting adaptive socialization.

An adolescent’s television viewing habits, choice of printed materials, movie attendance or computer use are likely to raise his level of exposure to explicit images and diverse value systems. It should be determined whether adults in the adolescent’s life are able to supervise media use and regulate access. Attempts should be made to identify discussions about media content between adult caretakers and adolescents. Such discussions would review reactions and answer questions related to media depictions of values, morality, sexuality, violence, health habits, body image, smoking, alcohol consumption, and drug use. A teenager’s ability to use media in a manner that does not inhibit involvement with other interests and activities should be examined. The clinician should remain alert for potential adverse behavioral and physical effects associated with excessive media use (Walsh et al. 1996).

The workplace Adolescents often hold jobs, and in this respect they should have access to appropriate adult role models and mentors in the workplace. The job skills emphasized should be transferable to adult settings. Supervisors should have experience working with adolescents and supervision should be conducted in a way that promotes a sense of competence in the adolescent. Opportunities for training and advancement should be available. Scheduling should be flexible enough to allow adolescents to participate in educational and recreational activities.

Sports Involvement in sports provides a source of friends while presenting opportunities to socialize under the supervision of adult role models. Values transmitted via sports programs should emphasize the enjoyment of active participation, skill acquisition, and healthy training practices. Youths can learn principles of cooperation and how to cope with adversity through sports participation. The role of sports and fitness as vital components of sound health habits should be presented by sports programs in a way that is pleasurable for the teenager and will lead to their long-term involvement in physical fitness activities. Sports programs should be planned to allow the adolescent to participate in a range of other developmentally important activities. Attention should be given to signs of maladaptive behaviors associated with sports involvement, such as

Violence Adolescents exposed to crime and violence are at risk for the development of mental illness (Pynoos et al. 1995), school problems (Shakoor and Chalmers 1991; Slaby and Stringham 1994) and legal problems. A violence history should be taken. Screening questions assess the nature of the violence, duration of exposure, the severity of the violence, the relationship to the perpetrator and the perceived threat resulting from the exposure. Often adolescents have witnessed violence or trauma inflicted on a relative or friend. The survivor status of the teenager or family members should be assessed (Pittel 1996). Attempts should be made to determine if the youth has victimized others, and what the nature of that victimization has been. Firearm availability and use should also be screened. Large numbers of adolescents and young adults staff military units that are exposed to combat situations. Civilian adolescents may come from communities exposed to war, terrorism, torture and natural disasters that place them at risk for multiple problems (Arroyo and Eth 1985; Carlin 1979; Dyregrov et al. 1987; Kinzie et al. 1989; Lin et al. 1984).

218 Assessment of the adolescent

Service organizations Adolescents and families might receive services from various public and private sector sources, including child protection agencies, developmental disabilities offices, special education programs, employee assistance programs, respite services, advocacy and support groups and volunteer programs. Teenage mothers may be eligible for specialized group homes and educational settings. Financial and nutritional assistance may also be available. Families of diplomats or foreign nationals might be able to access needed services through their embassy, consulate or mission.

Legal circumstances Involvement in legal proceedings can have significant effects on an adolescent’s condition, and should be assessed. A number of areas must be considered when evaluating adolescents who have been involved in juvenile delinquency or criminal law cases. These include the adolescent’s arrest record, the nature and number of prior convictions, experiences with incarceration, involvement in current prosecutions, pending warrants and expected arrests. Attempts should be made to anticipate negative reactions to upcoming legal events. A teenager may be involved in court-ordered treatment or educational programs. There may be a probation officer available to assist in developing an appreciation for the legal circumstances in a case. Potential civil law proceedings affecting adolescents might include the issues of emancipation, divorce and custody, visitation, persons in need of supervision (PINS), paternity, abuse and neglect, termination of parental rights, placement and educational law matters. Litigationrelated effects are likely to vary depending on the time course of the proceeding, the degree of the adolescent’s involvement, the anticipated outcome and the actual outcome of the case.

Transportation Transportation needs, patterns of use and potential transportation-related dangers, such as driving while intoxicated, require assessment. It should be remembered that young drivers are inexperienced and at increased risk for motor vehicle accidents. These new drivers should have opportunities to have adults monitor the development of their driving skills and road safety habits.

Policy effects Access to services is affected by government policies that alter the funding patterns of social and healthcare

entitlement programs for children and families. Government actions involving educational and social policies influence the conditions in schools and communities and should be monitored. Managed healthcare business practices and changes in private health insurance policies are likely to exert a significant effect on the access of many adolescents to healthcare and mental health services (England and Cole 1998).

INTEGRATING FINDINGS The integration of psychosocial data with other assessment findings is accomplished by listing social factors that relate to diagnosis and potential clinical recommendations. The interaction of psychopathology and social factors to produce impairments in adaptive functioning should be described. Efforts should be made to assess the interactions of the psychosocial elements of a case. The Diagnostic and Statistical Manual of Mental Disorder, 4th edition (DSM IV) (American Psychiatric Association 1994) provides several ways to include psychosocial factors in diagnostic findings. Social criteria are included in specific DSM IV diagnostic categories. Axis V dimensions are used to estimate impairment in social functioning. Axis IV is provided to list psychosocial and environmental stressors. Specific social problems that may not contribute to, or result from, a mental disorder are listed using v-codes. An awareness of the need to consider refinements in how social elements will be included in assessment and diagnosis is evinced by the publication in DSM-IV of the Social and Occupational Functioning Assessment Scale (SOFAS) as a criteria set and axis provided for further study. Notable limitations exist in the DSM-IV system that require a clinician to augment DSM-IV descriptions with additional data when attempting to integrate psychosocial assessment findings into a comprehensive clinical formulation and treatment plan. In particular, the DSM-IV system does not allow for descriptions of strengths, supports and protective factors associated with the psychosocial components of a case. These crucial elements should always be included when reviewing assessment findings and making treatment recommendations to adolescents and their families.

REFERENCES Achenbach, T.M. Manual for the Child Behavior Checklist 14–18 and 1991 Profile. Burlington, VT: University of Vermont, Department of Psychiatry, 1991. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994.

Psychosocial assessment 219 Arroyo, W., Eth, S. Children traumatized by Central American warfare. In Eth, S., Pynoos, R. (eds), Posttraumatic Stress Disorders in Children. Washington, DC: American Psychiatric Press, 1985, pp. 103–120. Bahrke, M.S., Yesalis, C.E., Brower, K.J. Anabolicandrogenic steroid abuse and performance enhancing drugs among adolescents. Child and Adolescent Psychiatric Clinics of North America 7: 821–838, 1998. Baker Miller, J. The development of women’s sense of self. In Jordan, J., Kaplan, A.G., Baker Miller, J., et al. (eds), Women’s Growth in Connection. New York: Guilford Press, 1991, pp. 11–26. Barbarin, Q.A., Chester, M.A. Coping as interpersonal strategy: families with childhood cancer. Family Systems Medicine 2: 279–289, 1984. Benson, P.L., Yeager, R.J., Wood, P.K., Guerra, M.J., et al. Catholic high schools; their impact on low-income students. Washington, DC: National Catholic Educational Association, 1986. Benson, P.L., Masters, K.S., Larson, D.B. Religious influences on child and adolescent development. In Noshpitz, J.D., Alessi, N.E. (eds), Handbook of Child and Adolescent Psychiatry, Volume 4. New York: John Wiley & Sons, 1997, pp. 200–219. Carlin, J.E. Southeast Asian refugee children. In Noshpitz, J.D. (ed.), Basic Handbook of Child Psychiatry. New York: Basic Books, 1979, pp. 290–300. Donahue, M.J., Benson, P.L. Religion and the well-being of adolescents. The Society for the Psychological Study of Social Issues 51: 145–160, 1995. Dyregrov, A., Raundalen, M. Children and the stresses of war: a review of the literature. In Dodge, C.P., Raundalen, M. (eds), War, Violence, and Children in Uganda. Oslo: Norwegian University Press, 1987, pp. 109–132. East, P.L., Hess, L.E., Lerner, R.M. Peer social support and adjustment of early adolescent peer groups. Journal of Early Adolescence 7: 153–163, 1987. Elliot, D., Huizinga, D. Social class and delinquent behavior in a national youth panel. Criminology 21: 149–177, 1983. England, M.J., Cole, R.J. Preparing for communities of care for child and family mental health for the twenty-first century. Child and Adolescent Psychiatric Clinics of North America 7: 469–481, 1998. French, D.C., Waas, G.A. Behavior problems of peerneglected and peer rejected elementary children: parent and teacher perspectives. Child Development 56: 246–252, 1985. Forliti, J.E., Benson, P.L. Young adolescents: a national study. Religious Education 81: 199–224, 1986. Gibbs, J.T. Assessment of depression in urban adolescent females: implications for early intervention strategies. American Journal of Social Psychiatry 6: 50–56, 1986. Gilligan, C. Teaching Shakespeare’s sister: notes from the underground of female adolescence. In Gilligan, C.,

Lyons, N.P., Hammer, T.J. (eds), Making Connections. Cambridge: Harvard University Press, 1990, pp. 6–29. Hollingshead, A.B., Redlich, F.C. Social class and mental illness. New York: Wiley, 1958. Katz Stryker, B., Katz, S.E., Cantwell, D.P. Youth sports and adolescent development. In Noshpitz, J.D., Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. Adolescence: Development and Syndromes. New York: John Wiley & Sons, 1997, pp. 209–224. Kinzie, J., Sack, W., Angell, R., et al. The psychiatric effects of massive trauma on Cambodian children. Journal of the American Academy of Child and Adolescent Psychiatry 25: 501–504, 1989. Kolvin, L., Miller, F.J., Fleeting, M., et al. Risk-protective factors for offending with particular reference to deprivation. In Rutter, M. (ed.), Studies of Psychosocial Risk: The Power of Longitudinal Data. New York: Cambridge University Press, 1988, pp. 77–95. Lempers, J., Clark-Lempers, D., Simons, R. Economic hardship, parenting and distress in adolescence. Child Development 60: 25–49, 1989. Lin, K., Masuda, M., Tazuma, L. Problems of eastern refugees and immigrants: adaptational problems of Vietnamese refugees, Part IV. Psychiatric Journal of the University of Ottawa 9: 79–84, 1984. McLoyd, V.C. The impact of economic hardship on black families and children: psychological distress, parenting, and socioemotional development. Child Development 61: 311–346, 1990. McLoyd, V.C., Ceballo, R., Mangelsdorf, S.C. The effects of poverty on children’s socioemotional development. In Noshpitz, J.D., Alessi, N.E. (eds), Handbook of Child and Adolescent Psychiatry, Volume 4. New York: John Wiley & Sons, 1997, pp. 191–206. Miller, B.C., Dyk, X. Sexuality. In Tolan, P.H., Cohler, B.J. (eds), Handbook of Clinical Research and Practice with Adolescents. New York: Wiley Interscience, 1993, pp. 95–123. Nattiv, A., Agostini, R., Drinkwater, B., et al. The female athlete triad: the interrelatedness of disordered eating, amenorrhea and osteoporosis. Clinics in Sports Medicine 13: 405–418, 1994. Pittel, E.M. How to take a violence history: guidelines for interviewing youth at risk for violence. AACAP News 27: issue 5: 9–12, 1996. Pynoos, R.S., Steinberg, A.M., Wraith, R. A developmental model of childhood traumatic stress. In Cicchetti, D., Cohen, D.J. (eds), Developmental Psychopathology, Volume 2: Risk, Disorder and Adaptation. New York: Wiley Interscience, 1995, pp. 72–95. Rutter, M. Protective factors in children’s response to stress and disadvantage. Annals of the Academy of Medicine, Singapore 8: 324–338, 1979.

220 Assessment of the adolescent Sampson, R.J., Raudenbush, S.W., Earls, F. Neighborhoods and violent crime: a multilevel study of collective efficacy. Science 277: 918–924, 1997. Sarigiani, P., Wilson, P., Peterson, A., et al. Self-image and educational plans of adolescents from two contrasting communities. Journal of Early Adolescence 10: 37–55, 1990. Shakoor, B., Chalmers, D. Co-victimization of African American children who witness violence: effects on cognitive emotional and behavioral development. Journal of the National Medical Association 83: 233–238, 1991. Slaby, R., Stringham, P. The prevention of peer and community violence: the pediatrician’s role. Pediatrics 94: 608–615, 1994. Surrey, J.L. The ‘self-in-relation’ a theory of women’s development. In Jordan, J., Kaplan, A.G., Baker Miller, J., et al. Women’s Growth in Connection. New York: Guilford Press, 1991, pp. 51–66. Tebbi, C.K., Mallon, J.C., Richards, M.E., et al. Religiosity and locus of control of adolescent cancer patients. Psychological Reports 61: 683–696, 1987. Walsh, D., Goldman, L.S., Brown, R. Physician Guide to Media Violence. Washington, DC: American Medical Association, 1996. Waters, E., Sroufe, L.A. Social competence as a developmental construct. Developmental Review 3: 79–97, 1983. Werner, E.E., Smith, R.S. Kauai’s Children Come of Age. Honolulu: University of Hawaii Press, 1977. Werner, E.E., Smith, R.S. Vulnerable But Invincible: A Study of Resilient Children. New York: McGraw-Hill, 1982. Werner, E.E., Smith, R.S. Overcoming the Odds: High Risk Children from Birth to Adulthood. Ithaca: Cornell University Press, 1992.

Suggested reading Canino, I.A., Spurlock, J. Culturally Diverse Children and Adolescents, Assessment, Diagnosis and Treatment. New York: Guilford Press, 1994. Clarkin, A.J. Altered relations with peers: peer-group affiliation, friendships, first love. In Noshpitz, J.D.,

Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. New York: John Wiley & Sons, 1997, pp. 113–124. Dubow, E.F., Roecker, C.E., D’Imperio, R. Mental health. In Ammerman, R.T., Hersen, M. (eds), Handbook of Prevention and Treatment with Children and Adolescents. New York: John Wiley & Sons, 1997, pp. 259–286. Esman, A.H. Adolescence and Culture. New York: Columbia University Press, 1990. Jani, S. Changing relationships with parents. In Noshpitz, J.D., Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. New York: John Wiley & Sons, 1997, pp. 87–95. Kausch Richter, S. Overview of normal adolescent development. In Noshpitz, J.D., Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. New York: John Wiley & Sons, 1997, pp. 15–25. McLoyd, V.C., Ceballo, R., Mangelsdorf, S.C. The effects of poverty on children’s socioemotional development. In Noshpitz, J.D., Alessi, N.E. (eds), Handbook of Child and Adolescent Psychiatry, Volume 4. New York: John Wiley & Sons, 1997, pp. 189–205. Petti, T.A. The rural child. In Noshpitz, J.D., Alessi, N.E. (eds), Handbook of Child and Adolescent Psychiatry, Volume 4. New York: John Wiley & Sons, 1997, pp. 220–227. Shapiro, T., Kalogerakis, A. Identity consolidation in adolescence. In Noshpitz, J.D., Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. New York: John Wiley & Sons, 1997, pp. 149–154. Spurlock, J., Canino, I.A. Central city families. In Noshpitz, J.D., Alessi, N.E. (eds), Handbook of Child and Adolescent Psychiatry, Volume 4. New York: John Wiley & Sons, 1997, pp. 16–26. Sugar, M. Adolescent sexuality. Child and Adolescent Psychiatric Clinics of North America 2: 407–413, 1993. Weist, M.D. Protective factors in childhood and adolescence. In Noshpitz, J.D., Flaherty, L.T., Sarles, R.M. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. New York: John Wiley & Sons, 1997, pp. 27–34.

4.4 Medical assessment ELIZABETH KAY SPENCER

INTRODUCTION Thorough medical assessment plays a key role in the psychiatric assessment of adolescents, as for patients of all ages. In the multiaxial classification in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), Axis III: General Medical Conditions is “…for reporting current general medical conditions that are potentially relevant to the understanding or management of the individual’s mental disorder” (American Psychiatric Association 1994, p. 27). Medical assessment not only provides data which may expand or narrow the patient’s psychiatric differential diagnosis, but also broadens the clinician’s overall understanding of the patient’s physical and emotional growth and development. The process of conducting a comprehensive medical assessment of an adolescent patient includes obtaining medical history, conducting physical and laboratory examinations and, as indicated, discussing with the patient various issues which may have ramifications for his or her physical and emotional health. For adolescents, this process may require a more flexible approach by the clinician than generally needed for younger children or for adults. Depending upon the adolescent patient’s age, development and presenting complaints, the clinician must consider and address issues of confidentiality, discussion with parents and how best to incorporate anticipatory guidance into the interview. These considerations may influence how the evaluation is conducted and how and to whom its findings are communicated. Medical assessment provides the clinician with an opportunity to understand the context in which an individual adolescent patient has presented with symptoms of psychiatric illness. Thorough medical assessment may also reveal previously undiagnosed contributors to the patient’s presenting symptoms, as well as indicators of other psychiatric or physical illness. Concurrently, medical

assessment affords the opportunity to focus upon issues of health maintenance and prevention of illness and to confirm that, beyond treatment of his or her present illness, the patient will have appropriate ongoing primary care.

ROLE OF THE PSYCHIATRIST Prior to beginning medical assessment of an individual adolescent, it is crucial for the various clinicians involved to have a clear understanding of the role each will play in evaluating and treating this particular patient. Several questions should be addressed before the evaluation proceeds. First, who is the patient’s treating physician, with primary responsibility for evaluating, treating and communicating with the patient and his or her parents or guardian? With specific reference to the medical assessment component, is the psychiatrist functioning as the patient’s treating physician, or as a consultant to the treating physician, who may be another psychiatrist, a pediatrician, family practitioner, internist, adolescent medicine specialist or another pediatric specialist? Second, who will actually conduct the patient’s medical assessment, including obtaining the patient’s history, conducting his or her physical examination and ordering laboratory testing? Third, who will arrange additional examinations, such as an electrocardiogram or human immunodeficiency virus (HIV) screening, and any subspecialty consultations, such as neurologic, nutritional or gynecologic assessment? In order to define various clinicians’ roles, it is also important for the treating physician to know what procedures already are established as routine within a particular treatment setting and to know what pertinent procedures may require special arrangement. For example, how will the need for psychological testing be assessed and a referral for testing initiated? Finally, how will

222 Assessment of the adolescent

findings from the patient’s medical assessment be integrated with those from his or her psychiatric, psychosocial, school function and family assessments? Further discussion in this chapter will be predicated upon the assumption that the psychiatrist is the treating physician and is coordinating the patient’s psychiatric care. Within the field of psychiatry itself, however, psychiatrists who treat adolescent patients have varied backgrounds and training and encounter adolescent patients in a variety of clinical settings, factors which also may influence the role they play in evaluating adolescents. Among psychiatrists treating adolescents are: general psychiatrists; child and adolescent psychiatrists, who have completed subspecialty child and adolescent residency training; graduates of ‘triple board’ residency programs, with training in pediatrics, adult and child and adolescent psychiatry; and adolescent psychiatrists certified by the recently established Board of Adolescent Psychiatry. In addition, adolescent patients may present for treatment in emergency rooms, outpatient clinics, private practice offices, general psychiatric inpatient units or adolescent psychiatric inpatient units. Whatever permutation results from the psychiatrist’s role as treating physician or consultant, their training and experience in working with adolescents and the clinical setting in which the adolescent presents, the process of comprehensive medical assessment is enhanced by clear communication. The role of the psychiatrist in this process requires: 1 Clear communication to the patient and, as appropriate, the patient’s family, of what the patient’s medical assessment will entail, what the clinician’s role in conducting or coordinating the medical assessment will be, and how results will be reported. 2 Ongoing communication with other professionals about the step-by-step collection of information about the patient, clarification of diagnosis and implementation of treatment.

‘routine’ pediatric visit or a scheduled psychiatric consultation. The sequence that a clinician follows in focusing upon the goals listed below thus may vary, and different goals may be addressed either directly or delegated to others. A key concept is to consider what goals should be met for a given patient and then to designate clearly which member of a treatment team will complete which of the following goals:

• •

• • •

• • • •

GOALS OF MEDICAL ASSESSMENT

• When medical assessment of an adolescent patient is initiated as part of a psychiatric evaluation, the clinician’s focus of investigation will begin with the patient’s presenting complaints and current status. While medical assessment in this context is geared specifically to address questions related to psychiatric diagnosis, establishing a thorough medical baseline about the patient enhances the clinician’s ability to identify and to treat active or potential problems appropriately. The goals of medical assessment can be seen as falling on a continuum of urgency, with priority reflecting the clinical circumstances and setting in which the adolescent is presenting, from the emergency room to a

Most immediately, to identify any acute physical process or any acute organic factors which may be potentially life-threatening to the patient or the cause of acute psychiatric illness. To establish an accurate picture of the patient’s current state of physical health, including assessment of whether his or her growth and development are appropriate for chronological age as well as for his or her individual past developmental pattern. To review current and past medical history, including pertinent family history, and to obtain information from collateral sources in order to complete and to confirm data provided by the patient. To screen for safety risks, such as use of cigarettes, drugs and alcohol, sexual activity, carrying of weapons and exposure to physical and sexual abuse. To discuss with the patient topics with special relevance to adolescents, including physical maturation and common developmental concerns characterizing early, mid- or late adolescence, and to provide him or her with anticipatory guidance. To discuss results of the medical assessment with the patient and, as appropriate, with his or her parents or guardian. To educate the patient, as clinically appropriate, about the clinical importance of his or her medical status and its relation, if any, to his or her current psychiatric illness. To perform indicated baseline studies prior to initiation of psychiatric treatment. To communicate medical findings to other professionals engaged in the patient’s evaluation and treatment or in consultation about the patient. To confirm that medical follow-up for acute problems and ongoing primary care are arranged.

MEDICAL HISTORY Obtaining an adolescent’s medical history in the context of a psychiatric evaluation presents the clinician with various considerations. It is likely that some medical history already has been obtained and reviewed. If so, the patient’s and other informants’ willingness to engage in further interviewing may be enhanced by the interviewer’s clarifying what he or she already knows and explaining why more detailed questioning is needed.

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One recommended approach, after an initial introduction to the patient and parents, is to obtain medical history by meeting first alone with the parents and then alone with the patient (Marks 1992a). Attention should be directed to maintaining both privacy and safety during these interviews. In addition, issues of confidentiality should be addressed at the outset of each interview, so that subsequent disclosure of information, as clinically and legally warranted, will not constitute a breach of trust. It is helpful for clinicians to keep informed about laws concerning the confidentiality of minors in the state where they practice, as well as laws mandating reporting of physical neglect and abuse to state agencies. Pertinent information about an adolescent’s psychiatric status and family dynamics also may be garnered by observation during the patient’s medical assessment. Initially introducing oneself to both the patient and parents provides an opportunity for observing their interaction. Similarities and discrepancies in the medical history each provides may indicate areas of poor communication, conflict, family secrets and whether appropriate family roles and interpersonal boundaries are evident. The patient’s interview also may reveal findings relevant to his or her mental status examination. The extent to which he or she knows about and understands the implications of his or her past medical history and family history may guide planning for further patient education and treatment. During the process of conducting interviews, the clinician should clarify areas requiring further exploration and obtain permission to speak with other professionals and to review previous medical records. Content guidelines reflect issues related both to well adolescent care (Marks 1992b; American Academy of Pediatrics 1997, updated 2002) and to psychopharmacologic treatment (Zametkin and Yamada 1993). The sequence of questioning may be varied according to the clinician’s assessment of how well informed and forthcoming the patient and parents appear. It is likely that parents will be better informed about the patient’s early past medical history. As adolescent patients may be reticent to disclose cigarette, drug and alcohol use or sexual activity, it is advisable for the clinician to maintain a reasonable degree of caution about these issues. Content areas to investigate when taking the medical history include:

• • •

Chief complaint and present medical status, including: – usual source of medical care – date of most recent examination – immunization status Acute and chronic medical problems, their duration and how treated Current and past medications – prescribed and over-the-counter medications; use of herbal or other alternative medicines

• • •

•

– compliance with recommended regimens; selfmedication Allergies and adverse reactions – to medications, foods or other substances – specific details of how such reactions are manifested Dates and findings of most recent vision, hearing and dental examinations Past medical history – Prenatal and perinatal history – Developmental history and acquisition of developmental milestones in the areas of: – gross and fine motor development – speech and language development – adaptive and functional development – social and emotional development – Hospitalizations, surgeries and blood transfusions – Accidents and trauma, including head injury – General overall functioning at home, at school and with peers Family history with reference to both medical and psychiatric history.

In this last area of inquiry, it may be productive to explore not only definitive medical and psychiatric diagnoses among family members, but also more general indications of psychiatric disorders which may not have been formally diagnosed.

MEDICAL REVIEW OF SYSTEMS This component of the interview serves as a convenient opportunity for the clinician to inquire about topics with particular relevance to adolescence and to explore somatic concerns which may reflect or relate to possible psychiatric illness. During this part of the interview, the clinician’s attunement to normal developmental concerns of adolescents in early, mid- and late adolescence will help subsequent assessment of whether the individual patient’s development is age appropriate. In addition to usual questions about different organ systems, the clinician may wish to gear the review of systems to assess:

• •

• •

The patient’s general sense of well-being and having enough energy, or sense of malaise, fatigue and a loss of interest in usual activities. Changes in usual appetite, with any weight gain or loss and degree of fluctuation during the past year; eating habits and dietary appropriateness for adolescent nutritional needs (Schebendach and Shenker 1992); efforts to gain or lose weight. Changes in usual sleep pattern, with insomnia or a decreased need for sleep. Use of caffeine, tobacco, alcohol, illicit drugs or overthe-counter medications recreationally; age of first use, frequency and pattern of use and noted effects; degree of risk for development of withdrawal symptoms.

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•

• • •

Sexual history, with exploration of age of onset of pubertal changes, emotional responses to or concerns about puberty; sexual orientation; history of sexual activity, including information about partners, use of contraception, practices to minimize sexually transmitted disease (STD) and human immunodeficiency virus (HIV) infection, history of past or current STD infections and HIV status. For girls, age of menarche, menstrual history, knowledge about breast selfexamination and history of any pregnancies. For boys, knowledge about testicular self-examination and any history of partners becoming pregnant. Other risk-taking behaviors, such as driving while intoxicated, carrying weapons, illegal activities. Physical or sexual abuse or harassment. Engagement in sports, with appropriate medical screening and monitoring, and exploration of any use of drugs to enhance performance.

As a conclusion to the medical history interview and transition to the physical examination, the clinician may wish to ask the patient whether he or she has any specific questions or concerns which have not yet been addressed.

PHYSICAL EXAMINATION Guided by the patient’s medical history and the nature of his or her psychiatric presentation, the clinician will focus upon specific complaints while concurrently conducting a general physical examination. This procedure has been described in the adolescent medicine literature (Schneider 1992). Aspects of the physical examination with particular relevance to psychiatric diagnosis include:

• •

• • • •

Vital signs and temperature, to help exclude intercurrent illness, including acute drug withdrawal, which may affect the patient’s level of consciousness or mood. Growth parameters (Kreipe 1992), with documentation of height and weight and comparison both with normal ranges for chronological age and with the patient’s individual growth curves, to evaluate possible effects of a mood or eating disorder on the patient’s weight. Skin, for evidence of old or new trauma suggesting possible physical abuse or injuries resulting from selfinjury or aggressive behavior. Head and neck, for dental enamel changes which may occur in eating disorders, and thyroid abnormalities which may contribute to mood disorders. Cardiac evaluation, to exclude arrhythmias which may contraindicate or necessitate close monitoring of the use of tricyclic antidepressant or other medications. Genital examination, including Tanner staging of secondary sex characteristics (Tanner 1962) to assess whether this individual’s development is within the

•

normal range for his or her chronological age, and examination for breast or testicular masses. Neurologic examination, to determine the presence of focal and soft neurologic signs, vocal tics, and motor tics. It is useful to document and rate the severity of tics, dyskinesias or other muscle movements on a standardized instrument such as the Abnormal Involuntary Movement Scale (AIMS) (National Institute of Mental Health, 1985) as a baseline before initiating medication and during the course of ongoing pharmacologic treatment.

LABORATORY ASSESSMENT With the background of pertinent findings from the patient’s history and physical examination, the clinician determines appropriate laboratory testing (Fisher 1992; Futterman and Hein 1992; Swift et al. 1991). These tests can be seen by the evaluating psychiatrist as comprising overlapping categories: general studies, to confirm overall good health, as well as to establish baseline status before initiation of medication; screening tests, again to confirm good health and also to assess patients whose presentation reveals risk factors; and special studies, to follow-up particular concerns about the individual patient. The clinician should keep informed about institutional policy as to what tests are standard or mandatory in a specific setting and, as indicated, should follow legal guidelines for obtaining informed consent from patients, their parents or guardians. The clinician also should keep informed about the technical capabilities and procedural protocols of a given laboratory, such as its requirements that specimens be collected in designated tubes or that specific drugs be requested for inclusion in a toxicology screen. In ordering laboratory tests for an individual patient, the clinician also is wise to review and confirm results of any previous tests and to coordinate the choice of studies with other professionals involved in the patient’s care. Clinical judgment will guide consideration of the following:

• • •

General studies: complete blood count, with differential and platelet count; serum chemistries; liver function tests; thyroid function studies; urinalysis; chest X-ray; electrocardiogram. Screening tests: tuberculin test; serum cholesterol; serologic test for syphilis; sickle cell screen; pregnancy test; toxicology screen; HIV test; lead screen. Special studies, as specifically indicated by an individual patient’s presentation, and by consideration of the differential diagnosis of his or her presenting complaints: electroencephalogram; brain imaging studies; lumbar puncture; endocrine studies, including

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measurement of catecholamines; metabolic studies; nutritional assessment; ocular slit-lamp examination; genetic studies.

SYNTHESIS OF DATA Upon completion of the patient’s initial medical assessment, the clinician should review all available material and evaluate to what degree the differential diagnostic questions have been addressed and what new questions have been raised. The clinician should note which data are still unavailable, such as outstanding laboratory results or past records for review, and should develop a plan for following up that all information is acquired and evaluated. The patient’s treating physician also should plan how to inform the patient and his or her parents or guardians about the evaluation results and treatment recommendations.

CONCLUSION The medical assessment of adolescent patients presenting with symptoms of psychiatric illness calls upon a clinician to organize an evaluation balancing complex considerations. Thorough assessment takes into account both pediatric and psychiatric concerns, issues of both normal growth and development and psychopathology, and the evolving physical and emotional maturation of the individual patient. A carefully planned and implemented medical assessment not only contributes to the appropriate diagnosis and treatment of a patient’s presenting psychiatric illness, but also may contribute to improvement in his or her general health and overall function.

Orr, D.P., et al. (eds), Textbook of Adolescent Medicine. Philadelphia, PA: W.B. Saunders, 1992, pp. 44–67. Marks, A. Medical history. In Friedman, S.B., Fisher, M., Schonberg, S.K. (eds), Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing, Inc., 1992, pp. 55–57. Marks, A. Well adolescent care. In McAnarney, E.R., Kreipe, R.E., Orr, D.P., et al. (eds), Textbook of Adolescent Medicine. Philadelphia, PA: W.B. Saunders, 1992b, pp. 198–205. National Institute of Mental Health. AIMS (Abnormal Involuntary Movement Scale). Special feature: rating scales and assessment instruments for use in pediatric psychopharmacology research. Psychopharmacology Bulletin 21: 1077–1080, 1985. Schebendach, J., Shenker, I.R. Nutrition. In Friedman, S.B., Fisher, M., Schonberg, S.K. (eds), Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing, Inc., 1992, pp. 206–212. Schneider, M.B. Physical examination. In Friedman, S.B., Fisher, M., Schonberg, S.K. (eds), Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing, Inc., 1992, pp. 58–69. Swift, R.M., Griffiths, W., Camara, P. Special technical considerations in laboratory testing for illicit drugs. In Stoudemire, A., Fogel, B.S. (eds), Medical Psychiatric Practice, Volume 1. Washington, DC: American Psychiatric Press, 1991, pp. 145–161. Tanner, J.M. Growth at Adolescence, 2nd edition. Springfield, IL: Charles C. Thomas, 1962. Zametkin, A.J., Yamada, E.M. Monitoring and measuring drug effects. I. Physical effects. In Werry, J.S., Aman, M.G. (eds), Practitioner’s Guide to Psychoactive Drugs for Children and Adolescents. New York: Plenum, 1993, pp. 75–97.

Suggested reading REFERENCES American Academy of Pediatrics. Guidelines for Health Supervision III. Elk Grove Village, IL: American Academy of Pediatrics, 1997, updated 2002, pp. 155–203. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1994. Fisher, M. Laboratory testing. In Friedman, S.B., Fisher, M., Schonberg, S.K. (eds), Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing, Inc., 1992, pp. 70–75. Futterman, D., Hein, K. AIDS and HIV infection. In Friedman, S.B., Fisher, M., Schonberg, S.K. (eds), Comprehensive Adolescent Health Care. St. Louis, MO: Quality Medical Publishing, Inc., 1992, pp. 521–531. Kreipe, R.E. Normal somatic adolescent growth and development. In McAnarney, E.R., Kreipe, R.E.,

Friedman, S.B., Fisher, M., Schonberg, S.K., Alderman, E. (eds) Comprehensive Adolescent Health Care, 2nd edition. St. Louis, MO: Mosby Yearbook, 1998. McAnarney, E.R., Kreipe, R.E., Orr, D.P., et al. (eds) Textbook of Adolescent Medicine. Philadelphia, PA: W.B. Saunders, 1992. Straub, D.M. Adolescent medicine. In Siberry, G.K., Iannone, R. (eds), The Johns Hopkins Hospital, The Harriet Lane Handbook, A Manual for Pediatric House Officers, 15th edition. St. Louis, MO: Mosby-Year Book, Inc., 2000, pp. 97–118. Zametkin, A.J., Ernst, M., Silver, R. Laboratory and diagnostic testing in child and adolescent psychiatry: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 5: 464–472, 1998.

4.5 Biological assessment BRIAN J. KLEE

Consensus in the field of biological psychiatry supports the ongoing investigation of associations between mental disorders, brain development, genetics, and central nervous system characteristics. This research tradition informs clinical psychiatric practice by emphasizing the need to locate the biological underpinnings of psychiatric illness and mental health. Clinicians working at the level of the individual case routinely draw upon the principles of biological psychiatry as they conduct assessments, make diagnostic formulations and offer treatment recommendations. Areas related to biology that are commonly assessed include family history, developmental history, genetic studies, laboratory studies and brain imaging.

FAMILY HISTORY Much research has been conducted to elucidate the role of genetic inheritance in psychiatric disorders (Placida and Boldrini 1997). Although genetic linkage studies have not been replicated in the investigation of any major psychiatric conditions, the familial patterns observed in many disorders suggest that some risks are transmitted intergenerationally via biologic mechanisms. This view is supported further by the discovery of familial patterns of inheritance involving several neurodegenerative and neuromuscular disorders. When proceeding clinically to obtain the family history, the pattern of symptoms in the patient and his or her biologic relatives should be investigated. Attempts should be made to verify reports using multiple sources of information to enhance the accuracy of the family history. Contacts with treating clinicians and clinical records relating to prior treatments can be helpful in this regard. Questionnaires and checklists can be used to screen for family psychiatric history. When assessing family psychiatric illness, age of onset and periodicity should be evaluated. Any treatment response to somatic therapies should

be established as they may inform treatment selection in the current case.

DEVELOPMENTAL HISTORY A review of the adolescent’s development should include a search for pre- and perinatal factors, such as obstetric care of the biologic mother, in-utero exposure to substances, and birth injuries. Language, motor and sensory developmental milestones from infancy through adolescence should also be investigated. A screening neurologic examination can be conducted to identify subtle nonspecific findings indicative of possible central nervous system dysfunction.

GENETIC STUDIES Chromosomal analysis is employed when assessing clinical syndromes associated with genetic abnormalities that can be associated with mental, behavioral, or psychosocial disabilities. Examples of such genetic syndromes which may warrant genetic testing include Down’s syndrome, Klinefelter’s syndrome, Fragile X syndrome, Prader–Willi syndrome, and Turner’s syndrome. The investigation of syndromes associated with abnormal sexual development may be particularly salient for adolescents. Genetic screening and counseling might be considered when working with individuals of reproductive age with possible genetic disorders who are considering having children.

ELECTROENCEPHALOGRAPHIC (EEG) STUDIES EEG monitoring has often been used as a routine part of a complete psychiatric evaluation, despite limited

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evidence of the utility of this practice. The major indication for obtaining an EEG is in cases where there is the possibility of an organic etiology. This would include suspected cases of dementia, delirium, or epilepsy. Abnormal EEG tracings can predict a worse outcome for developmentally delayed children and adolescents with regard to intelligence, speech, and educational performance. Patients with disruptive behavior disorders and EEG abnormalities may show a favorable response to anticonvulsant medications.

BRAIN IMAGING Technological advances in neuroimaging methods have extended the capacity of investigators to study brain structure and function. Neuroimaging research has benefited from these advances, leading to refinements in the methods used to discover relationships between psychiatric disorders and brain structure and function. The methods of brain imaging currently in use can be grouped as either structural or functional imaging modalities. Methods such as computed tomography (CT) and magnetic resonance imaging (MRI) are useful in visualizing brain anatomy, but provide little information on brain function. Techniques such as positron emission tomography (PET), single photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI) permit the visualization of areas of brain activity. Descriptions of the technology and theory of the various brain imaging techniques are available in several texts (e.g., Lyon and Rumsey 1996; Peterson and Tucker 1996).

Brain imaging techniques COMPUTED TOMOGRAPHY CT scans allow the study of bone, blood, white and gray matter, cerebrospinal fluid (CSF), and pathological lesions. CT remains the methodology of choice for studying acute trauma or when calcified lesions are suspected. It is also used when patients have metal implants or clips which preclude the use of MRI, when a patient has a pacemaker (which interferes electronically with the CT system), or is claustrophobic (they cannot tolerate the confined environment of the scanner). Disadvantages include exposure to radiation and the risk of allergic reactions to the contrast dye that is sometimes needed. When brain calcifications are suspected, CT is the preferred imaging modality as MRI cannot differentiate calcifications from brain parenchyma. CT scanning is used largely for clinical purposes at this time, having been supplanted in research use by the superior resolution and image quality of MRI.

MAGNETIC RESONANCE IMAGING MRI provides clearer pictures than CT, and also avoids some of the shortfalls of CT caused by bone artifact. Compared to CT, MRI offers superior resolution and delineation between white matter, gray matter, CSF, blood, and lesions. MRI has several advantages over CT, including the absence of radiation exposure, the reduced need for contrast injection, the greater flexibility in imaging planes and the superior visualization of brain structures contained in the posterior cranial fossa. MRI can be particularly useful when investigating neurodegenerative disorders and demyelinating diseases. Functional MRI (fMRI) utilizes the close relationship of neuronal activity, energy metabolism and blood flow to measure the signal change associated with brain activity. fMRI cannot image at the level of neurotransmitter receptors or quantify glucose or oxygenation metabolism. The use of fMRI remains limited to research purposes.

POSITRON EMISSION TOMOGRAPHY PET has allowed in-vivo monitoring of receptor-level activity in the brain related to neurotransmitter function and pharmacological effects. The resolution of this technique is not as good as with CT or MRI, but is superior to that of SPECT. Disadvantages of PET include the cost of the equipment, logistical difficulties associated with developing the necessary radioactive tracers, and the radiation exposure that must occur during the imaging process. PET scanning remains limited to research use at present.

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY SPECT is noninvasive and less expensive than PET, and isotopes can be obtained commercially at low cost. Spatial resolution is not as good as that seen with PET. Observation of neurotransmitter and receptor-level effects is possible. The use of SPECT remains limited to research purposes at this time.

Indications and contraindications Consensus holds that brain imaging studies should be pursued when there is any suspicion of focal abnormality suggested by EEG or neurologic examination, suspicion of anatomic developmental abnormalities, possible sequelae of prenatal or perinatal injury, head trauma, delirium of unknown etiology or brain tumors (Bailey 1994). Zametkin et al. (1998) state that the indiscriminate routine use of MRI or CT scanning has a low positive yield related to clarifying diagnosis or altering treatment decisions. These authors also state that the routine clinical use of imaging techniques is not justified in the evaluation

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of attention deficit hyperactivity disorder (ADHD), autism, or mental retardation. Dye allergy and pregnancy are contraindications to CT scanning. The use of MRI is contraindicated for patients with metal implants, including prostheses, surgical clips or cardiac pacemakers. Until the recent introduction of open scanner designs, claustrophobic patients have had difficulty with the confined space of the closed scanner. Consultation with a radiologist should be pursued when possible contraindications to MRI are encountered. Patients who are agitated or extremely anxious may not be able to tolerate the scanning process and may benefit from the judicious use of medication, informed by the specific clinical characteristics of each case, to reduce their level of distress and permit the completion of imaging studies.

RESEARCH FINDINGS Autism and other pervasive developmental disorders Studies involving CT methodology have yielded mixed results. Some have demonstrated ventricular abnormalities to be the predominant finding (Damasio et al. 1980; Caparulo et al. 1981; Campbell et al. 1982), while others revealed a preponderance of cysts, cerebellar atrophy and lower mean caudate radiodensity (Gilberg and Svendsen 1983; Bauman and Kemper 1986; Jacobson et al. 1988). At least three studies showed no differences between subjects and controls (Rosenbloom et al. 1984; Prior et al. 1984; Harcherik et al. 1985). Several MRI studies have also shown ventricular abnormalities, and decreased area of structures such as the cerebellum, lenticular nucleus, and brainstem (Gaffney et al. 1987, 1988, 1989; Courchesne et al. 1988). Functional imaging studies have yielded contradictory results. One PET study demonstrated hypermetabolic activity in the frontal cortex, parietal, temporal and occipital lobes, hippocampus, thalamus and basal ganglia (Rumsey et al. 1985), while another showed an absence of such hypermetabolic areas (Herold et al. 1988). SPECT studies have demonstrated no difference in cortical blood flow compared to controls (Zilbovicius et al. 1992), and hypoperfusion in left cerebral hemisphere structures (Chiron et al. 1995; Gillberg et al. 1993; Mountz et al. 1995).

Schizophrenia Structural imaging techniques in adults have shown a decrease in cortical, temporal lobe, hippocampal, and thalamic volumes (Falkai and Bogerts 1995). They have also shown enlarged lateral and third ventricles (Kotrla and Weinberger 1995), with enlargement of the lateral

ventricles having been the most consistent finding (Gilmore et al. 1997). Some studies report that most abnormalities are present at the onset of symptoms (Weinberger et al. 1982; Andreasen et al. 1990). MRI studies have shown a decrease in the size of temporal lobe structures which is associated with a greater degree of symptoms (Kotrla and Weinberger 1995). One study of treatment-refractory subjects with onset of schizophrenia prior to age twelve years suggests that progressive ventricular enlargement can occur during adolescence (Rapoport et al. 1997). Functional methods have shown abnormalities in prefrontal perfusion that have been suggestive of anomalies in the dopamine system (Kuperman et al. 1990).

Tourette’s syndrome The results of studies assessing neuroanatomy in Tourette’s syndrome have been shown to vary. One study found 38 per cent of afflicted patients to have abnormal CT scans (Caparulo et al. 1981), whereas a recent study revealed a reduction in the volume of the left lenticular nucleus and a reduced basal ganglia asymmetry relative to controls (Peterson and Klein 1997). Functional studies have revealed reductions in basal ganglia volume, metabolism and blood flow (Peterson and Klein 1997). Other results indicate no differences in striatal dopamine (D2) receptor density between subjects and controls (Turjanski et al. 1994). There have been findings of increased caudate nucleus dopamine receptor availability (Wolf et al. 1996), elevations in striatal dopamine transporters (Malison et al. 1995), and increased metabolic activity in the premotor and primary sensorimotor regions of the brain (Peterson and Klein 1997).

Obsessive–compulsive disorder CT and MRI investigations are usually normal. Closer evaluation utilizing techniques allowing for measurements of volume have revealed possible abnormalities in the caudate nuclei (Rauch et al. 1997; Scarone et al. 1992; Robinson et al. 1995).

ADHD Studies assessing brain structure have yielded mixed results, finding no difference between subjects and controls (Shaywitz et al. 1983) and demonstrating a decrease in size of the posterior cerebellar vermis (Mostofsky et al. 1998). The brains of adults with ADHD have demonstrated a decrease in global cerebral metabolic rates, but this has not been confirmed in adolescents (Castellanos 1997). Some authors have reported a loss of the normal caudate nucleus symmetry, while others have reported a

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unilateral decrease in caudate nuclear volume, hypoperfusion of the caudate or, in adults, a decrease in right caudate metabolism (Castellanos 1997). PET studies have demonstrated a decrease in cortical metabolism in adult ADHD subjects (Zametkin et al. 1990) and have failed to demonstrate cortical hypometabolism in adolescent ADHD subjects (Zametkin et al. 1993). Stimulant treatment has produced increases in both caudate metabolism and blood flow (Lou et al. 1984; Matochik et al. 1993).

Affective disorders The heterogeneity of affective disorders has made categorization of findings difficult, and this has led to a lack of consensus regarding structural or functional imaging findings in this area.

INTEGRATION OF FINDINGS Biological assessment findings should be evaluated according to the acute and chronic effects exerted by biological factors on an adolescent’s development along physical, cognitive, emotional, behavioral, and social lines. Descriptions of associated disabilities should be listed in functional terms and intervention strategies considered with an awareness of biological, psychological and social approaches that can be individualized to meet the unique needs of the adolescent.

REFERENCES Andreasen, N.C., Swayze, V.W., Flaum, M., et al. Ventricular enlargement in schizophrenia evaluated with computed tomographic scanning. Archives of General Psychiatry 47: 1008–1015, 1990. Bailey, A. Physical examination and medical investigations. In Rutter, M. (ed.), Child and Adolescent Psychiatry: Modern Approaches, 3rd edition. Oxford: Blackwell Scientific, 1994, pp. 79–93. Bauman, M., Kemper, T.L. Developmental cerebellar abnormalities: a consistent finding in early infantile autism. Neurology 36 (suppl. 1): 190, 1986. Campbell, M., Rosenbloom, S., Perry, R., et al. Computerized axial tomography in young autistic children. American Journal of Psychiatry 139: 510–512, 1982. Caparulo, B.K., Cohen, D.J., Rothman, S.L., et al. Computed tomographic brain scanning in children with developmental neuropsychiatric disorders. Journal of the American Academy of Child and Adolescent Psychiatry 20: 338–357, 1981. Castellanos, F.X. Neuroimaging of attention-deficit hyperactivity disorder. In Peterson, B.S. (ed.), Child and Adolescent Psychiatric Clinics of North America:

Neuroimaging. Philadelphia, PA: W.B. Saunders Co., Volume 6, number 2, 1997, pp. 383–411. Chiron, C., Leboyer, M., Leon, F., et al. SPECT of the brain in childhood autism: evidence for a lack of normal hemispheric asymmetry. Developmental Medicine and Child Neurology 37: 849–860, 1995. Courchesne, E., Yeung-Courchesne, R., Press, G.A., et al. Hypoplasia of cerebellar vermal lobules VI and VII in autism. New England Journal of Medicine 318: 1349–1354, 1988. Damasio, H., Maurer, R.G., Damasio, A., et al. Computerized tomographic scan findings in patients with autistic behavior. Archives of Neurology 37: 504–510, 1980. Falkai, P., Bogerts, B. The neuropathology of schizophrenia. In Hirsch, S.R., Weinberger, D.R. (eds), Schizophrenia. Cambridge, MA: Blackwell Science, 1995, pp. 275–292. Gaffney, G.R., Kuperman, S., Tsai, L.Y., et al. Midsagittal magnetic resonance imaging of autism. British Journal of Psychiatry 151: 831–833, 1987. Gaffney, G.R., Kuperman, S., Tsai, L.Y., et al. Morphological evidence of brainstem involvement in infantile autism. Biological Psychiatry 24: 578–586, 1988. Gaffney, G.R., Kuperman, S., Tsai, L.Y., et al. Forebrain structure in infantile autism. Journal of the American Academy of Child and Adolescent Psychiatry 28: 534–537, 1989. Gilberg, C., Svendsen, P. Childhood psychosis and computed tomographic brain scan findings. Journal of Autism and Developmental Disorders 13: 19–31, 1983. Gillberg, I.C., Bjure, J., Uvebrant, P., et al. SPECT (single photon emission computed tomography) in 31 children and adolescents with autism and autistic-like conditions. European Child and Adolescent Psychiatry 2: 50–59, 1993. Gilmore, J.H., Sikich, L., Lieberman, J.A. Neuroimaging, neurodevelopment, and schizophrenia. In Peterson, B.S. (ed.), Child and Adolescent Psychiatric Clinics of North America: Neuroimaging. Philadelphia, PA: W.B. Saunders Co., Volume 6, number 2, 1997, pp. 325–341. Harcherik, D.F., Cohen, D.J., Ort, S., et al. Computed tomographic brain scanning in four neuropsychiatric disorders in childhood. American Journal of Psychiatry 142: 731–734, 1985. Herold, S., Frackowiak, R.S.J., LeCouteur, A., et al. Cerebral blood flow and metabolism of oxygen and glucose in young autistic adults. Psychological Medicine 18: 823–831, 1988. Jacobson, R., LeCouteur, A., Howlin, P., et al. Selective subcortical abnormalities in autism. Psychological Medicine 18: 39–48, 1988. Kotrla, K.J., Weinberger, D.R. Brain imaging in schizophrenia. Annual Review of Medicine 46: 113–122, 1995. Kuperman, S., Gaffney, G.R., Hamdan-Allen, G., et al. Neuroimaging in child and adolescent psychiatry.

230 Assessment of the adolescent Journal of the American Academy of Child and Adolescent Psychiatry 29: 159–172, 1990. Lou, H.C., Henriksen, L., Bruhn, P. Focal cerebral hypoperfusion in children with dysphasia and/or attention-deficit disorder. Archives of Neurology 41: 825–829, 1984. Lyon, G.R., Rumsey, J.M. (eds) Neuroimaging: a window to the neurological foundations of learning and behavior in children. Baltimore, MD: Paul H. Brookes, 1996. Malison, R.T., McDougle, C.J., van Dyck, C.H., et al. [123]Beta-CIT SPECT imaging demonstrates increased striatal dopamine transporter binding in Tourette’s syndrome. American Journal of Psychiatry 152: 1359–1361, 1995. Matochik, J.A., Nordahl, T.E., Gross, M., et al. Effects of acute stimulant medication on cerebral metabolism in adults with hyperactivity. Neuropsychopharmacology 8: 377–386, 1993. Mostofsky, S.H., Reiss, A.L., Lockhart, P., et al. Evaluation of cerebellar size in attention-deficit hyperactivity disorder. Journal of Child Neurology 13: 434–439, 1998. Mountz, J.M., Tolbert, L.C., Lill, D.W., et al. Functional deficits in autistic disorder: characterization by technetium-99m-HMPAO and SPECT. Journal of Nuclear Medicine 36: 1156–1162, 1995. Peterson, B.S., Tucker, D.M. Neuroimaging in developmental neuropsychiatric disorders. In Lewis, M. (ed.), Child and Adolescent Psychiatry: A Comprehensive Textbook, 2nd edition. Baltimore: Williams & Wilkins, 1996, pp. 96–115. Peterson, B.S., Klein, J.E. Neuroimaging of Tourette’s syndrome neurobiologic substrate. In Peterson, B.S. (ed.), Child and Adolescent Psychiatric Clinics of North America: Neuroimaging. Philadelphia, PA: W.B. Saunders Co., Volume 6, number 2, 1997, pp. 343–364. Placida, G.P.A., Boldrini, M. Considerations on the role of genetics in psychiatric research. CNS Spectrums 2: 42–44, 1997. Prior, M.R., Tress, B., Hoffman, W.L., et al. Computed tomographic study of children with classic autism. Archives of Neurology 41: 482–484, 1984. Rapoport, J.L., Giedd, J., Kumra, S., et al. Childhood onset schizophrenia: progressive ventricular change during adolescence. Archives of General Psychiatry 54: 897–903, 1997. Rauch, S.L., Bates, J.F., Grachev, I.D. Obsessive–compulsive disorder. In Peterson, B.S. (ed.), Child and Adolescent Psychiatric Clinics of North America: Neuroimaging. Philadelphia, PA: W.B. Saunders Co., Volume 6, number 2, 1997, pp. 365–381. Robinson, D., Wu, H., Munne, R.A., et al. Reduced caudate nucleus volume in obsessive–compulsive disorder. Archives of General Psychiatry 52: 393–398, 1995. Rosenbloom, S., Campbell, M., George, A., et al. High resolution CT scanning in infantile autism: a quantitative approach. American Journal of Psychiatry 23: 72–77, 1984.

Rumsey, J.M., Duara, R., Grady, C., et al. Brain metabolism in autism: resting cerebral glucose utilization rates as measured with positron emission tomography. Archives of General Psychiatry 42: 448–455, 1985. Scarone, S., Colombo, C., Livian, S., et al. Increased right caudate nucleus size in obsessive–compulsive disorder: detection with magnetic resonance imaging. Psychiatry Research and Neuroimaging 45: 115–121, 1992. Shaywitz, B.A., Shaywitz, S.E., Byrne, T., et al. Attention deficit disorder: quantitative analysis of CT. Neurology 33: 1500–1503, 1983. Turjanski, N., Sawle, G.V., Playford, E.D., et al. PET studies of the presynaptic and postsynaptic dopaminergic system in Tourette’s syndrome. Journal of Neurology, Neurosurgery and Psychiatry 57: 688–692, 1994. Weinberger, D.R., DeLisi, L.E., Perman, G.P., et al. Computed tomography in schizophreniform disorder and other acute psychiatric disorders. Archives of General Psychiatry 39: 778–783, 1982. Wolf, S.S., Jones, D.W., Knable, M.B., et al. Tourette’s syndrome: prediction of phenotypic variation in monozygotic twins by caudate nucleus D2 receptor binding. Science 273: 1225–1227, 1996. Zametkin, A., Nordahl, T., Gross, M., et al. Cerebral glucose metabolism in adults with hyperactivity of childhood onset. New England Journal of Medicine 323, 1361–1366, 1990. Zametkin, A., Liebenauer, L., Fitzgerald, G., et al. Brain metabolism in teenagers with attention deficit hyperactivity disorder. Archives of General Psychiatry 50: 333–340, 1993. Zametkin, A.J., Ernst, M., Silver, R. Laboratory and diagnostic testing in child and adolescent psychiatry: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37: 464–472, 1998. Zilbovicius, M., Garreau, B., Tzourio, N., et al. Regional cerebral blood flow in childhood autism: a SPECT study. American Journal of Psychiatry 149: 924–930, 1992.

Suggested reading CNS Spectrums. The International Journal of Neuropsychiatric Medicine. New York: MBL Communications. Kertesz, A. (ed.) Localization and Neuroimaging in Neuropsychology. San Diego: Academic Press, 1994. Peterson, B.S. (ed.) Neuroimaging. In Child and Adolescent Psychiatric Clinics of North America. Philadelphia, PA: W.B. Saunders Co., Volume 6, number 2, April 1997. Zametkin, A.J., Ernst, M., Silver, R. Laboratory and diagnostic testing in child and adolescent psychiatry: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37: 464–472, 1998.

4.6 Psychological assessment ALAN S. ELLIOT AND ENRIQUE GULAR

INTRODUCTION The goal of psychological testing is to obtain information about specific types of verbal, perceptual, and motor behaviors through systematic, standardized procedures (Anastasi 1988; Rapaport et al. 1968). In the psychiatric evaluation of an adolescent, psychological testing can help to discriminate acute syndromes from chronic disorders, identify learning disabilities, uncover underlying thought disorders and locate signs of subtle organic factors not detectable through standard neurological and psychiatric evaluations (Esman 1988). Psychological testing procedures are particularly useful in assessing intelligence level, probing for the presence of specific brain dysfunction, providing indications of the adolescent’s emotional development and personality characteristics, and estimating the nature and quality of his/ her psychosocial environment (Benton and Sines 1985). Assessment methods may include self-report inventories, parent rating scales, teacher rating scales, behavioral observations, peer-referenced tests, projective techniques, structured diagnostic interviews, and adaptive rating scales (Kamphaus and Frick 1996). Some theorists have held the view that the psychological testing of adolescents is difficult, due to the adolescent’s state of developmental flux, oscillating between childhood and adulthood. This view of adolescence as a transitional period of turmoil and disturbance has been challenged by various contemporary theorists who postulate a more normative, balanced understanding of adolescence as a developmental phase (Offer 1980; Levy-Warren 1996). Testing interpretations can therefore be grounded in the context of an empirically based, developmentally sensitive formulation.

CONSTRUCTION OF THE TEST BATTERY A philosophical tension exists between advocates of the traditional test battery and proponents of focal

assessment techniques (Carr 1985). While the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association 2000) is based upon observable and reported symptoms, other patient characteristics which are less accessible to direct observation affect treatment and prognosis. Defenders of the traditional battery maintain that the patient’s clinical state is subject to frequent change, and that a reliable evaluation can be achieved only by examination of consistencies and inconsistencies between tests which present the patient with a broad range of stimuli. Advocates of focal assessment, pointing to increasing emphasis on brief hospitalizations, short-term treatment and economy, stress that techniques designed specifically to evaluate operationally defined traits and behaviors are more useful. Practically, the specificity of the referral question may determine the nature of the test battery selected. A single test is rarely, if ever, sufficient to respond to the referral question with confidence. Reliability and validity of results are enhanced through multiple levels of assessment. While the number of adolescent-specific test instruments is growing, many are still designed predominantly for either children or adults. Interviews and rating scales with parents, teachers and therapists can be used to review psychiatric, medical and educational histories, and to augment and contextualize data obtained directly from the adolescent.

INTERPRETATION OF TEST RESULTS Once administration and scoring of the testing battery is completed, inferences from various tests must be integrated based upon the level of confidence the psychologist holds in them, and presumptions about the areas of functioning being tapped. For adolescent evaluations, a broad-based knowledge of intellectual, emotional, moral and psychosocial development is needed to interpret and craft a valid, balanced formulation. An understanding of developmental subphases within adolescence is critical

232 Assessment of the adolescent

in arriving at accurate diagnoses, prognoses and treatment recommendations. Sensitivity to social, religious and cultural aspects of the adolescent’s life frame and place adolescent behaviors and belief systems in a larger context, to help the evaluator avoid erroneous diagnosing of psychopathology.

THE REPORT

TESTS OF INTELLECTUAL FUNCTIONING The development of cognitive psychological testing was originally stimulated by the need to identify individuals with mental retardation (Anastasi 1988). Today, intellectual assessment represents one of the major areas of functioning assessed through psychological testing, and utilizes the following test systems:

• Most psychologists follow a general outline in preparing a psychological report which includes some form of the following categories:

• • • •

•

• •

•

Reason for referral: A brief statement of the purpose of the evaluation, which may include questions of differential diagnosis, educational placement, residential placement, treatment or prognostic considerations. Tests administered: Each test administered or attempted. Behavioral observations: Descriptions of the adolescent’s behavior during testing, including level of motivation, manifest anxiety, attitude and cooperation with the evaluation. Intellectual functioning: Intelligence quotients (IQs), ranges and scaled subtest scores, with interpretation of strengths and weaknesses in the intellectual testing profile. Evidence suggesting organicity, learning disability or mental retardation, as well as capacities for verbal and nonverbal intelligence, retention of school-based information, memory, social judgment and sequencing, attention, concentration, motor coordination, problem solving, abstract reasoning, mathematical reasoning, and organization and synthesis of incoming stimuli. Personality functioning: Quality of reality testing in structured and unstructured situations, evidence of psychotic process, mood disturbance, personality disorder or suicidal ideation. Salient preoccupations or themes such as aggression, anxiety, fear, sex, love, guilt and self-esteem. Quality of interpersonal relationships and characteristic defenses employed. Diagnosis: DSM-IV-TR diagnostic category, based upon analysis of test data and information available from all sources. Summary: A brief paragraph summarizing the highlights and most important themes from all previous areas of the test report. Alternative hypotheses raised by the evaluation may be discussed here, including the suspicion of subclinical or encapsulated syndromes not detected through standard psychiatric assessment. Recommendations: Recommendations may include individual, group or family psychotherapy, medication trials, medical evaluation, specialized psychological testing, specific types of remediation, referral to special education, or referral to more or less structured residential or hospital settings.

•

•

•

Wechsler Intelligence Scale for Children, third edition (WISC-III) (Wechsler 1991). This is the most widely used measure of a child’s intellectual ability (IQ). It is appropriate for use with children above the age of six years and below the age of seventeen years. This latest edition includes updated items to address sex and race/ethnicity biases identified in previous editions. In addition, norms for the WISCIII are based on a standardized sample, representative of sex, age, parental education levels, geographical region, and race/ethnicity. The WISC-III is composed of ten core subtests and three supplemental subtests yielding a Verbal IQ, a Performance IQ and a Full Scale IQ. Wechsler Adult Intelligence Scale, third edition (WAIS-III) (Wechsler 1997). This is the adult complement to the WISC-III and covers the upper end of the adolescent age range (seventeen years and older). The WAIS-III also yields Verbal, Performance, and Full Scale IQs. It is composed of fourteen subtests. Stanford–Binet Intelligence Scale, fourth edition (SBIS). The SBIS (Thorndike et al. 1986a,b) is organized according to a theoretical model which distinguishes between fluid intelligence (functions which may vary depending upon current circumstances and past experience) and crystallized intelligence (functions which are fully developed and stable over time). The SBIS yields a general index of intelligence, and measures the following four broad cognitive areas: Verbal; Abstract/Visual; Quantitative; and Short-Term Memory Reasoning. The test provides IQ estimates from the age of two years to twenty-three years. Raven’s Progressive Matrices. The Raven matrices (Raven 1938, 1947, 1965) are useful for individuals with language deficiencies, or whose native language is not English. There are three forms: one is particularly useful with individuals with learning disabilities, aphasias, cerebral palsy, or deafness, and is also appropriate for individuals of below average intellectual ability. It encompasses cognitive processes typical of children under age eleven years. The other two forms are designed to differentiate people with superior intellectual ability. Scores are reported in percentiles. Although there are tables for conversion of Raven’s scores into Wechsler IQ scores (Peck 1970), such conversions are discouraged because Raven’s scores are

Psychological assessment 233

•

•

rough estimates of intelligence and therefore cannot provide discrete classifications (Spreen and Strauss 1991). The Leiter International Performance Scale (LIPS). The LIPS (Levine 1993) was developed through years of research with various ethnic groups and with elementary and high-school students. The LIPS contains minimal verbal instructions. It yields mental age and IQ data for non-English speaking, illiterate or disadvantaged patients or those with speech, hearing or other medical disabilities. The Comprehensive Test of Nonverbal Intelligence (CTONI). The CTONI (Wiederholt and Rees 1998) was developed to assess nonverbal reasoning and requires no spoken language or complex motor skills to complete. It consists of six subtests designed to measure three interrelated nonverbal abilities: analogical, categorical and sequential reasoning. It can be used with children as young as six years. It can be useful when subjects speak languages other than English, are bilingual or multi-lingual, have a language disorder, are deaf, socially or economically disadvantaged, or have neurological impairment. It yields a nonverbal IQ.

TESTS OF PERSONALITY FUNCTIONING Personality is assessed through two predominant testing methods: projective techniques and personality inventories. Projective testing is based upon the four central propositions that: 1 A person’s unique thinking patterns are the result of enduring modes of attempting to bring internal demands into harmony with external stimulation. 2 Responses to test items are verbalized end-products of thought processes initiated by those items. 3 The patient must think in a variety of problem situations to enable the examiner to distinguish pervasive or pathological aspects of characteristic adjustment efforts. 4 Thinking reflects both past experience and creative application of assets and liabilities to new problems (Schafer 1948).

Rorschach test of psychodiagnostics The Rorschach test (Rorschach 1949) is a set of ten inkblots. The individual is instructed to describe what he/she sees, and then is probed further about the elements determining their responses. There are various extensively researched methods of scoring and interpretation for this test, some based upon perceptual patterns and others on content analysis (Aronow and Reznikoff 1983; Exner 1974; Klopfer and Davidson 1962). The

Rorschach can be useful in uncovering personality themes and dynamics, assessing the quality of reality testing and visual perceptual organization, and identifying underlying psychotic processes.

Thematic Apperception Test (TAT) and Children’s Apperception Test (CAT) The TAT (Morgan and Murray 1935) and CAT (Bellak and Abrams 1997) investigate personality dynamics as manifested in interpersonal relationships. The TAT, appropriate for older or higher-functioning adolescents (age ten years to young adult), consists of a set of thirty-one drawings, a subset of which is presented to the patient. Most drawings contain vague depictions of people interacting with each other in different settings. The examinee is asked to tell a story based upon the drawing he/she sees. The TAT is based on the assumption that in telling stories about the drawings, the examinee reveals personal needs and conflicts as they relate to interpersonal relationships. The CAT is for younger adolescents (ages three to ten years) and is similar to the TAT but consists of ten animal pictures in a social context involving the adolescent in conflict identities, roles, family structures, and interpersonal interaction.

Minnesota Multiphasic Personality Inventory (MMPI-2) The MMPI-2 (Butcher et al. 1989) is a self-administered personality inventory, available in several languages, which yields a profile based upon several personality dimensions. A version specifically used with adolescents, the Minnesota Multiphasic Personality Inventory-Adolescent Version (MMPI-A) (Archer 1997), can provide more specific clinical information, taking into account adolescent developmental perspectives.

NEUROPSYCHOLOGICAL TESTING Neuropsychological tests can be used to assess intellectual deterioration or impairment resulting from a variety of causes (Anastasi 1988), including drug use, head trauma, or progressive disease processes. Used as an adjunct to a more general psychological evaluation, neuropsychological testing can localize specific areas of brain dysfunction by evaluating findings associated with specific brain locations. Such testing can be used to corroborate data derived from computed tomography (CT) scanning, magnetic resonance imaging (MRI) or electroencephalography (EEG) procedures which suggest abnormalities. Neuropsychological tests which target functions associated with particular brain areas can be

234 Assessment of the adolescent

combined to create customized batteries based upon hypotheses and referral questions for specific patients. A neuropsychological assessment begins with a test of general cognitive ability, as described above, in combination with a number of tests addressing the specific problem in question. Some of the general areas assessed may include memory, language acquisition and use, motor behavior and thought processing. When dysfunction in a specific area is suspected or evident, highly specialized tests focusing on that particular brain function are added. Such specificity may allow for the development of tailored recommendations for remediation therapy. While ‘ready-made’ batteries, such as the Halstead–Reitan Neuropsychological Battery (Reitan and Wolfson 1985), are options, they may not yield data as clinically useful as a custom-assembled battery (Kolb and Whishaw 1980). For more information on specific tests used within each of the major areas of neuropsychological functioning, readers are referred to Spreen and Strauss (1991).

Wide Range Assessment of Memory and Learning (WRAML) The WRAML (Adams and Sheslow 1990) is normed on a nationally representative sample of more than 2300 children and adolescents between the ages of five and seventeen years. The WRAML provides a relatively comprehensive assessment of learning and memory functions, consisting of verbal, visual and learning subtests.

The Developmental Test of Visual–Motor Integration 4th edition, revised (VMI) The VMI (Beery 1997) is designed to help identify learning problems through early screening. The twenty-sevenitem test includes standardized measures for visual perception, motor coordination, and visual-motor integration in patients from three to eighteen years of age. Results are reported as percentiles and standard score equivalents.

ADAPTIVE BEHAVIOR SCALES Tests of psychosocial adaptation assess the adolescent’s level of functioning in social contexts such as home, school and work. Information is gathered from parents, caretakers, teachers, nurses and other people familiar with the adolescent’s level of everyday functioning. DSMIV-TR criteria now require that a diagnosis of mental retardation occurs on the basis of both an IQ and an assessment of adaptive functioning. Psychosocial testing results yield information which may be helpful in determining the need for various educational and daily living services.

Vineland Adaptive Behavior Scale The Vineland Adaptive Behavior Scale test (Sparrow et al. 1984) assesses social and personal adaptive abilities in daily living. It is a semi-structured interview administered to the person most familiar with the adolescent. Four domains of functioning are assessed: communication; daily living skills; socialization; and motor skills. An optional maladaptive domain measures behaviors such as running away, swearing, impulsiveness, and stealing.

RATING SCALES AND CHECKLISTS The Conners’ Rating Scales, Revised (CRS-R; Conners 1997) assess a broad range of behavior problems as reported by adolescents, teachers, parents, or caregivers. The teachers’ ratings include scales for oppositional, hyperactive, cognitive problems/inattention, and an attention deficit hyperactivity disorder (ADHD) index. The parents’ ratings contain scales for psychosomatic symptoms, anxiety behaviors, perfectionism, and social problems. Conners’ scales are particularly useful in identifying children and adolescents at risk for ADHD. The Child Behavior Checklist/4-18 (CBCL/4-18; Achenbach 1991) is an empirically developed instrument, and can be completed by parents, teachers or caregivers. It yields scores for behavioral dimensions, including withdrawal, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, delinquent behavior, aggressive behavior and sex problems. In addition, the CBCL/4-18 provides global scales for internalizing, externalizing and total problems. The CBCL/ 4-18 can determine whether behaviors fall within clinical, borderline or subclinical ranges, thus facilitating the identification of target areas for intervention. The Youth Self-Report and Profile for Ages 11–18 (YSR) contains most of the same competence and problem items as the CBCL/4-18, can be administered orally, or completed by youths having fifth-grade reading skills. The Teacher’s Report Form and Profile for Ages 5–18 obtains teacher ratings of many problems rated on the CBCL/4-18, and adds scales for academic performance and adaptive functioning. The Young Adult Behavior Checklist (YABCL) (Achenbach 1997) and Young Adult Self-Report (YASR) (Achenbach 1997) are new versions of the CBCL and YSR appropriate for older adolescents and young adults (aged eighteen to thirty years).

PSYCHOLOGICAL TESTING OF SPECIAL POPULATIONS Testing guidelines and procedures have been developed to ensure proper use of psychological tests and their

Psychological assessment 235

results (American Educational Research Association, American Psychological Association and National Council on Measurement in Education 1985). To account for cultural differences affecting the development of aptitudes, interests, motivation, attitudes and other psychological characteristics of minority group members, many tests have been modified and normed on those specific populations to be assessed. Nevertheless, language and cultural bias in interpretation of test results remains a problem overall. Testing of physically impaired children and adolescents presents special considerations regarding test administration and proper interpretation. Specific guidelines, available from the American Psychological Association, suggest: 1) modification of existing tests; and 2) individualized assessment combining assessments from multiple sources. A major limitation is the difficulty in establishing appropriate norms, owing to small sample sizes. Special tests for the visually, hearing, and motorically impaired child are available from multiple sources (Anastasi 1988).

REFERENCES Achenbach, T.M. Manual for the Child Behavior Checklist/ 4-18 and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry, 1991. Achenbach, T.M. Manual for the Young Adult Self-Report and Young Adult Behavior Checklist. Burlington, VT: University of Vermont Department of Psychiatry, 1997. Adams, W., Sheslow, D. Wide Range Assessment of Memory and Learning (WRAML). Wilmington: Jastak Associates, Inc., 1990. American Educational Research Association, American Psychological Association and National Council on Measurement in Education. Standards for Educational and Psychological Testing. Washington, DC: American Psychological Association, 1985. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychiatric Association, 2000. Anastasi, A. Psychological Testing, 6th edition. New York: Macmillan Publishing Company, 1988. Archer, R.P. MMPI-A: Assessing Adolescent Psychopathology. Hillsdale, NJ: Lawrence Erlbaum, 1997. Aronow, E., Reznikoff, M. A Rorschach Introduction: Content and Perceptual Approaches. New York: Grune & Stratton, 1983. Beery, K.E. Developmental Test of Visual-Motor Integration, 4th edition, Revised. Cleveland, OH: Modern Curriculum Press, 1997. Bellak, L., Abrams, D.M. The TAT, CAT, and SAT in Clinical Use, 6th edition. New York: Grune & Stratton, 1997.

Benton, A.L., Sines, J.O. Psychological testing of children. In Kaplan, H.I., Sadock, B.J. (eds), Comprehensive Textbook of Psychiatry, Volume 4. Baltimore, Williams & Wilkins, 1985, pp. 1625–1634. Butcher, J.N., Dahlstrom, W.G., Graham, J.R., et al. MMPI-2: Minnesota Multiphasic Personality Inventory-2 Manual for Administration and Scoring. Minneapolis, MN: University of Minnesota Press, 1989. Carr, A.C. Psychological testing of personality. In Kaplan, H.I., Sadock, B.J. (eds), Comprehensive Textbook of Psychiatry, Volume 4. Baltimore, Williams & Wilkins, 1985, pp. 514–535. Conners, C.K. Conners’ Rating Scales, Revised. New York: Multi Health Systems, Inc., 1997. Esman, A.H. Assessment of the adolescent. In Kestenbaum, C.J., Williams, D.T. (eds), Handbook of Clinical Assessment of Children and Adolescents, Volume I. New York: New York University Press, 1988, pp. 217–231. Exner, J.E. The Rorschach: A Comprehensive System. New York: John Wiley & Sons, 1974. Kamphaus, R.W., Frick, P.J. Clinical Assessment of Child and Adolescent Personality and Behavior. Needham Heights: Allyn & Bacon, Inc., 1996. Klopfer, B., Davidson, H.H. The Rorschach Technique: An Introductory Manual. New York: Harcourt, Brace & World, 1962. Kolb, B., Whishaw, I.Q. Fundamentals of Human Neuropsychology, 2nd edition. New York: W.H. Freeman and Company, 1980. Levine, M.N. Leiter International Performance Scale: A Handbook, 5th Printing. Los Angeles: Western Psychological Services, 1993. Levy-Warren, M. The Adolescent Journey. New Jersey: Jason Aronson, Inc., 1996. Morgan, C.D., Murray, H.A. A method for investigating fantasies: the thematic apperception test. Archives of Neurology and Psychiatry 34: 289–306, 1935. Offer, D. Adolescent development: a normative perspective. In Greenspan, S., Pollock, G. (eds), The Course of Life, Volume 2. Washington, DC: National Institute for Mental Health, 1980, pp. 357–372. Peck, D.F. The conversion of progressive matrices and mill holl vocabulary raw scores into deviation IQs. Clinical Psychology 26: 67–70, 1970. Rapaport, D., Gill, M.M., Schafer, R. Diagnostic Psychological Testing, Revised Edition by Robert R. Holt. Madison, CT: International Universities Press, Inc., 1968. Raven, J.C. Progressive Matrices: A Perceptual Test of Intelligence: Individual Form. London: H.K. Lewis, 1938. Raven, J.C. Colored Progressive Matrices Sets A, Ab, B. London: H.K. Lewis, 1947. Raven, J.C. Advanced Progressive Matrices Sets I, and II. London: H.K. Lewis, 1965.

236 Assessment of the adolescent Reitan, R.M., Wolfson, D. The Halstead–Reitan Neuropsychological Test Battery: Theory and Clinical Interpretation. Tucson, Arizona: Neuropsychology Press, 1985. Rorschach, H. Psychodiagnostics. New York: Grune & Stratton, 1949. Schafer, R. The Clinical Application of Psychological Tests. New York: International Universities Press, 1948. Sparrow, S.S., Balla, D.A., Cicchetti, D.V. Vineland Adaptive Behavior Scales. Circle Pines, MN: American Guidance Service, Inc., 1984. Spreen, O., Strauss, E. A Compendium of Neuropsychological Tests. New York: Oxford University Press, 1991. Thorndike, R.L., Hagen, E.P., Sattler, J.M. Stanford–Binet Intelligence Scale, 4th edition. Chicago: Riverside Publishing, 1986a. Thorndike, R.L., Hagen, E.P., Sattler, J.M. Technical Manuals: Stanford–Binet Intelligence Scale, 4th edition. Chicago, IL: Riverside Publishing, 1986b. Wechsler, D. WAIS-III manual: Wechsler Adult Intelligence Scale, 3rd edition. San Antonio, TX: Psychological Corporation, 1997.

Wechsler, D. WISC-III manual: Wechsler Intelligence Scale for Children, 3rd edition. San Antonio, TX: Psychological Corporation, 1991. Wiederholt, J.L., Rees, F.J. Description of the comprehensive test of nonverbal intelligence. Journal of Child Neurology 13: 224–225, 1998,

Suggested reading Conoley, J.C., Impara, J.C. (eds) The Twelfth Mental Measurements Yearbook. Lincoln, NE: University of Nebraska Press, Inc., 1995. Haplerin, J.M., McKay, K.E. Psychological testing for child and adolescent psychiatrists: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37: 575–584, 1998. Kaplan, H.I., Sadock, B.J. (eds) Comprehensive Textbook of Psychiatry, Volume IV. Baltimore, MD: Williams & Wilkins, 1985. Kestenbaum, C.J., Williams, D.T. (eds) Handbook of Clinical Assessment of Children and Adolescents, Volumes I and II. New York: New York University Press, 1988.

4.7 Cultural assessment PHILL V. HALAMANDARIS AND TANYA R. ANDERSON

Census Bureau statistics (US Government 1990) indicate that ongoing immigration continues to change the racial, ethnic, and cultural complexion of our society. The increasing multi-cultural composition of society is reflected in healthcare facilities, from the urban tertiary care teaching hospital to rural solo practices. Therefore, it is imperative that all practitioners learn how cultural factors affect the assessment and treatment of patients. This chapter provides an overview of the cultural factors that the practitioner should consider in clinical work with adolescents from diverse backgrounds. It focuses on issues that surface while collecting a history, performing a mental status examination, using assessment tools, arriving at a diagnosis, and crafting a treatment plan.

atmosphere of openness in the encounter, build rapport with the patient and introduce a sense of trust that will facilitate the assessment process.

APPROACHING THE ASSESSMENT

The immigration history

A cultural assessment should include consideration of the patient’s and family’s national origin, ethnic background, religious affiliation, spiritual beliefs, socioeconomic status, immigration history, degree of assimilation, healthcare practices and child-rearing methods. While it is a formidable task for any clinician to be versed in the specific beliefs of every cultural group, it is vital to have an understanding of the common problems, issues, symptoms and syndromes of the community in which one practices, while keeping in mind that this broad level of understanding might not be specifically applicable to any one patient. Therefore, the clinician must attempt to obtain case-specific information directly from patients and their families. Such an approach requires a healthy curiosity about the meaning of behaviors for each patient and family, without judging it as either normal or pathologic based solely on beliefs derived from the clinician’s cultural system or professional values. Allowing patients and their families to tell their life stories in their own words serves the clinician’s efforts to establish an

TAKING A CASE HISTORY While eliciting the clinical history, the clinician should proceed according to accepted professional standards, remaining mindful that there is important additional information that must be obtained from patients of other cultures. It should be remembered that the symptoms presented exist within a larger cultural context that must be addressed.

The family’s immigration history should be reviewed, and attempts should be made to understand the meanings of immigration to the family and the patient. Specific inquiries should seek to identify:

• • • • • • • • • •

Family members that immigrated. Family members that remained in the country of origin. The time frames and geographic course of the immigration. The motivations and reasons for immigration. Exposure to traumatic events related to the immigration. The potential legal and political effects of the immigration The personal significance of the immigration to the family. The socioeconomic effects of the immigration. The impact of immigration on quality of life. The effect of immigration on religious practices and beliefs.

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Intergenerational issues Discussions should be held to determine the degree to which different generations (i.e., parents and children) have assimilated and acculturated to the new setting. Awareness of the meanings of cultural heritage and traditions can be explored with the adolescent and the family. Information should be sought regarding the role of children in the family, the family’s child-rearing beliefs, and their disciplinary practices. Intergenerational family relations and gender roles in the extended family should be considered.

Community factors Potential sources of support or antagonism related to ethnic or national groups in the local community should be identified. The family’s experiences of discrimination due to race, culture, nationality, or class should be examined.

choice, then a bilingual mental health professional who is culturally sensitive should be brought in to assist. Cultural and linguistic differences that require the introduction of a third party into the doctor–patient relationship may affect the report provided by the patient. Monolingual practitioners are at a disadvantage when attempting to discern the difference between clinical translation and interpretation. In clinical translation, the verbal exchange is communicated as close as possible to verbatim, with little content added by the translator. On the other hand, interpreters take liberties to modify content in ways that seem to fit the situation. They may serve as culture brokers or advisors to the patient, without the clinician’s awareness of this role. Hidden agendas and biases can be introduced to contaminate the assessment process. These subtle dynamics can be impossible to detect and can be powerful enough to undermine the goals of the clinical encounter. Particular caution should be exercised when contemplating the use of family members as translators.

Clinical factors

Collateral contacts

It should be determined whether the family is seeking or receiving the services of folk healers or practitioners of traditional medicine from their native culture that may exert effects on the clinical work at hand. The clinician should speak with the patient and the family about their reactions to any cultural differences existing in the clinical encounter. An awareness should be maintained that such differences are likely to affect the doctor–patient relationship and subsequently the assessment and treatment process.

Additional sources of information should be sought through collateral contacts with agency workers, teachers, doctors or other professionals, including culturally rooted professionals such as traditional healers, clergy and spiritualists. Caution must be taken because those individuals without knowledge of a child’s culture, such as a child’s teacher, may misinterpret behaviors that they observe. Additionally, the clinician should maintain sensitivity to the possible negative cultural, legal and political effects of collateral contacts.

Language Diagnosing mental illness Another important factor associated with culturally diverse populations involves the challenges and barriers related to language. In families that have recently immigrated, children often learn English more quickly and effectively than their parents. They may be called upon to translate and conduct family business for parents. This places the child in a position of power, control and increased responsibility. Some children and families may have difficulty with this role reversal, leading the child to develop behavioral problems or other symptomatology which presents to the practitioner. Language is a fundamental component of the doctor– patient relationship, and ideally, the evaluating psychiatrist will speak the language in which the patient is most comfortable communicating. This will foster the building of trust and allow for a richer, more accurate account of the patient’s symptomatology. If the evaluating clinician is not fluent in the patient’s language of

Understanding the patient’s behavior in their cultural context is crucial in defining normal and abnormal behavior. Cultural norms are key reference points in the diagnostic process. There must be a mechanism to guard against the underdiagnosis of mental illness that occurs when cultural explanations are used to normalize behaviors. This requires culture-specific knowledge in many instances, and ideally, a clinician skilled in the assessment of adolescents from a particular cultural group can provide assistance when attempting to differentiate normative findings from the signs and symptoms of mental illness. Unfortunately, such a clinician may not be available. In such instances, other professionals, paraprofessionals, relatives and neighbors may be able to serve this purpose by helping to identify whether the behavior exhibited is culturally acceptable or appropriate.

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THE PSYCHIATRIC INTERVIEW A complex system of cultural factors affects the psychiatric examination. These factors must be identified and understood in order to arrive at accurate diagnoses and construct effective treatment plans. When approaching the clinical interview, great care must be used in evaluating the elicited symptoms. The clinician must possess knowledge of the patient’s individual cultural identifications and language abilities as they fit within the patient’s culture of origin. The clinician must explore the cultural explanation of the illness, including the cause, meaning and significance of the symptoms. Consideration should be given to the culturally normative style of conveying distress and the local illness category used to identify the symptoms (Kleinman 1995). Additionally, it is important to learn about previous treatment experiences the patient has had with traditional or nontraditional healers. Family norms and behaviors need to be defined. The family or the adolescent may distort or present symptoms in a manner that is acceptable to the family. This may be especially true if the adolescent’s culture emphasizes family loyalty. In such instances the patient might distort symptoms so that they will be seen in a way that is culturally acceptable to the family. Culture and cultural differences affect the doctor– patient relationship and must be monitored with a high level of awareness. Subtle shifts in the dynamics of this relationship can influence the quality and quantity of information elicited during the interview.

Case example An eighteen-year-old female was referred for an emergency evaluation after expressing suicidal thoughts and feelings. The patient, who was born in the Dominican Republic, remained close to her culture of origin. While articulate in English, she felt more comfortable expressing certain aspects of her experience in Spanish. With some surprise and comfort, the patient learned that the examiner also spoke Spanish. This had the effect of immediately decreasing the patient’s anxiety. During exploration of her suicidal ideation, the patient revealed that she heard voices. The psychiatrist probed gently and was respectful of the patient’s cultural explanation for the voices. She reported that they were the voices of two siblings who had died in infancy. Her culturally rooted belief was that her siblings were in heaven, and their spirits were sent to watch over her and protect her, a culturally syntonic feature of spiritism, which the child and family practiced. When the patient would feel suicidal or think about wanting to die, the voices of her siblings would come to her and tell her, ‘not to do it, you have a lot to live for, and everything will be

OK.’ The patient denied hearing any other voices at any other time. Upon direct inquiry about the cultural belief system, the patient replied, ‘I thought doctors didn’t want to talk about stuff like that.’ The patient appeared surprised and relieved that the interviewer demonstrated an interest, curiosity, and understanding of her experience. It was clear that she felt understood and valued. The patient denied all other symptoms which might be indicative of psychosis except the voices of her dead siblings, which occurred only during moments of active suicidal ideation. This symptom manifested in the broader cultural context with a culturally syntonic significance and was not interpreted as a symptom of psychosis. The final diagnosis was not a psychotic disorder.

ASSESSMENT INSTRUMENTS Numerous factors must be taken into account when considering whether a particular instrument is appropriate for use with a particular population. It is not sufficient to select a questionnaire or test that has been developed in one culture and simply administer it to individuals from another culture. The translation of standardized instruments to forms that can be used across cultural groups requires more than linguistic translation of the test items. A complex process must take place to adapt or develop an assessment instrument that yields reliable, valid data to make cross-cultural assessments and comparisons. Canino and Bravo (1994) have outlined five factors that are crucial to the adaptation of instruments developed in the United States that will be used in other countries or in immigrant/minority populations in the United States. Familiarity with these factors is essential in order to appropriately apply structured or semi-structured assessment tools in the evaluation of adolescents and young adults from other cultures. These five components address semantic, contextual, conceptual, technical, and criterion parameters. As an example, to ensure semantic relevance and equivalence in another culture and language, an instrument must be rigorously translated from English into the relevant language by one set of experts, then translated back into English by a different group of scholars to ensure accuracy of translation. The instrument must then be field tested in the alternative language and culture to ensure that semantic equivalence has been achieved. Kleinman (1995) has illustrated the necessity for ethnographic study and/or the participation of bicultural, bilingual mental health experts in order to attain equivalence in these parameters. The clinician must understand the process by which an instrument has been adapted and/or developed in order to determine whether it is appropriate for use in the evaluation of a particular patient.

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The Wechsler Intelligence Scale for Children, Revised (WISC-R) is an example of an instrument used to evaluate adolescents which has been adapted for use in another culture. While the WISC-R has been translated into Spanish and has been used often for Spanish-speaking teenagers from many parts of the Spanish-speaking world: it was translated and ‘normed’ in Puerto Rico, and therefore can only be considered reliable and valid when assessing Puerto Rican patients (Canino and Bravo 1994). Using the WISC-R in evaluating teenagers from other cultures and countries may introduce bias and skew the results. It is imperative that clinicians have an awareness of potential sources of bias in order to conduct testing which will yield reliable and valid data that enhance the development of a case formulation, diagnosis and treatment plan that accurately reflect the patient’s problem in a culturally relevant context.

According to DSM-IV, these syndromes are defined as ‘recurrent, locality-specific patterns of aberrant behavior and troubling experiences that may or may not be linked to a particular DSM-IV diagnostic category’ (American Psychiatric Association 1994). Most are thought to be signs of significant distress or illness within the culture itself and are denoted by names particular to that culture. The glossary in DSM-IV assists the clinician by pointing to similarities between DSM-IV diagnostic categories and culture-bound syndromes, when present. Although the descriptions of these syndromes is not specific to the assessment of adolescents, the glossary of culture-bound syndromes provides the clinician with useful descriptions to promote an understanding of the cultural elements in an adolescent’s presentation.

TREATMENT CONSIDERATIONS DIAGNOSTIC FORMULATION The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) (American Psychiatric Association 1994) addresses the notion that accounting for cultural issues is crucial to the diagnostic process. As such, in the introduction to DSM-IV, a section on ‘Ethnic and Cultural Considerations’ is mandatory reading if one is to use the DSM-IV in a culturally relevant and sensitive manner. Additionally, the text for each diagnostic category contains a section discussing cultural considerations, including a reminder of the importance of utilizing assessment tools which have been standardized on population samples representative of the patient. Further, Appendix I, the ‘Outline for Cultural Formulation and Glossary of Culture-Bound Syndromes,’ provides guidelines for the implementation of a cultural formulation to be used adjunctively with the standard five-axis diagnostic system. The cultural formulation includes of a description of how the patient’s culture affects diagnosis and treatment. The essential features of such formulations include ‘cultural identity of the individual, cultural explanations of the individual’s illness, cultural factors related to psychosocial environment and levels of functioning, cultural elements of the relationship between the individual and the clinician and overall cultural assessment for diagnosis and care’ (American Psychiatric Association 1994). The clinician should be aware of the existence of the culture-bound syndromes. Descriptions of culturebound syndromes can be found in Appendix I of DSMIV (American Psychiatric Association 1994), as well as the general cross-cultural literature, which contains rich and informative discussions of specific syndromes.

The clinician’s ability to understand the cultural context of patients’ lives is a critical component of successful work with diverse populations. Appreciating the patient’s self view gives the clinician an advantage toward intervening in a more relevant, appropriate and meaningful way (Ponce 1994). Cultural factors will influence how the patient will view treatment recommendations. For example, compliance is an issue with all patients, but side effects and dosage frequency are not the only influential factors in ethnically diverse patients. If a family’s culture believes that mental illness is the product of ancestral unrest or spirit possession, then recommendations for psychopharmacological management may be politely accepted in the office but ignored at home. This is not to suggest that Western treatments should not be recommended for an adolescent whose family embraces such traditional beliefs. However, inquiring about, acknowledging and even integrating the use of spiritual or traditional healers into the treatment will undoubtedly increase the therapeutic alliance with the child and family and possibly enhance compliance. Conversely, the possible negative effects on treatment compliance exerted by a patient’s or family’s simultaneous involvement with folk healers must be considered. Interventions for culturally diverse patients will contain all the elements of modern psychiatric treatment. Psychotherapy should be considered as a potential component of treatment for a culturally diverse adolescent just as for any other patient. The adult literature provides a cautionary tale, indicating that even African-American patients, as opposed to African patients who have recently immigrated to the United States, are often deemed poor candidates for psychotherapy and are immediately assigned to a psychopharmacologist (Geller 1988). When psychotherapy is employed as the treatment modality, cultural transference and countertransference

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issues must be constantly monitored and explored. Patients’ beliefs may be based on cultural, historical or personal prejudice, but if attempts are not made to understand and address these issues early, a futile cycle may begin that is frustrating to both patient and therapist (Norris and Spurlock 1992). The clinician must be aware that their own cultural, historical or personal biases can color psychotherapeutic processes and lead to therapeutic impasses. Again, when using psychotherapy as a treatment modality, the practitioner must proceed in an informed manner with a critical mind and an astute self-awareness. Few double-blind, placebo-controlled studies assessing interethnic psychopharmacologic variations have been carried out to guide medication use (Hudziak and Geller 1996). Caution must be taken when attempting to extrapolate the small amount of data in the literature to diverse adolescent populations (Zito et al. 1998; Lin et al. 1995). Until adequate research on ethnically diverse adolescents has been carried out, the general principles of adolescent psychopharmacology should be applied. As there are likely to be important inter-ethnic differences related to drug effects that have not been discovered, it is important to proceed carefully when prescribing to diverse cultural groups.

FUTURE DIRECTIONS Cultural factors significantly affect evaluation and treatment, and must be integrated into a clinician’s thinking about patients and their families. Knowledge of the ways in which culture influences diagnosis and treatment, though expanding, is still limited, creating numerous challenges for the future. Every clinician should learn to use the DSM-IV in its intended culturally informed manner. The clinician practicing in this increasingly mobile, multi-cultural world should gain knowledge about the ethnic and cultural groups represented in his community. Methods must be developed to apply this ethnic and cultural awareness to fit the patient’s cultural context. New standardized tests should be developed and existing tests broadened in their cultural applications to facilitate proper diagnosis and treatment planning. Service systems must be revamped to eliminate barriers to care for the culturally diverse. Multi-cultural staff members need to be recruited in every discipline to accurately represent the diversity of the population being served. Training efforts addressing the interaction of clinical and cultural issues need to be developed. And finally, research needs to be conducted to evaluate the effectiveness of these efforts. Perhaps, as these measures are placed into effect, a new standard of care will evolve to meet the needs of

the diverse cultural groups that will be encountered in clinical practice on a regular and frequent basis.

REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994. Canino, G., Bravo, M. The adaptation and testing of diagnostic and outcome measures for cross-cultural research. International Review of Psychiatry 6(4): 281–286, 1994. Geller, J.D. Racial bias in the evaluation of patients for psychotherapy. In Comas-Diaz, L., Griffith, E.H. (eds), Clinical Guidelines in Cross-cultural Mental Health. New York, NY: John Wiley & Sons, 1988, 112–134. Hudziak, J.J., Geller, B. Interethnic psychopharmacologic research in children and adolescents. Psychopharmacology Bulletin 32(2): 259–263, 1996. Kleinman, A. Do psychiatric disorders differ in different cultures? The methodological questions. In Goldberger, N.R., Veroff, J.B. (eds), The Culture and Psychology Reader. New York, NY: New York University Press, 1995, pp. 631–651. Lin, K.-M., Poland, R.E., Anderson, D. Psychopharmacology, ethnicity and culture. Transcultural Psychiatric Research Review 32(1): 3–40, 1995. Norris, D.M., Spurlock, J. Racial and cultural issues impacting on countertransference. In Brandell, J.R. (ed.), Countertransference in Psychotherapy with Children and Adolescents. Northvale, NJ: Jason Aronson, Inc., 1992, pp. 91–103. Ponce, D.E. Value orientation: clinical applications in a multi-cultural residential treatment center for children and youth. Residential Group Care and Treatment 2(4): 71–83, 1994. United States Government Department of Commerce. Bureau of the Census; 1990 Census of Population and Housing. Zito, J.M., Safer, D.J., dosReis, S., et al. Racial disparity in psychotropic medications prescribed for youths with medicaid insurance in Maryland. Journal of the American Academy of Child and Adolescent Psychiatry 37: 179–184, 1998.

Suggested reading Alarcon, R.D. (ed.) Cultural Psychiatry, Psychiatric Clinics of North America. Volume 18.3. Philadelphia: W.B. Saunders, 1995, pp. 433–679. American Psychiatric Association. Introductory remarks on Ethnic and Cultural Considerations (pp. xxiv–xxv) and Appendix I: Outline for Cultural Formulation and

242 Assessment of the adolescent Glossary of Culture Bound syndromes (pp. 843–849). In Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994. Canino, I., Spurlock, J. Culturally Diverse Children and Adolescents Assessment, Diagnosis and Treatment. New York: The Guilford Press, 1994. Gaw, A. (ed.) Culture, Ethnicity and Mental Illness. American Psychiatric Press, 1993. Caracci, G., Mezzich, J.E. Culture and urban mental health. Psychiatric Clinics of North America 24: 581–593, 2001. Doi, Y., Roberts, R.E., Takeuchi, K., Suzuki, S. Multiethnic comparison of adolescent major depression based on the DSM-IV criteria in a U.S.-Japan study. Journal of the American Academy of Child and Adolescent Psychiatry 40: 1308–1315, 2001. Griffith, E.E.H., Gonzalez, C.A. Essentials of cultural psychiatry. In Hales, R.E., Yudofsky, S.C. (eds), The American Psychiatric Press Synopsis of Psychiatry. Washington, DC: American Psychiatric Press, 1996, pp. 1283–1306.

Harper, G. Cultural influences on diagnosis. Child and Adolescent Psychiatric Clinics of North America 10: 711–728, 2001. McGoldrick, M., Giordano, J., Pierce, J. (eds) Ethnicity and Family Therapy, 2nd edition. New York: Guilford Press, 1996. Robbins, M.S., Kumar, S., Walker-Barnes, C., Feaster, D.J., Briones, E., Szapocznik, J. Ethnic differences in comorbidity among substance-abusing adolescents referred to outpatient therapy. Journal of the American Academy of Child and Adolescent Psychiatry 41: 394–401, 2002. Schwab-Stone, M., Ruchkin, V., Vermeiren, R., Leckman, P. Cultural considerations in the treatment of children and adolescents. Operationalizing the importance of culture in treatment. Child and Adolescent Psychiatric Clinics of North America 10: 729–743, 2001. Turner, R.J., Gil, A.G. Psychiatric and substance use disorders in South Florida: racial/ethnic and gender contrasts in a young adult cohort. Archives of General Psychiatry 59: 43–50, 2002.

4.8 Educational assessment EDWARD A. MAINZER

The perspective that equates education with schooling has been challenged both historically and philosophically (Cremin 1988). At the turn of the nineteenth century, John Dewey, the influential American educator, wrote that education begins almost at birth and continually shapes an individual’s ideas, habits, feelings and emotions (Dewey [1897] 1940). These ideas have found expression in recent trends that have extended assessment practices beyond the bounds of the classroom to include professionals from various disciplines to construct a contextual picture of an adolescent’s learning processes. This trend toward comprehensive interdisciplinary assessment practices has been complemented by the increasing use of portfolio assessments that have learners display samples of their work rather than relying upon standard paper-and-pencil tasks or multiple choice tests (Moss 1996). Approaches that extend beyond the classroom to include noneducators, such as family members, employers and clinical professionals, build upon the notion that learning must be evaluated as a process that occurs in the overall context of an individual’s life. Such approaches recognize that many settings can interact to affect learning, that multiple sources of data enhance the accuracy of assessment findings, and that developing adolescents are actively learning as they extend their interests, activities and learning processes beyond the home and school settings.

EDUCATIONAL TESTING Educational testing of adolescents occurs within schools and universities for admission and placement purposes, via state and national testing programs, and in clinical settings for diagnostic purposes. Various forms of tests are used in the classroom to assign grades or credits to

high school and college students. Many tests used at the classroom level for these purposes are constructed by teachers and are not norm-referenced or tested to assure their reliability or validity. Subject matter examinations may be linked to high school graduation requirements, and some understanding of local or state requirements for such graduation may be useful for practitioners who work with adolescent clients. Many public school students are given staterequired examinations to progress through elementary and secondary schools. The use of tests has also been promoted by the United State Department of Education (USDE) as a means to measure accountability, together with the development of state and national standards in subject matter areas (USDE 1986, 1991; Linn 1998; No Child Left Behind 2002). The use of testing for these purposes varies by state or locality, and the clinician is encouraged to keep informed of local practices by maintaining contact with school officials.

STANDARDIZED TESTS Standardized assessments can include multiple choice questions or essay assignments where specific grading criteria have been established. Standardized tests are commonly divided based upon their format as either individual or group-administered instruments. Tests may be norm-referenced or criterion-referenced. Norm-referenced tests present scores in comparison to a large sample of test scores. The validity of a normreferenced test for a particular population will depend upon whether that population was properly represented in the norming process. For example, separate norms may be available for a language minority group. Criterionreferenced tests are developed and standardized to measure achievement as reflected in content area mastery.

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Individually administered standardized tests For purposes of clinical diagnosis and certification for special education, individually administered instruments are preferred. The Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) diagnostic criteria for Reading Disorder and Mathematics Disorder both specifically require that ability in reading or mathematics be measured by individually administered standardized tests (American Psychiatric Association 1994). Most publishers of individual assessment instruments have customer qualification requirements for each test. These requirements often include a graduate degree in psychology or education with specific training in tests and measurement. Some states regulate testing by requiring a specific license, usually that of a psychologist, to administer certain instruments. Any practitioner administering a test or reviewing results for assessment purposes should be familiar with the strengths and limitations of the instrument being used. Tests administered should be appropriate for the test taker’s developmental level, gender, and cultural background. The test taker should understand the test format and testing procedures. The test taker should also be informed about how the results of the examination will be explained to them, their parents, or to professionals who make use of the information. Contamination of standardized test results can occur if the examinee was administered the identical instrument and remembers parts of questions or answers, or incorrectly believes that he or she previously took the examination and reduces or alters his efforts as a result. These issues should be reflected in the presentation of results if they are suspected to be present. Examples of commonly used individually administered standardized tests include:

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The Woodcock–Johnson Psychoeducational Battery (WJ-R). This is a norm-referenced set of tests designed to measure cognitive abilities, scholastic aptitudes, and achievement for individuals aged from two to ninety years. The WJ-R has been statistically analyzed for bias. Studies looking at bias based on gender and Hispanic origin of students at both elementary and secondary level found no statistically significant differences between the patterns of males and females or Hispanics and non-Hispanics (Cotten 1991; Hinton 1995). The Bateria Woodcock Psico-Educativa en Espanol, also by Woodcock, consists of seventeen subtests which cover content similar to the WJ-R, but in Spanish. The Kaufman Test of Educational Achievement (K-TEA). This is an individually administered battery for grades 1 to 12. It measures reading (decoding and comprehension), mathematics (applications and computations), and spelling skills. Although a brief form

•

•

•

may be completed in 30 minutes, the comprehensive form at the secondary level takes approximately 75 minutes. The full version offers norm-referenced scores and criterion-referenced analysis of student errors. Wide Range Achievement Test-3 (WRAT3). This measures reading, spelling, and arithmetic in a format intended for use with subjects aged five to seventy-five years. It requires only 15 to 30 minutes to administer, and less than 5 minutes to score. However, some authors have warned about problems with the validity and reliability of the WRAT (Mabry 1996). One study suggested that caution should be exercised when using the test to evaluate individuals with limited proficiency in English, while another on the use of the WRAT with Hispanic youth found that although some of its subtests were significantly related to socioeconomic and urban acculturation scales, overall the test was not discriminatory when used with either lower socioeconomic or minority group youth (Wilcox 1991; Rodriguez 1989). The Key Math. In Forms A and B, this is subtitled A Diagnostic Inventory of Essential Mathematics, and although intended for grades K-9 will sometimes be found in evaluations of learning disabled secondary school students. The Brigance Inventory of Essential Skills. This is designed for students in grades 4 to 12, and assesses twenty-six different content areas when used in full, including measures of both academic and applied skills. Its measures of functional academics at the secondary level may be particularly useful when assisting learning disabled clients.

Group-administered standardized tests Group-administered tests such as the California Achievement Test (CAT) or the Metropolitan Achievement Test (MAT) are designed so that a pre-selected set of sub-tests is administered by one person to a group of students. The CAT and the MAT are examples of group-administered, norm-referenced tests. These examinations usually include a variety of sub-tests such as reading, spelling, language, writing, study skills, science, and social studies. Results are scored by computer and the test’s publisher compares the results to those of norm groups. The specific relationships between raw scores, percentile scores or stanines obtained from particular assessment instruments should be understood if the test results are to have any meaning.

ALTERNATIVE ASSESSMENT Alternative assessment methods are also called authentic assessments or portfolio assessments. They seek to measure

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knowledge through the use of nonstandardized items such as work portfolios, student performances, and field observations. Authentic assessment emphasizes the need to examine the processes as well as the products of learning (Herman et al. 1992). Central tenets of authentic approaches include the notions that students are active learners, that learning involves more than a one-way transmission from teacher to student, that educators should be able to share material with noneducators, and that students specifically look beyond the classroom or school in considering the meaning of their work. Advocates of authentic assessment argue that traditional large-scale tests do not measure actual properties of learning experiences (Gitomer 1993) and may act as barriers to educational opportunity for minority groups. Others raise concerns that classroom-level changes in teaching and assessment methods to a more portfoliobased approach will not prepare students for the standardized tests used by most school districts and states for accountability purposes (Falk et al. 1996). Despite these concerns, the examination of actual work samples can be a valuable addition to the information provided by standardized testing when evaluating an individual client.

VOCATIONAL ASSESSMENT Vocational assessments focusing on school-to-work transitions and career interests and abilities may be particularly important for an adolescent needing a work placement as an educational alternative. Vocational assessments occur in a variety of settings, including high school guidance programs, college counseling centers, rehabilitation facilities, correctional settings and placement and retraining centers (Raskin 1987). A variety of techniques have been applied to vocational assessment approaches, including apprenticeship programs, on-site observation, interviews with supervisors, and completion of questionnaires. When conducting a vocational assessment, an individual’s vocational interests must be balanced by an assessment of their academic skills, technical skills, health status and personal background information that may influence their suitability for certain job positions. This information is often obtained in an interdisciplinary manner utilizing multiple sources of information. Instruments used to assess career and vocational interests include:

•

Strong Interest Inventory. This can be used with individuals in grade 7 through adulthood to assess how interests on over three hundred items compare with individuals already working in a wide range of occupational areas. This inventory is computer-scored, and has a good research base. It now uses a single form for both males and females.

•

• •

Kuder Interest Inventories. This is another popular interest inventory with versions designed for both grades 6 to 12 and adults; the results portray an individual’s occupational interests relative to one another, but not as absolute values. Self-Directed Search (SDS). This is a self-administered interest inventory available in both printed and computer-based formats that can be used with individuals aged twelve years and above. Armed Services Vocational Aptitude Battery (ASVAB). This is a group assessment that considers aptitudes, rather than interests. Originally designed to classify and assign enlisted personnel, a version designed for high school students is mass-administered in some school districts.

SPECIAL EDUCATION One of the important contexts within which the educational assessment of American adolescents occurs is special education. States and localities varied widely in their determination of to whom and how to provide educational services to individuals with disabilities prior to 1975, when the landmark federal Public Law 94-142 (Education of all Handicapped Children Act) for the first time mandated that all school-age children receive a free and appropriate public education in the least restrictive environment. A number of assessment-related mandates first put forth in Public Law 94-142 have continued to evolve with time. One of these is that each child receiving special education services have an Individualized Education Program (IEP). The IEP is a document defining the unique needs of and services to be granted to a specific student and must be reviewed, and as necessary revised, at least once per year, with the participation of, among others, the student and his or her parents. As updated by 1997 Amendments to what is now known as the Individuals with Disabilities Education Act (IDEA), federal law requires that the IEP include the results of assessments of the student’s present levels of educational performance, measurable annual goals, any individual modifications that the learner may require in the administration of both district and State assessments, and the means by which the student’s progress toward the annual goals will be measured. Although the IEP as such is only applicable to students until such time as they earn a State-approved diploma or the end of the school year in which they turn twenty-one (whichever comes first), an IEP from a high school may be used as evidence of a disability by a student requesting modifications for work at the college-level (where the IDEA also applies) (Küpper 1997). Another piece of federal legislation with significance for practitioners assisting clients with special needs is

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Section 504 of the Rehabilitation Act of 1973 as amended (Section 504). Covering healthcare, housing, social services, and parks and recreation in addition to education, Section 504 defines a ‘handicapped individual,’ and states their right to free and appropriate educational services. Regarding assessment, the implementing regulations for Section 504 specify that only validated tests should be used, that tests other than IQ tests must be considered, and that the tests must accommodate any sensory, manual, or speaking challenges of the test taker. The regulations are applicable to both public and private programs receiving federal funding, and within education include not only public schools, but also colleges and other postsecondary institutions.

their abilities and their academic performance are often influenced by assessment results (Hamachek 1995). Adolescents’ identities and self-esteem are deeply affected by their experiences with educational assessments and contacts with the educational system. Findings from educational assessments might have considerable developmental, cultural and social significance for the adolescent which extend beyond the issues of school placement, academic achievement, vocational choice, college admission and scholarships. To improve an adolescent’s chances for the best possible outcome under such circumstances, assessment methods must be selected and administered with skill, results reviewed and interpreted with care and recommendations presented with a sensitivity to the unique needs of each individual.

EDUCATORS AS RESOURCES REFERENCES When evaluating clients who are (or who have recently been) enrolled in educational programs, the teachers, school administrators, and guidance counselors may all be valuable sources of information. Many clinics and schools have report forms that provide opportunities for clinically useful social and behavioral as well as academic feedback, and some clinics routinely request a parental release to obtain such information (and share relevant information with school officials) when screening clients under the age of eighteen years. In addition, there is a variety of published instruments that school personnel may be requested to complete. The Teacher and Parent ratings scales of Keith Conners are commonly used to provide clinical feedback when considering a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD), which is at times most apparent and problematic in a child’s school setting. Versions are available to evaluate clients through high school. The Behavior Assessment System for Children (BASC) is a more broad-based inquiry also intended for children through high school age, and also including a teacher component. Other tools assess behavioral strengths and weaknesses and may be completed based on the input of school personnel. Although the Vineland Adaptive Behavior Scales, which exist in versions for both those aged under eighteen years and low-functioning adults, are usually administered to parents, the Adaptive Behavior Inventory, normed for those aged eighteen years and under, is specifically designed to be completed by teachers.

PRESENTING FINDINGS AND MAKING RECOMMENDATIONS Practitioners involved in the educational assessment of adolescents should remember that students’ attitudes to

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition. Washington, DC: American Psychiatric Association, 1994. Cotten, M.A. Gender Differences on the Woodcock–Johnson Revised Tests of Cognitive Abilities and Tests of Achievement. Texas Woman’s University PhD Thesis, UMI Abstract, 1991. Cremin, L.A. American Education, The Metropolitan Experience, 1876–1980. New York: Harper & Row, 1988. Dewey, J. Education Today. New York: Putnam’s Sons, 1940. Falk, B., Pecheone, R., Darling-Hammond, L. Issues in Designing a Learner-Centered Assessment System in New York State. Paper presented at the annual meeting of the American Educational Research Association, New York, NY, April, 1996. ERIC #ED401289. Gitomer, D.H. Performance assessment and educational measurement. In Bennett, R.E., Ward, W.C. (eds), Construction versus Choice in Cognitive Measurement: Issues in Constructed Response, Performance Testing, and Portfolio Assessment. Hillsdale, NJ: Lawrence Erlbaum Associates, Publishers, 1993, pp. 241–263. Hamachek, D. Self-concept and school achievement: interaction dynamics and a tool for assessing the self-concept component. Journal of Counseling and Development 73: 419–425, 1995. Herman, J.L., Aschbacher, P.R., Winters, L. A Practical Guide to Alternative Assessment. Alexandria, VA: Association for Supervision and Curriculum Development, 1992. Hinton, C.E. Cognitive Performance Pattern Underlying WJ-R Test Performance of Hispanic Children. University of Arizona PhD Thesis, UMI Abstract, 1995. Küpper, L. The Individuals with Disabilities Education Act Amendments of 1997: A Curriculum. Washington, DC: National Information Center for Children and Youth with Disabilities, 1997.

Educational assessment 247 Linn, R.L. Assessments and Accountability: CSE Technical Report 490. Los Angeles, CA: Center for the Study of Evaluation, 1998. Mabry, L. WRAT-3. In Conoley, J.C., Impara, J.C. (eds), Supplement to the Twelfth Mental Measurement Yearbook. Lincoln, Nebraska: Buros Institute of Mental Measurement/University of Nebraska Press, 1996, pp. 1108–1110. Moss, P.A. Enlarging the dialogue in educational measurement: voices from interpretive research traditions. Educational Researcher 25: 20–28, 43, 1996. No Child Left Behind: What Will It Take? Washington, DC: Thomas B. Fordham Foundation, 2002. Raskin, P.M. Vocational Counseling: A Guide for the Practitioner. New York: Teachers College, Columbia University, 1987. Rodriguez, R.F. The Effect of Sociocultural Factors on the Achievement of Minority Children in Education and the Changing Rural Community. Proceedings of the 1989 American Council on Rural Special Education/National Rural and Small Schools Consortium. United States Department of Education. What Works, Research About Teaching And Learning. Washington, DC: U.S. Department of Education, 1986. United States Department of Education. America 2000, An Educational Strategy Sourcebook. Washington, DC: U.S. Department of Education, 1991. Wilcox, W.B. The Predictive Validity of the Wide Range Achievement Test and Achievement Scores of ESOL Adults. University of Kansas Master’s project. ERIC Abstract, 1991.

Suggested reading Anastasi, A., Urbina, S. Psychological Testing, 7th edition. Upper Saddle River, NJ: Prentice Hall, 1997. Herman, J.L., Aschbacher, P.R., Winters, L. A Practical Guide to Alternative Assessment. Alexandria, VA: Association for Supervision and Curriculum Development, 1992. Murphy, L.L., Plake, B.S., Impara, J.C., Spies, R.A. (eds) Tests in Print VI. Lincoln, Nebraska: Buros Institute of Mental Measurement/University of Nebraska Press, 2002. (Two volumes.) Nettles, M.T., Nettles, A.L. (eds) Equity and Excellence in Educational Testing and Assessment. Boston, MA: Kluwer Academic Publishers, 1995. North Central Regional Education Laboratory. What Does Research Say About Assessment? Oak Brook, IL: NCREL, 1994.

Overton, T. Assessment. In Special Education, An Applied Approach, 2nd edition. Upper Saddle River, NJ: Merrill, 1996. Plake, B.S., Imparo, J.C., Spies, R.A. (eds) The Fifteenth Mental Measurement Yearbook. Lincoln, Nebraska: Buros Institute of Mental Measurement/University of Nebraska Press, 2003. Rudner, L.M., Schafer, W.D. (eds) What Teachers Need to Know About Assessment. Washington, DC: National Education Association, 2002. Salvia, J., Ysseldyke, J.E. Assessment, 8th edition. Boston, MA: Houghton, Mifflin, 2001. Sattler, J.M. Assessment of Children, 3rd edition. San Diego: J.M. Sattler, Publisher, 1992. Taylor, R.L. Assessment of Exceptional Students, Educational and Psychological Procedures, 6th edition. Boston: Allyn and Bacon, 2003. Wiggins, G.P. Assessing Student Performance, Exploring the Purpose and Limits of Testing. San Francisco, CA: Jossey-Bass Publishers, 1999.

Additional resources The Buros Institute of Mental Measurements and the University of Nebraska publish Mental Measurement Yearbooks (MMYB), in print, CD-ROM and on-line formats (see http://www.unl.edu/buros/). They include fulllength reviews and publisher information for tests that are either new or significantly revised since the previous, non-annual MMYB. Tests may be accessed by title, author, publisher or subject. Buros also publishes Tests in Print (TIP), which features brief entries for all tests currently available in English including test purpose, publisher, and citations for published reviews (but not the reviews themselves). TIP indexes MMYB. The Education Resource Information Center (ERIC) is a clearinghouse on assessment and evaluation which, together with the Buros Institute, Pro-Ed Publishers, and Educational Testing Service (ETS), operates a test locator service on-line at the ERIC/AE web site:http://ericae.net/ testcol.htm. From the site, separate searches can be done on an ETS database containing summaries of over 10 000 tests and research instruments, citations of reviews from Buros directories, and a Buros/ERIC test publisher directory of over 900 commercial test publishers. Direct links are also provided to the ETS and Buros web sites.

4.9 Assessment and treatment planning GLENN S. HIRSCH AND RICHARD GALLAGHER

INTRODUCTION The development of comprehensive treatment plans through structured treatment planning activities is a relatively new practice in the field of psychiatry. Modern treatment planning is informed by the range of available treatments and the results of research on the efficacy of those treatments. Contemporary treatment planners are faced with many decisions when selecting from the wide range of current therapies, the multiple levels of care and the diverse settings for service delivery available to them. Ultimately, all treatment planning choices should address the findings generated by the comprehensive assessment of the adolescent. During the past decade, treatment planning and clinical practice have been influenced increasingly by the growth of insurance companies and managed care organizations that pay for services. Systematic treatment planning and the detailed documentation of treatment plans have been mandated in many more settings because of these fiscal influences. Guidelines previously established by institutions to meet the standards of organizations such as the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and state offices of mental health have become applicable to private practice settings as accountability for treatment decisions has grown in all sectors. Trends in treatment planning have also been shaped by the various treatment planning resources in computer software and printed manual formats that have been released into the marketplace to guide the treatment planning practices of clinicians working in a rapidly changing healthcare system. This chapter will help clinicians move through the process of treatment planning, beginning with assessment findings and moving, step by step, through the development of a written treatment plan that is

presented to the adolescent patient and his or her parents.

GENERAL PRINCIPLES The treatment plan forms the framework that allows the clinician to monitor and reassess the progress or lack of progress of treatment and, when necessary, make changes in treatment or in the goals of treatment. Many formats for treatment planning have been proposed. These include the one-sentence format described as answering the query: ‘who is going to do what, how often and for how long, to whom, for what problems, with what desired outcome by what date, and when are we going to check on how it is going?’ (Zuckerman 1997). Although this might be an elegant summary of the components needed in a treatment plan, a more elaborate approach is recommended.

BASIC ORGANIZATION OF THE TREATMENT PLAN The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association 1994) and its multi-axial system for diagnosis is an excellent framework for the development of a treatment plan. The multi-axial format allows for transforming diagnoses and psychosocial stressors into concrete problems that are the focus of treatment efforts. The problem-oriented record is recommended as an organizing template for treatment plans. This approach is widely used in medicine and focuses care on a problem, the goal for alleviating that problem, and the interventions intended to alleviate the problem by a specified date (Weed 1969).

Assessment and treatment planning 249

STEPS IN CONSTRUCTION OF THE TREATMENT PLAN The full development of the treatment plan follows a logical sequence of four steps that systematically includes all the elements necessary to document a comprehensive treatment plan based on the assessment findings in a case.

Step 1: Craft the diagnostic formulation The case formulation is a descriptive summary of the adolescent’s condition, including problems and strengths, arranged using all five DSM-IV axes in their broadest sense. The case formulation should discuss the dynamic interaction of the different diagnostic problems and assets with one another in a way that elaborates on the simple listing provided in the five-axis diagnosis. For example, an adolescent with a history of a reading disorder (Axis I) may have developed secondary dysthymic disorder (Axis I) and social anxiety (Axis I) in school after years of failure. Family circumstances (Axis IV) of a parental divorce two years ago could have contributed to the adolescent’s depressed mood. A moderate case of persistent acne (Axis III) may have aggravated the social phobia. Axis V is used to summarize the functional status of the youth after the interaction and effects of all factors are considered. The case formulation should also incorporate statements indicating hypothesized sources of the problems found. For example, if an adolescent has bipolar disorder and a review of their family history finds that several members of the extended family suffer with the same disorder, a formulation can be made that genetic factors may play a heightened role in the emergence of the disorder. The formulation should be constructed on each DSM-IV Axis in the following way.

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•

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Axis I: This part of the case formulation should incorporate the psychiatric symptoms and developmental disorders uncovered, as well as summarizing psychological or developmental strengths. For example, these strengths may include good tolerance of anxiety, optimism about the long-term future, and special areas of academic expertise. Axis II: Personality traits that may be problematic should be discussed, but also enduring behavior patterns that reflect positive qualities should also be considered. Special characteristics of the adolescent, such as assertiveness, psychological mindedness and high intelligence, should be noted. Mental retardation and associated adaptive impairments are also recorded on Axis II. Axis III: Physical health and medical conditions are considered here. The formulation also includes physical assets. Factors such as attractive appearance, good

•

health, and athletic participation may place a troubled adolescent at an advantage in comparison to another young person with the same problems who is not in good health and is unattractive. Risks to health such as the use of substances that is subclinical, cigarette smoking and sexual activity should be reviewed in this section. A special review of the adolescent’s knowledge regarding the impact of substances and sexually transmitted diseases on their health should be taken. Also, how that knowledge affects the behaviors of the adolescent should be discussed. Axis IV: A series of psychosocial factors should be considered as the Axis IV component of the formulation is written. Sources of stress and support within the family are of high priority. The parents’ behavior, physical condition and mental health should be considered. Economic resources of the family are evaluated. Relationships with siblings and extended family members are assessed. The participation in social relationships and the characteristics of the peer group are surveyed. The adolescent’s experience in school should be reviewed and the resources that are available in school should be identified. The extent of involvement in nonacademic clubs or activities is reviewed. Work experience or any special vocational activity outside of school is evaluated. All of these areas of activity should be reviewed for the amount of time that an adolescent devotes to them. Involvement with the legal system should be explored. Petitions for legal supervision by parents, custody battles, and involvement with the juvenile justice system can exert significant effects on the adolescent and their family. An adolescent’s strengths should be emphasized prominently in the diagnostic formulation. A careful review of the assets present will highlight personal qualities, developmental skills, and environmental resources that can be utilized in treatment to help an adolescent cope with the presenting problems. As reimbursement practices limit the use of psychotherapy and psychopharmacological efforts, the psychosocial strengths and resources noted can be used to help achieve therapeutic goals with nonclinical resources. For example, knowing that an adolescent’s school has effective guidance services may allow therapy to be conducted once a week while the counselor at school provides on-site support for crises, rather than requiring that the adolescent engage in therapy twice a week. The interactions of risks and assets may also be considered in the formulation. For example, an adolescent who experienced a recent break-up of a romantic relationship manifested symptoms of a mood disturbance and was considered to be at risk for the development of a reactive depression. However, a

250 Assessment of the adolescent

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review of personal strengths revealed a high level of insight and intelligence that enabled them to appreciate this risk for depression and the potential role of psychotherapy in reducing those risks. This adolescent was motivated to participate in treatment and responded well to a course of cognitive therapy. Axis V: The global assessment of functioning (GAF) score has been designed as a global measure of overall functioning. It is useful to score a youngster’s functioning in all domains. This provides an estimate of baseline functioning to use while monitoring the child’s progress. Although this axis tends to be underutilized, it can provide a very useful baseline measure and enable the practitioner to track global progress. However, owing to the way the scale is constructed, practitioners may overestimate or underestimate the GAF. To avoid this pitfall, it is useful to have the Axis V criteria available for review when assigning a rating.

Step 2: Construct the problem list A list of problems is constructed that follows from the formulation and the diagnostic review. The problems are stated in operational terms that describe the functional impact of case-specific findings on the everyday life of the adolescent and his family. A list of psychiatric and psychological problems is presented and any specific developmental concerns are listed to correspond with Axis I findings. For Axis II, any problems associated with enduring personality characteristics are specified. Health problems or the consequences of health problems are listed with Axis III. Potential psychosocial problems are reviewed on Axis IV. Areas of concern should be designated as problems on Axis IV if they are perceived to exert a detrimental effect on the adolescent’s condition. The problem list is not limited to problems that will be the focus of the treating clinician’s actions, but other problems that may be the concern of other people should also be listed. Several quality control agencies require that the clinician remain aware of problems in all areas of life. Such requirements are helpful because they allow for a comprehensive understanding of the adolescent’s life. Problems from each axis are spelled out in a numerical list ranked according to the severity of impact each problem exerts on the patient’s functioning. Once the problem list is constructed, the next step requires a review of the problems to determine which will be addressed in the treatment plan. A psychiatrist’s clinical efforts will focus mainly on the problems corresponding to DSM-IV Axes I and II. Identified problems that will be addressed by other agents or agencies for the youth’s benefit should also be listed. A check is placed next to those problems that will be treated by the clinician.

Step 3: Specify the goals and objectives Once the problems to be addressed have been selected, treatment goals are formulated. Goals are the long-term outcomes at which treatment is aiming. They are broadly stated, long-term, and optimistic. For example, the goal for the problems associated with depression could be attainment of a neutral mood, appropriate emotional reactions to events and a positive plan for the future. Objectives are the concrete steps that will be taken to reach a particular goal within a time period. For depression, three concrete objectives might include: 1 A clinician obtaining laboratory results by a specified date prior to prescribing medication. 2 A patient’s demonstration, within a specified time period, of adherence to prescribed antidepressant medication. 3 A patient’s demonstration, within a specified time frame, of the ability to identify and list cognitive distortions that contribute to his or her depressed mood. The treatment goals and their related objectives are constructed by reviewing Axes I through IV in the case formulation. The problems associated with Axis I that will be addressed should each have a treatment goal specified. Objective steps to be taken to reach each goal will then be spelled out. Next, problems on Axis II are reviewed and goals with associated objectives are delineated. Problems for Axis III and the many components of Axis IV are then addressed in turn. The completion of this step in treatment planning produces a list of coherent goals and objectives that is consistent with the comprehensive case formulation. Two points about objectives should be observed. First, they should be written in observable terms: any reasonable person reviewing the case should be able to tell if an objective has been reached. Second, the person or persons responsible for attaining the objective must be identified. The treatment of adolescents is team treatment that involves the adolescent, their family, and the practitioner. There may be objectives that are patient centered, some that are family centered, and others that involve the community or school. Finally, there are objectives that need to be carried out by and which are the responsibility of the mental health practitioner writing the plan or providing treatment. Although we stress that several people can be involved in meeting objectives, it should be noted that some regulatory agencies are strongly recommending that all objectives be client centered; that is, the objective should be written in the form: ‘the client will … ’. We believe that this approach is too restrictive.

Step 4: Delineating indicated treatments The treatments and interventions that will be used to achieve the listed goals and objectives must be spelled

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out. Broad categories of treatment method include forms of psychotherapy such as individual, family, or group approaches. Psychopharmacotherapy, and somatic therapies such as electroshock therapy, are included when indicated. Additionally, environmental therapies and interventions in coordination with school and community agencies should be listed. These may include after-school programs, socialization activities or groups, exercise programs, job experiences and school counseling which the practitioner may help to organize while encouraging the adolescent to participate. Within the broad categories, specific forms of treatment are delineated. The specification should include type of treatment (e.g., interpersonal psychotherapy, cognitive therapy, relaxation training, specific medication and dose), frequency of contact, length of expected contact, and the person or agency responsible for conducting that form of treatment. A specified date for a review of treatment should also be stated. Some regulatory agencies require a 90-day review after the initial treatment plan. Shorter review periods are appropriate especially for inpatient or day hospital programs and time-limited situations.

PRESENTATION OF THE TREATMENT PLAN The assessment and planning phase of care moves into treatment when the treatment plan is presented. Treatment can succeed or fail based upon decisions made about how and to whom the treatment plan is initially presented. It must be remembered that although the practitioner works with the adolescent and family as a team, the practitioner brings special expertise and knowledge to the table. This expertise drives the treatment and presentation of the plan. The practitioner develops rapport and uses reasonable negotiation skills to provide factual information, advice, and recommendations about the illness, treatment options and their likely success, and the prognosis with and without treatment. The patient and family must come away from the meeting with an understanding of how conclusions were reached and how the recommendations flow from the assessment findings. Most successful therapists share the logical steps and thinking with the adolescent and the parents so that the plan is clear. The timing and orchestration of feedback on the treatment plan are essential elements for success when working with teenage patients. Many situations enter into decisions about feedback. If an adolescent has sought treatment independent of their parents, and this is allowed under state regulations, then the adolescent is presented with the plan for consideration. However, in most cases both the adolescent and the parents are involved and decisions have to be made about who should consider the treatment ideas and in what order. In cases in

which the adolescent suffers from a severe disorder in which judgment and impulse control are impaired, it is probably best to involve parents first and then describe the plan to the adolescent. In other cases, the presentation depends on many factors. With cooperative patients and families, a presentation to all parties is probably warranted. In this ideal situation, the parents and the youngster can enter into a dialogue, ask appropriate questions, and discuss the parts of the plan that are acceptable and feasible. Many families come with resistant youngsters. These youngsters are not only resistant to the idea of treatment, but also resistant to any consideration that there is a problem at all. Although some practitioners intending to form an alliance with these youngsters meet with the patient alone first, our experience is that this does not work. It has been our experience that parents need to support most treatment plans in order for them to be successful. In these cases, it is necessary to form and maintain an alliance with the parents at this stage. We recommend the presentation of ideas to the parents first when such circumstances exist. A presentation to the adolescent may then be made to see if the youth will be engaged in the process. If the adolescent refuses, treatment planning may shift initially to parent counseling and support. Of course, meeting to engage the parents in the treatment process does not mean that all matters that the adolescent discusses with the clinician must be revealed to the parents. The confidentiality limitations that will be observed are defined using good clinical judgment applied to the specifics of each case.

CASE EXAMPLE Background Melanie is a fifteen-year-old girl with an eighteen-month history of being increasingly withdrawn from her peers and at home, marked irritability at home, and a drop in grades from ‘A’s to ‘C’s. She has been in individual therapy with a counselor at the school but she has not really ‘opened up.’ A gifted athlete, she has been participating, but has not shown much energy or enthusiasm this season. There had been a question of substance use by one of the teachers. The referral for evaluation came from the school as well as from the girl’s pediatrician, who wonders whether she is manifesting signs and symptoms of schizophrenia.

Diagnostic formulation

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Axis I: Melanie is a girl with depressive symptoms and anxiety symptoms. She is an extremely shy youngster who is easily embarrassed and meets all the criteria for social phobia. In addition, she meets the diagnostic

252 Assessment of the adolescent

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criteria for dysthymic disorder. However, during the assessment, she and her parents were unable to clarify the length of time or frequency of depressive symptoms, so the diagnosis of a mood disorder was made provisionally. Melanie has experienced recent interpersonal losses that have contributed to a worsening of her symptoms. Her current symptoms of social withdrawal and decreased concentration have impaired her ability to access her existing relationships with friends and teachers to help her recover. She does not meet diagnostic criteria for major depressive disorder, and there is no evidence of any psychotic symptoms that would be suggestive of schizophrenia. There is no evidence of substance abuse and the patient willingly submitted to two urine toxicology screens that were negative. Although she had a recent drop in grades, there is no evidence of a specific learning disability. Axis II: No problematic personality traits were found. The strengths exhibited by this young woman include a good sense of humor, an insightful understanding of her situation, and high intelligence. Her typical method for dealing with stress was temporary avoidance followed by advice-seeking from her parents. Although she has not been able to open up in therapy, she has cognitive capacity and the motivation to benefit from psychotherapeutic approaches. Axis III: Physically, Melanie has reached puberty and is in good health. She has not engaged in sexual relations and she does not use drugs. Axis IV: The stressors present in this case included the presence of an eleven-year-old sister with severe asthma who required frequent emergency room visits, and her maternal grandmother died six months ago after a long illness with breast cancer. A close childhood friend had recently moved to a distant city. Although her parents are interested in helping her, they are also under significant emotional and physical strain related to the grandmother’s death and the demands of the sister’s active medical needs. Melanie has grown more irritable with her parents over her perception that they have not been available to meet her needs at this time. Despite these factors, Melanie’s relationship with her parents is reasonably good and they are invested in her care. Melanie also graduated to the regional high school in the fall. Melanie was an athlete who, prior to the present illness, had engaged in two sports. Additionally, through her writing, she has gained the interest of a teacher who would often inquire into her adjustment and thoughts. Her family has financial assets that could support comprehensive care. Axis V: Overall, her GAF is estimated to be 45. Melanie is noted to have major impairments in social and academic functioning.

Problem list

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Axis I (psychiatric and psychological): 1 Mood disturbance 2 Social withdrawal 3 Decreased school performance Axis II (enduring traits or behaviors): No problems noted Axis III: (physical status): 1 Lowered energy 2 Sleep disturbance 3 No medical concerns Axis IV (psychosocial stressors): 1 Limited contact with parents because of sister’s illness 2 Limited social contact because of friend’s move 3 Limited success in school despite effort

Goals and objectives PROBLEM 1. MOOD DISTURBANCE

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Goal 1. Melanie will attain an improved mood. Objective 1: Melanie will report a decreased level of dysphoria as measured by statements in response to questions and the Beck Depression Inventory scores. (Time frame: 4 weeks.) Objective 2: Melanie’s parents will report that they observe less irritability during her interactions with them. (Time frame: 4 weeks.)

PROBLEM 2. SOCIAL WITHDRAWAL

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Goal 1. Melanie will increase her social contacts and social activity. Objective 1: Melanie will report that she participated in two phone conversations per week with classmates. (Time frame: 2 weeks.) Objective 2: Melanie will report that she ate lunch in a group setting on at least three out of five school days. (Time frame: 2 weeks.) Objective 3: Melanie will be observed by her therapist to be more comfortable and interactive in sessions. (Time frame: 3 weeks.)

PROBLEM 3. DECREASED SCHOOL PERFORMANCE

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Goal 1. Melanie will improve her school performance. Objective 1: Melanie will report timely homework completion three of five nights per week. (Time frame: 2 weeks.) Objective 2: Melanie will report an average increase of ten points on each test she takes. (Time frame: 4 weeks.) Objective 3: Melanie will report seeking help from teachers in subjects that she does not understand. (Time frame: 1 week.)

Assessment and treatment planning 253

Indicated treatments 1 Individual psychotherapy to address mood disturbance and social anxiety. (Provided by R.G., PhD. Frequency: twice weekly; initial duration of treatment 10 weeks.) 2 Family contacts to increase support and help the family deal with recent and chronic stressors. (Provided by L.K., Li.C.S.W. Frequency: twice monthly; initial duration of treatment 12 weeks.) 3 Tutoring at school to build her academic knowledge in subjects with which she has been struggling because of the intellectual effects of depression. (Provided by school-based tutor. Frequency: twiceweekly, initial duration of service three months or until improvement is noted.) 4 Pharmacotherapy to be considered if major improvement in mood and anxiety level was not seen in six weeks. (Provider and medication details to be specified when indicated.)

Presentation of findings and recommendations This plan was presented with Melanie and her parents together in a conference because of their cooperative nature and reasonable relationships with one another. In addition, a written report detailing the findings and recommendations was provided to the family.

THE TREATMENT PLAN IN PATIENT CARE

with limited success is not advised. We recommend a careful review every few weeks for practical purposes. Some regulatory agencies and third-party payers often require a written review ranging from every fifth contact to every 90 days after the initial treatment plan. Shorter review periods are appropriate especially for inpatient or day hospital programs. It is best to err on the side of more frequent reviews to make certain that treatment is fresh and effective.

CONCLUSION This chapter outlines a framework for constructing practical treatment plans. This format has been used successfully in inpatient, day program, and outpatient settings. It is suggested that the practitioner use this approach or similar approaches that are designed for their specific practice settings. Effective treatment planning is the backbone of patient care. It helps to clarify assessment findings and diagnostic issues. It allows practitioners to be creative in considering treatments and interventions. Treatment plans provides guideposts for treatment provision and revision when the defined goals are not being met. And the act of treatment planning is an important opportunity to establish an effective alliance with the adolescent and her family early in the clinical encounter by including them in the process of organizing a systematic and comprehensive approach to assessment, diagnosis and intervention uniquely designed for their benefit.

REFERENCES

Progress notes It is best to integrate the treatment plan with treatment documentation. The problem-oriented record is based on the concept that specified problems become the focus of record keeping. Session notes should document the problems under treatment for that contact and what progress has been achieved in completing the objectives for that problem. A series of problems may be addressed in any contact or the contact may be limited to one problem at a time. In any event, the progress notes should be linked to the treatment plan for the most effective care.

Reassessing and revising treatment Evaluation of the treatment plan is an ongoing process. If the practitioner does not see expected progress based on the defined objectives and time frames, then revisions in the treatment plan might be indicated. Of course, changes in the plan should not be made impulsively, but adherence to a fixed plan over an extended period of time

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association, 2000. Weed, L.L. Medical records, medical evaluation, and patient care. Cleveland: Case Western Reserve University Press, 1969. Zuckerman, E.L. The Paper Office, 2nd edition. New York: Guilford Press, 1997.

Suggested reading Casat, C., Pearson, D. The mental status exam in child and adolescent evaluation. In Booney, V.H., Pumariega, A. (eds), Clinical Assessment of Child and Adolescent Behavior. New York, NY: John Wiley & Sons, Inc., 2001, pp. 86–97. Fonagy, P. Outcome measurement in children and adolescents. In Is Hak, W.W., Burt, T., et al. (eds), Outcome Measurement in Psychiatry: A Critical Review.

254 Assessment of the adolescent Washington, DC: American Psychiatric Publishing, Inc., 2002, pp. 59–75. Hoffmann, F., Leckman, E., Russo, N., Knauf, L. In it for the long haul: the integration of outcomes assessment, clinical services, and management decision-making. Evaluation and Program Planning 22: 211–219, 1999. Jensen, P., Rubio-Stipec, M., Canino, G., Bird, H., Dulcan, M., Schwab-Stone, M., Lahey, B. Parent and child contributions to diagnosis of mental disorder: are both informants always necessary? Journal of the American Academy of Child and Adolescent Psychiatry 38: 1569–1579, 1999. Jongsma, A.E., Peterson, L.M., McInnis, W. The Child and Adolescent Treatment Planner. New York: Wiley, 1996. Lazarus, J.A., Sharfstein, S.S. (eds) New Roles for Psychiatrists in Organized Systems of Care. Washington, DC: American Psychiatric Press, 1998. Looney, J.G. Treatment planning in child psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry 23: 529–536, 1984.

Nurcombe, B., Fitzhenry-Coor, I. Diagnostic reasoning and treatment planning: I. Diagnosis. Australian and New Zealand Journal of Psychiatry 21: 477–483, 1987. Nurcombe, B. Diagnostic reasoning and treatment planning: II. Treatment. Australian and New Zealand Journal of Psychiatry 21: 483–490, 1987. Nurcombe, B. Diagnostic reasoning and treatment planning: III. A case example. Australian and New Zealand Journal of Psychiatry 21: 490–499, 1987. Parsons, P.J. Building better treatment plans. Journal of Psychosocial Nursing 24: 9–14, 1986. Robbins, J., Taylor, J., Rost, K., Burns, B., Phillips, S., Burnam, M., Smith, G.R. Measuring outcomes of care for adolescents with emotional and behavioral problems. Journal of the American Academy of Child and Adolescent Psychiatry 40: 315–324, 2001. Schreter, R.K. Essential skills for managed behavioral health care. Psychiatric Services 48: 653–658, 1997.

SECTION

5

Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood EDITED BY RICHARD M. SARLES

5.1 Pervasive developmental disorders and adolescence Harinder S. Ghuman and Jaswinder K. Ghuman

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5.2 Obsessive–Compulsive Disorder and Tourette’s Syndrome in children and adolescents Mai Karitani, Kenneth C. Rickler, Douglas A. Beer, Susan E. Swedo, and Henrietta L. Leonard

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5.3 Anxiety disorders during adolescence Mohammad Haerian, Gloria Reeves, and Sushma Jani

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5.4 Mood disorders and suicide in children and adolescents Paramjit T. Joshi and Jay A. Salpekar

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5.5 Eating disorders and disordered eating Lynn E. Ponton

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5.6 Personality disorder in adolescence Glen T. Pearson

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5.7 Disruptive behavior disorders David Mullen and Robert L. Hendren

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5.8 Adolescent substance abuse Marsha E. Bates and Robert L. Hendren

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5.9 Psychotic disorders Lois T. Flaherty

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5.1 Pervasive developmental disorders and adolescence HARINDER S. GHUMAN AND JASWINDER K. GHUMAN

HISTORICAL NOTE, DEFINITION, AND CLINICAL PRESENTATION Psychiatrists, psychologists, and neurologists have struggled for several decades to understand, diagnose, categorize, and treat severe developmental and behavioral disturbances closely linked in their clinical manifestation by delay and deviance in social, communicative and cognitive development. The latest Diagnostic and Statistical Manual of Mental Disorders (DSM-IV 1994) categorized these clinical entities under a broad umbrella diagnosis of Pervasive Developmental Disorder, with Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder, and Pervasive Developmental Disorder, not otherwise specified as individual entities.

Autistic Disorder (autism) The concept of autism originated with Kanner’s 1943 publication of his classic paper, ‘Autistic Disturbance of Affective Contact’ in which he used the term ‘infantile autism’ to describe eleven children who showed extreme disturbance of relationship, language and cognition and who demonstrated an anxious obsession for the maintenance of sameness and a limited variety of spontaneous activity. Currently, major criteria for the diagnosis of autistic disorder include qualitative impairment in social interaction and communication, and restricted, repetitive and stereotyped patterns of behavior, interests, and activities. Delays or abnormal functioning in at least one of the following are included, with onset prior to age three years:

difficulty in reciprocal interaction, in responding empathically to others, and in integrating multiple sources of information. Normal friendship patterns including dating are rare in autistic adolescents. In higher-functioning autistic adolescents, difficulty in relationships may be a source of frustration and depression. Autistic adolescents show disturbance in communication, including total lack or delay in the development of speech and abnormal pattern of language development as well as language use. Their speech is often monotonic and marked by I–you pronomial reversal, immediate and delayed echolalia and idiosyncratic word usage. Even higher-functioning autistic adolescents may show difficulty in understanding basics of use of speech for social communication, including turn taking, conversational repair, facial expression and gestures. The autistic adolescent’s behavior is marked by stereotyped, repetitive movements and mannerisms, for example rocking, clapping, and finger flicking. They may spend an inordinate amount of time on one activity, such as collecting maps or bus routes, and they show difficulty dealing with small changes in routine or the environment. The majority of individuals with autism score in the moderate range of mental retardation on intelligence testing. Tasks involving language comprehension or picture arrangement are depressed. Occasionally unusual ‘splinter or savant skills’ are observed. Many of these autistic adolescents show aggressiveness, abnormalities of mood and affect, self-injurious behavior, impulsivity and sexually inappropriate behavior. The incidence of major motor seizures is 25–35 per cent, with a second peak of onset during adolescence.

1 Social interaction. 2 Language as used in social communication. 3 Symbolic or imaginative play (DSM-IV 1994).

Childhood Disintegrative Disorder

During adolescence, autistic youngsters may show some improvement in social skills but continue to experience

This disorder was originally described as ‘dementia infantilis’ by Heller, a Viennese educator. He reported six

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cases of children in 1908 who developed normally until their third and fourth years and then showed extreme cognitive and neurological regression leading to complete loss of speech, to complete idiocy, with many becoming incontinent. The DSM-IV diagnostic criteria includes apparently normal development for at least the first two years of life followed by a clinically significant loss of previously acquired skills in at least two of the following five areas:

• • • • •

Expressive or receptive language. Social skills or adaptive behavior. Bowel or bladder control. Play. Motor skills.

In addition, there is qualitative impairment in social interaction and communication and restricted, repetitive, and stereotyped patterns of behavior, interest and activities, including motor stereotypes and mannerisms. The onset is often marked by the child becoming moody, agitated and dysphoric. Childhood Disintegrative Disorder resembles autism in behavioral and developmental manifestations, except that deterioration in self-help and motor skills is more marked. There is a marked decline in intellectual functioning, often to a severe mental retardation level. Seizure disorders are associated with this disorder.

Asperger’s Disorder In 1944, Hans Asperger published a paper ‘Autistic psychopathy,’ and described a number of boys who showed severe and difficulties of two-way social interaction, unusual aspects of nonverbal communication and voice quality, unusual interests, and clumsiness of gait and gross motor functions. The DSM-IV diagnostic criteria for Asperger’s Disorder are similar to diagnostic criteria for Autistic Disorder, as described above, except that there is no clinically significant delay in language. Children with Asperger’s Disorder do not have significant delay in cognitive development, self-help skills, adaptive behavior, and curiosity about the environment. Adolescents with Asperger’s Disorder are, however, socially isolated with a lack of interest in peers or only as a passive participant in others’ activities, being obsessed with their own interests. They can be socially intrusive, awkward, disinhibited, and appear to lack the ability to modulate their social behavior to the demands of the social context or the environment. Nonverbal communication difficulties include lack of eye-to-eye contact, gestures and facial expressions. They show difficulty initiating and sustaining conversation, which is often one-sided and tangential, and show little interest in feelings or concerns of others. Adolescents with Asperger’s Disorder sometimes develop intense interest in horror movies and certain sports, and may also develop a complex fantasy life (Szatmari 1996).

Rett’s Disorder Andreas Rett, an Austrian physician, reported in 1966 a series of female cases who were apparently normal until six to twelve months of age and subsequently developed a progressive loss of motor and cognitive skills, inappropriate social interactions, absence of an ability to communicate, and deceleration of head growth. The essential DSM-IV diagnostic features of Rett’s Disorder include severe developmental regression in multiple areas following a period of normal development. There is deceleration of head growth between the ages of five and forty-eight months, and a loss of previously acquired purposeful hand skills between ages five and thirty months, with subsequent development of stereotyped midline hand movements such as hand wringing or hand washing. These children show an early loss of social engagement, their gait or trunk movements look poorly coordinated, and there is severe impairment of expressive and receptive language development with severe psychomotor retardation. Naidu et al. (1986) evaluated 70 females with Rett’s syndrome ranging from 21⁄2 to 341⁄2 years of age. The five- to fifteen-year-old cases in the study showed stagnation at a severely demented level, yet improvement of seizure control, sleep pattern, and social interaction such as intermittent eye contact or sitting in mother’s lap. There was little or no improvement in language, which had either disappeared or remained at two or three phrases or words. They continue to show hand wringing, hyperventilation, bruxism and breath-holding. Additional major concerns were ongoing weight loss, reduction of muscle mass and onset of scoliosis. Secondary sexual characteristics developed with onset of menarche at an appropriate age, and masturbation was noticed in some. Three had ‘prophylactic hysterectomies’ at a later date. Toilet training was never achieved.

DEVELOPMENTAL ISSUES OF ADOLESCENCE AND PERVASIVE DEVELOPMENTAL DISORDERS Adolescence is the transitional stage between childhood and adulthood marked by major physical, cognitive, emotional, social and vocational changes. Campbell et al. (1980) reported delay in height and skeletal growth in autistic children, while DeMyer (1979) reported that for male adolescents there was little drive for sexual intercourse and that more autistic teenagers masturbated (63%) than normal controls (45%), and 6 per cent of autistic children masturbated very frequently or most of the time. Mildly autistic children may show interest in heterosexual relationships, but their approaches may not be successful due to poor verbal and social skills. Rutter (1970) reported onset of seizures in 28 per cent and progressive

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mental deterioration in 10 per cent of teenagers in adolescence. The majority of autistic teenagers show some degree of intellectual impairment, often prominent in verbal areas. Cognitive deficits prevents most autistic teenagers from reaching the stage of formal operations as defined by Piaget, resulting in difficulty in understanding abstract constructs and subtleties of interpersonal interactions. The autistic teenager who develops incomplete or inconsistent formal operational thinking may experience increased stress owing to higher expectations by teachers and parents. Social and emotional changes include the adolescent’s increased importance, reliance and influence in the peer group rather than with parents. The autistic teenager often shows interest in interacting with peers, but experiences difficulties due to limited cognitive, verbal and interpersonal skills. The autistic adolescent has difficulty changing his/her routine and shows a lack of empathy (Rutter 1970); thus, the autistic adolescent is often avoided by nonautistic adolescents, and this results in further rejection, avoidance and isolation. Autistic adolescents and adults are rarely involved in heterosexual relationships. Higher-functioning autistic adolescents often experience frustration and disappointment for their inability to do what other teenagers can, such as driving a car and having girlfriends. The majority of autistic adolescents and adults are dependent on their parents or other adults to function in life. Drug abuse, running away, suicide and antisocial behavior are rare in autistic adolescents.

behaviors, interests and activities and are much more severely impaired in social interaction. Childhood Disintegrative Disorder and Rett’s Disorder in adolescents should be differentiated from neurodegenerative disorder. Severe developmental regression observed in Childhood Disintegrative Disorder and Rett’s Disorder may be associated with a range of genetic disorders, including metachromatic leukodystrophy, gangliosidosis, and Niemann–Pick disease. Childhood Disintegrative Disorder should be differentiated from an early-onset dementia which occurs as a consequence of a general medical condition such as head trauma.

Prevalence and epidemiology Most epidemiological studies of autistic children suggest worldwide prevalence rates of four to five cases per 10 000. Autism is more frequent in boys, with a sex ratio of 3–5:1. Girls with autism may be more severely affected, and are more likely to have a family history of learning and language problems. Gillberg and Gillberg (1989) concluded that Asperger’s syndrome occurs at a minimum frequency of 26 per 10 000 in school-age children, and with a boy:girl ratio higher than that in autism. A prevalence rate of 0.11 per 10 000 has been suggested for Childhood Disintegrative Disorder, with an overall male:female ratio of 4:1. The prevalence rate for Rett’s Disorder has been reported as one per 15 000, and this disorder is identified only in females (Tsai 1994).

DIFFERENTIAL DIAGNOSIS Assessment Schizophrenia and Pervasive Developmental Disorders both show disturbance in language, interpersonal relatedness and behavior, but Pervasive Developmental Disorders are early in onset and show marked impairment in social interaction and language development, plus there is an absence of prominent delusions or hallucinations in Pervasive Developmental Disorders. Individuals with Development Language Disorders and hearing impairment are not associated with impairment in social interactions and restricted, repetitive, and stereotyped patterns of behavior as seen in Pervasive Developmental Disorders. Asperger’s Disorder should be distinguished from Obsessive–Compulsive Disorder and Schizoid Personality Disorder. The adolescent with Obsessive–Compulsive Disorder does show repetitive and stereotyped patterns of behavior, but there is no qualitative impairment in reciprocal social interactions and difficulties in the pragmatics of communication as seen in Asperger’s Disorder. Adolescents with Schizoid Personality Disorder show self-centeredness and a lack of interest in human relationships, whereas Asperger’s Disorder and milder forms of Autistic Disorder are characterized by stereotyped

Most individuals with Pervasive Developmental Disorders are identified by the time they become adolescents. Assessment requires an interdisciplinary approach by various professionals, including child psychiatrists, neurologists, psychologists, speech pathologists and others. A careful history should be obtained regarding pregnancy, birth, and developmental milestones. The medical history should ask specifically about maternal infections during pregnancy, perinatal or postnatal insult to the brain, meningitis, encephalitis, or seizures in the patient. While obtaining the family history one needs to inquire into family history of medical conditions as well as psychiatric illness, including autism, schizophrenia, and other genetic and development disorders. The adolescent should be observed in a one-to-one setting as well as with the family, and if possible in a group setting like the classroom. The clinical history can be aided by several instruments, for example parent or teacher checklists (Krug et al. 1978), a semi-structured interview (Lecouteur et al. 1989) and structured observation (Lord et al. 1989).

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Psychological and educational testing, speech and language evaluation, and hearing screening are helpful to provide measures of cognitive abilities and adaptive functioning, differential diagnosis and prognosis, and to plan appropriate interventions which address areas of strength and weakness. Assessment by a behavioral specialist may be necessary to develop specific behavioral interventions/strategies to be used at home and/or in the classroom. A thorough physical examination is indicated to identify any dysmorphic features and signs of specific disorders such as tuberous sclerosis, Fragile-X syndrome, congenital rubella or other genetic disorders that may be responsible for the child’s symptomatology. Consultation from pediatric neurologist is necessary at the time of first evaluation, especially in Childhood Disintegrative Disorder and Rett’s Disorder. A family history of mental retardation suggests a need for Fragile-X screening (DNA testing if possible). Waking and sleeping electroencephalography (EEG) is indicated if the history is suggestive of seizures, behavioral regression, or loss of language. Metabolic screening, amino acid chromatography, tests for serum copper and ceruloplasmin, and serological evidence of intrauterine infections such as toxoplasmosis or cytomegalic disease is necessary if symptoms appeared after the age of three years, or are progressive. Magnetic resonance imaging (MRI), and/or computed tomography (CT) may be indicated sudden for and progressive neurological deterioration in Childhood Disintegrative Disorder and Rett’s Disorder.

Etiology Autism is now considered to be a neurological disorder, even though many psychodynamic theories have been suggested in the past to explain symptom development in children and adolescents with autism. Although an organic neurological etiology is postulated, a specific etiology is identified in only 5–10 per cent of patients.

•

et al. 1992); a decrease in parietal lobe volume (Courchesne et al. 1992); cytoarchitectonic abnormalities consisting of increased cell-packing density in the hippocampus, amygdala, entorhinal cortex, mammillary body and septum bilaterally (Bauman and Kemper 1994); and decreased complexity and extent of the dendritic arbors in some pyramidal neurons of the hippocampus (Raymond et al. 1989). Brainstem abnormalities: Bauman and Kemper (1989) found evidence of persistence of a fetal pattern of circuitry in olivocerebellar pathways in neuropathologic studies of individuals with autism. Gaffney et al. (1988) reported smaller pons and total brainstem area in an autistic group and Hsu et al. (1991) reported an absence of pontine abnormalities.

Neurochemistry Neurochemical abnormalities include the following:

•

•

Monoamines: Anderson et al. (1987) found elevated whole-blood levels of serotonin in 25–40 per cent of patients with autism, though in a more recent study McBride et al. (1998) suggested that the prevalence of hyperserotonemia in autistic individuals may have been overestimated because of failure to control for both race and pubertal status. Gillberg and Svenerholm (1987) found elevated mean basal cerebrospinal fluid (CSF) levels of the primary brain metabolite dopamine, homovanillic acid (HVA); by contrast, Narayan et al. (1993) found normal CSF HVA levels in autistic individuals. Neuropeptide function: Reports of elevated CSF endorphin levels in children with autism (Gillberg et al. 1985) and resemblance of autistic symptomatology with effects of opiates (e.g., decreased pain sensitivity and self-injurious behavior) have led to the speculation of an association between some symptoms of autism and a defect in maturation of the brain endorphin system.

Prenatal and perinatal factors Neuroanatomy Neuroanatomic abnormalities include the following:

•

•

Cerebellar abnormalities: Selective hypoplasia of the neocerebellar vermis has been reported on midsagittal MRI scans (Courchesne et al. 1988), though Piven et al. (1992) were unable to replicate this finding. Purkinje neuron loss has been reported in the vermis in autopsy studies (Arin et al. 1991). Cortical and intracerebral abnormalities: Various abnormal cortical findings have been reported, including cortical gyral malformations suggesting developmental errors in neuronal migration (Piven et al. 1990); an increase in cerebral cortex volume (Filipek

Congenital rubella and cytomegalovirus infection have been reported to be associated with autism (Chess 1971; Stubbs 1987). There is evidence of more prenatal and perinatal problems in children with autism than in controls (Folstein and Rutter 1977; Gillberg and Gillberg 1983), although Mason-Brothers et al. (1990) did not report any increased pre- or perinatal problems among a group with autism compared with a control group.

Genetic influence The prevalence of autism in the siblings of autistic probands has been estimated to be 50- to 100-fold

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greater than expected (Stefenberg and Gillberg 1986). Family members of affected probands and nonautistic monozygotic (MZ) co-twins have been found to have a variety of cognitive deficits, specific language abnormalities, certain personality characteristics (e.g., social deficits), and psychiatric disorders (e.g., anxiety and affective disorder) more commonly than individuals with other developmental disabilities and nonautistic dizygotic (DZ) co-twins (Folstein and Rutter 1977). Folstein and Rutter (1977) also reported 36 per cent concordance for autism in MZ pairs compared to no concordance in DZ pairs. Features of autistic disorder have been described as part of some genetic conditions, for example Fragile-X syndrome, certain single-gene disorders including tuberous sclerosis, untreated phenylketonuria, and possibly neurofibromatosis. Even though some differences have been noted in the etiology of autism and Asperger’s syndrome, most neuropsychological and family studies point to a similar etiologic basis for the two conditions. Possible associations of Rett’s Disorder with high peripheral ammonia levels, potential genetic contribution, decreased brain weight, loss of neurons and mild brain atrophy have been speculated, but a definitive pathogenesis of Rett’s Disorder remains elusive (Rett 1966; Tsai 1994). In a small number of cases of Childhood Disintegrative Disorder, especially with very late onset, specific neuropathological conditions (e.g., neurolipidosis, metachromatic leukodystrophy, Addison–Schilder’s disease, and subacute sclerosing panencephalitis) have been identified. However, in most cases the etiology of the condition remains unknown.

TREATMENT Pervasive Developmental Disorders require a comprehensive treatment program to address various aspects of the disorder, and no single treatment has been curative. The goals of treatment should include fostering normal development, promoting cognitive, language and social learning, reducing rigidity and stereotypy, eliminating nonspecific maladaptive behaviors, and alleviating family distress (Rutter 1985). There has been increased emphasis on community-based services instead of residential placement. Adolescents with Pervasive Developmental Disorder need social skills training to help them relate to others and express their needs and feelings in a socially appropriate manner. Depending upon the level of an adolescent’s abilities and functioning, sexual education can be useful in increasing awareness of the youngster about their body parts and their functioning, masturbation, taking care of personal hygiene, and socially acceptable behavior regarding dress and intimacy. Adolescents with Pervasive Developmental Disorder rarely become

involved in sexual relationships but they can be exploited by others. Adolescents with some language skills can benefit from direct speech training, and alternative modes of communication such as signing and writing can be introduced if there is little or no progress in speech. An individualized educational program is the main focus of management in a Pervasive Developmental Disordered adolescent. There is a need for structured teaching due to lack of selfdirection, and limiting the prompts to only essential cues has been advocated (Lovaas et al. 1979; Schopler 1994). Areas of particular attention include more specialized academic/cognitive intervention, vocational counseling and supported employment for the higher functioning autistic individuals (with direct attention paid to the adolescent’s inability to generalize learned skills to new situations), self-help skills for the more severely affected individual, and structured exposure to other adolescents who do not have similar communication and socialization deficits. Various behavioral therapy techniques have been applied to reduce rigidity, stereotypy and perseveration, to eliminate maladaptive behaviors such as tantrums, aggression and self-injurious behavior, and to learn new skills. Supportive psychotherapy and occasionally insight-oriented therapy, especially in the higherfunctioning individual, can be helpful to the adolescent dealing with limitations and emotions, and to improve expression of needs and feelings to others. The parents must be actively involved in the education program for their adolescent, including development and implementation of the individualized education plan. They should be encouraged to teach certain living and leisure skills in the home. Families often need support to deal with their excessive denial, guilt, and frustration with the slow, or seeming lack of, progress, to advocate for their child’s educational needs, financial needs for various therapeutic interventions, financial/ disability eligibility, and respite care to enable them to attend to other members of the family. Information regarding self help and support groups is available through the local branches of the National Society of Autism. The parents of the adolescent with Pervasive Developmental Disorder may experience confusion in how to deal with developmental issues related to sexuality and more independent functioning on the part of adolescent.

Pharmacotherapy Drug treatment in Pervasive Developmental Disorders is helpful in dealing with aggression, ritualistic/stereotypic/ self-injurious behavior, attentional problems, and seizures. Dopamine antagonists such as haloperidol (0.25–4 mg/day; Anderson et al. 1989; Campbell et al. 1978; Joshi et al. 1988) and pimozide (1–9 mg/day; Naruse et al. 1982) have been effective in reducing withdrawal, stereotypy,

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hyperactivity, fidgetiness, negativism, and angry affect. These drugs seem to improve relatedness and facilitate discrimination learning owing to their effects on attentional mechanisms. Geller et al., in 1982, reported improvement in three autistic boys with fenfluramine, an indirect 5-hydroxytryptamine (5-HT) agonist. Subsequent studies with fenfluramine have not been positive in improving stereotypies or in the core symptoms of autism, while many side effects such as weight loss, excessive sedation, loose stools and irritability have been reported (Campbell et al. 1988). The potent 5-HT re-uptake inhibitors, fluvoxamine (150–300 mg/day in adults; McDougle et al. 1993), clomipramine (90–170 mg/day in children; Gordon et al. 1992), fluoxetine (20 mg every other day to 80 mg/day in children and adults; Cook et al. 1992), and sertraline (50–200 mg/day in adults; McDougle et al. 1993), were each useful in improving stereotyped, repetitive behaviors, obsessive–compulsive symptomatology and aggression in individuals with autism. In addition, risperidone, a very potent dopamine D2/serotonin 5-HT2A receptor antagonist, has been found to be useful in decreasing repetitive behavior, aggression and impulsivity in children and adolescents with Pervasive Developmental Disorders (McDougle et al. 1997; Nicolson et al. 1998). Stimulants can be helpful for short attention span, hyperactivity and impulsivity; however, close follow-up is needed as these agents can worsen the behavior and stereotypies in some autistic individuals. Anti-convulsants can be used in treating seizures, mood lability and aggression in adolescents with autism.

SUMMARY AND CONCLUSION Pervasive Developmental Disorders are lifelong disorders. The outcome for autistic individuals is poor in that only about one-third show some ability to be self-sufficient and make social adjustment. Some autistic children show behavioral improvement during adolescence, whereas others deteriorate – possibly due to onset of major motor or complex seizures (Lockyer and Rutter 1970). Of the higher-functioning autistic adults, 1–2 per cent are able to live fully independently, while another 5–17 per cent may live independently with minimum supervision and participate in ‘supported employment.’ The best predictors of outcome include the presence of communicative speech by age five years, and overall intellectual level. Szatmari et al. (1989) found less impairment in social responsiveness, communication, and restricted range of activities in individuals with Asperger’s Disorder. In Rett’s Disorder, the loss of skills is generally persistent and progressive with an occasional period of plateau. Seizures, motor problems, bruxism, breathing difficulties and scoliosis are often present. Adults with this disorder often require careful supervision and support. Volkmar

(1992) reported three patterns of the clinical course for individual with Childhood Disintegrative Disorder: 1 In three-fourths of cases the loss of skills reaches a plateau, after which some limited improvement may occur. 2 In some cases there is limited or noteworthy recovery. 3 In other cases, developmental regression is progressive and death may eventually result.

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264 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood American Academy of Child and Adolescent Psychiatry 37: 372–376, 1998. Piven, J., Berthier, M.L., Starkstein, S.E., Nehme, E., Pearlson, G., Folstein, S. Magnetic resonance imaging evidence for a defect of cerebral cortical development in autism. American Journal of Psychiatry 147: 734–739, 1990. Piven, J., Nehme, E., Simon, J., Barta, P., Pearlson, G., Folstein, S.E. Magnetic resonance imaging in autism: measurement of the cerebellum, pons and fourth ventricle. Biological Psychiatry 31: 491–504, 1992. Raymond, G., Bauman, M.I., Kemper, T.L. The hippocampus in autism: Golgi analysis. Annals of Neurology 26: 483–484, 1989. Rett, A. Uber ein cerebral-atropnisches Syndrom bei Hyperammonaemie. Wien: Bruder Hollinek, 1966. Rutter, M.. Autistic children: infancy to adulthood. Seminars in Psychiatry 2: 435–450, 1970. Rutter, M. Infantile autism. In Shaffer, D., Ehrhardt, A.A., Greenhill, L.L. (eds), Clinical Guide to Child Psychiatry. New York: The Free Press, 1985, pp. 48–78. Schopler, E.A. Statewide program for the treatment and education of autistic and related communication handicapped children (TEACCH). In Volkmar, F. (ed.), Child and Adolescent Psychiatric Clinics of North America: Psychoses and Pervasive Developmental Disorders. Pennsylvania: W.B. Saunders Co., 1994, Volume 3, pp. 91–103. Steffenberg, S., Gillberg, C. Autism and autistic-like conditions in Swedish rural and urban areas: a population study. British Journal of Psychiatry 149: 81–87, 1986. Stubbs, E.G. Does intrauterine cytomegalovirus plus autoantibodies contribute to autism? In Wing, L. (ed.), Aspects of Autism: Biological Research. Gaskell Psychiatry Series, 1987, pp. 91–101. Szatmari, P. Asperger’s Disorder and atypical pervasive developmental disorder. In Volkmar, F. (ed.), Psychoses and Pervasive Developmental Disorders in Childhood

and Adolescence. Washington, DC: American Psychiatric Press, Inc., 1996, pp. 191–221. Szatmari, P., Bartolucci, G., Bremner, R. et al. Asperger’s syndrome and autism: comparisons on early history and outcome. Developmental Medicine and Child Neurology 31:709–720, 1989. Tsai, L. Rett syndrome. Child and Adolescent Psychiatric Clinics of North America 3: 105–118, 1994. Volkmar, F.R. Childhood disintegrative disorder: issues for DSM-IV. Journal of Autism and Developmental Disorders 22: 625–642, 1992.

Suggested reading Green, J., Gilchrist, A., Burton, D., Cox, A. Social and psychiatric functioning in adolescents with Asperger syndrome compared with conduct disorder. Journal of Autism and Developmental Disorders 30: 279–293, 2000. Loveland, K., Pearson, D., Tunali-Kotoski, B., Ortegon, J., Gibbs, M. Judgement of social appropriateness by children and adolescents with autism. Journal of Autism and Developmental Disorders 31: 367–376, 2001. Malone, R., Maislin, G., Choudhury, M., Gifford, C., Delaney, M. Risperidone treatment in children and adolescents with autism: short- and long-term safety and effectiveness. Journal of the Academy of Child and Adolescent Psychiatry 41: 140–147, 2002. Research Units on Pediatric Psychopharmacology. Autism Network: Risperidone in Treatment of Children with Autism and Serious Behavior Problems. New England Journal of Medicine, 347(5), 314–321, 2002 Schopler, E, Mesibov, G. (eds) Autism in Adolescents and Adults. Plenum Press: New York and London, 1985. Tanguay, P. Pervasive developmental disorders: 10-year review. Journal of the American Academy of Child and Adolescent Psychiatry 39: 1079–1095, 2000.

5.2 Obsessive–Compulsive Disorder and Tourette’s Syndrome in children and adolescents MAI KARITANI, KENNETH C. RICKLER, DOUGLAS A. BEER, SUSAN E. SWEDO, AND HENRIETTA L. LEONARD

INTRODUCTION Increasing attention has focused on Obsessive–Compulsive Disorder (OCD) and Tourette’s Syndrome (TS), which are more common in the pediatric age group than previously thought. Recent research suggests that early diagnosis and treatment are important in these disorders. Familial etiological and developmental factors are under current study. The phenomenology, assessment, and treatment of OCD and TS are discussed in this chapter.

DEFINITIONS Obsessive–Compulsive Disorder Obsessive–Compulsive Disorder (OCD), as defined in DSM-IV, is characterized by recurrent obsessions and/ or compulsions which cause marked distress or impairment in one’s social or academic functioning (American Psychiatric Association 1994). Obsessions are persistent thoughts or images that are ego-dystonic, intrusive, and predominantly senseless. The specific content of the obsession should not be related to another Axis I diagnosis, such as thoughts about food resulting from an eating disorder or guilty thoughts from a major depression. Compulsions are repetitive behaviors or mental acts that are performed in response to an obsession, often to prevent or reduce distress. Individuals with OCD usually recognize that their obsessive thoughts are excessive or unreasonable, although this criterion is waived for young children, as they may not describe their thoughts and behaviors as senseless (American Psychiatric Association 1994).

Tourette’s Syndrome Tourette’s Syndrome (TS) is characterized by the presence of both motor and vocal tics, which wax and wane in course. Onset is in childhood or adolescence, and symptoms must persist at least one year for the diagnosis to be made. The disturbance cannot be attributable to a medical condition (such as Huntington’s disease), nor to the effects of neuroleptic medications (American Psychiatric Association 1994). The change in DSM-IV to require impairment – a criterion that had not previously been present – has generated controversy, so in both clinical and research settings often the DSM-III-R definition or the Tourette Syndrome Classification Study Group Consensus Criteria for tic disorders is used (American Psychiatric Association 1987; Fahn et al. 1993). The classification in the Consensus Criteria is that tic disorders represent a clinical continuum. Other tic disorders – chronic motor or vocal tic disorder, transient tic disorder, and tic disorder not otherwise specified (NOS) – are listed in DSM-IV. For the diagnosis of either chronic motor or chronic vocal tic, one type but not the other must be present, distinguishing it from TS. Additionally, severity and impairment are less than are seen in TS. A transient tic disorder must occur nearly every day for at least four weeks, but not for longer than twelve consecutive months. Tic NOS might include tics lasting less than four weeks or with an onset after eighteen years of age (American Psychiatric Association 1994).

CLINICAL PRESENTATION In one of the largest studies, seventy consecutive child and adolescent patients were systematically examined at

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the National Institute of Mental Health (NIMH) (Swedo et al. 1989b). A mean age of onset of ten years, with a range of two to sixteen years, was found among the fortyseven boys and twenty-three girls who met diagnostic criteria for primary severe OCD. Seven of the patients had had the onset of their illness prior to the age of seven years. The gender distribution changed with age, with earliest age of onset having the greatest male predominance. Other studies have reported generally similar results, suggesting a bimodal age of onset (pre- and postpubertal) in children and adolescents, with a mean age of onset of about ten years (Geller et al. 1995; Hanna 1995; Riddle et al. 1990; Swedo et al. 1989b; Thomsen 1993). Adult studies have reported a mean age of onset of twentyone years, which likely includes those with both childhood and adult onset (Rasmussen and Eisen 1992). The clinical symptoms of pediatric OCD are essentially identical to those seen in adults (Geller et al. 1995; Hanna 1995; Riddle et al. 1990, Swedo et al. 1989b). Children and adolescents with OCD typically have both obsessions and compulsions, although a small number have only one or the other. The most common ritual was excessive ‘cleaning,’ such as showering, which was experienced at some point by 85 per cent of patients (Swedo et al. 1989b). Repeating rituals, such as going in/out of doors and checking behaviors, such as making sure that windows were locked, were often reported. Other common rituals included counting, ordering and arranging, and hoarding. Some obsessions and rituals involved an internal sense that ‘it didn’t feel right’ until the thought or action was completed. The description of the sensations resembled that of the premonitory urge preceding some tics (Leckman et al. 1993). Almost every patient reported that their primary symptom changed over time, and retrospective analysis revealed that most had experienced a wide variety of obsessions and compulsions without any clear pattern of progression (Rettew et al. 1992). Thus, the specific symptom content (e.g., obsessions versus rituals, or washing versus checking) seems unlikely to provide clues into pediatric OCD subgroups. Children who recognize the irrationality of their obsessions and compulsions attempt to conceal their symptoms. A child may attempt to hide obsessions and compulsions from family, friends, and even therapists. Therefore it is difficult to recognize signs of OCD in a young child or in the less severely ill child. Many children and adolescents are treated for depression or other anxiety disorders for several months before they disclose their OC symptoms. Behaviors that are suspicious for an OCD diagnosis include spending long, unproductive hours on homework, retracing over letters, or re-reading paragraphs. A dramatic increase in laundry, and toilets overflowing from excessive use of paper may warn of contamination fears. Although ritualized behaviors are common for the

young child around times of transition, those of OCD are typically excessive and at a later-than-expected age. Long, rigid bedtime rituals, exaggerated needs for reassurance, or requests for family members to perform certain acts to make the child ‘safe’ may all indicate a child who has OCD. Hoarding of useless objects, such as fingernail clippings or used bandages, should be differentiated from normal childhood collecting of rocks, baseball cards, or sentimental treasures. Tics may be simple or complex, have some suppressibility, and wax and wane in course. Tic severity can vary greatly, although exacerbations often occur with fatigue or stress. Frequency of tics is unpredictable and ranges between intermittent bouts and continuous production. Usually, motor tics precede phonic tics in onset with the mean age of onset at seven years. Attention Deficit Hyperactivity Disorder (ADHD), obsessions and compulsions, impulsivity, and affective lability are commonly associated with tic disorders. The course of symptoms in any one individual may vary. Leckman and colleagues (1998) followed forty-two patients with TS and reported a mean age of tic onset of 5.6 years and a subsequent progressive pattern of tic worsening. The most severe symptoms were at a mean age of ten years. By age eighteen years, almost half of the adolescents were essentially ticfree, suggesting that many have this time course of severity.

Associated disorders The repetitive stereotypies seen in children with autism and Pervasive Developmental Disorders may seemingly resemble OCD rituals, but they are different in that these tend to be ego-syntonic, simple, and more perseverative. OCD rituals are usually purposeful and intentional. ‘Obsessive’ interest in calories displayed by those with an eating disorder may resemble OCD, but is centered on food and body image. Disturbance of body image is not typically found in OCD per se; however, adolescents who have Body Dysmorphic Disorder (BDD) – a preoccupation with an imagined or slight defect in appearance – exhibit ‘obsessional’ fixation with body image, and BDD may be considered an OCD ‘spectrum disorder.’ Recent studies suggest that BDD may occur at an early age and may easily go undiagnosed (Phillips et al. 1995). Children and adolescents with OCD have a high rate of a lifetime tic disorder (Leonard et al. 1992). Sometimes it is difficult to categorize a behavior as a ritual or as a complex tic. Generally, if an action is preceded by a specific cognition, then it is considered to be a compulsive ritual; however, some complex motor tics may be preceded by a sensation or ‘urge’ (Leckman et al. 1993). Sensory tics are not usually accompanied by a cognitive anxiety. Sometimes, it may be impossible to distinguish a complex motor tic from a complex ritual, especially in patients with both OCD and TS diagnoses. For example,

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a behavior such as tapping or spitting may be either a tic or a ritual. However, it is important to try to make the distinction, since each responds to different treatments.

THE LINK BETWEEN OCD AND TS OCD and TS have been associated ever since Gilles de la Tourette first described concomitant obsessions and compulsions in some patients (Shapiro et al. 1987). Patients with TS frequently exhibit obsessive–compulsive behaviors and/or true OCD; and OCD patients often have tics (Cohen and Leckman 1994; Frankel et al. 1986; Leonard et al. 1992). There is a genetic vulnerability for OCD and for TS in many cases. Some 20 per cent of firstdegree relatives of OCD probands met diagnostic criteria for a lifetime OCD diagnosis (Lenane et al. 1990). Additionally, first-degree relatives of OCD probands and of TS probands have increased rates of TS/chronic multiple tics and OCD, respectively (Leonard et al. 1992; Pauls et al. 1995). Pauls and colleagues (1986) have hypothesized that OCD and TS may represent different phenotypes of the same gene(s), and a mixed model of inheritance has been proposed by Walkup and colleagues (1996). OCD is a heterogeneous condition, with some being familial and related to tic disorders, some are familial and unrelated to tic disorders, and some are not familial (Pauls et al. 1995). Those with early onset of OCD are more likely to be related to tic disorders and to be familial (Pauls et al. 1995). Family studies of probands with OCD support that tic disorders constitute an alternative expression of the familial OCD phenotype (Grados et al. 2001).

EPIDEMIOLOGY Initial estimates of the incidence of pediatric OCD ranged from 0.2 to 1.2 per cent within psychiatric clinic samples (Hollingsworth et al. 1980; Judd 1965). In an adolescent epidemiological study, Flament and colleagues (1988) reported a prevalence rate of 0.8 per cent and a lifetime prevalence of 1.9 per cent. Valleni-Basile and colleagues (1996) found the one-year incidence rates of OCD and subclinical OCD in an adolescent sample to be 0.7 and 8.4 per cent, respectively. These figures suggest that OCD may be relatively common in adolescents. No large epidemiologic study of TS has been conducted to date. Estimates of prevalence range from 0.01 to 0.4 per cent (Burd et al. 1986; Caine et al. 1988; Comings et al. 1990), though generalization of the results from these select populations may underestimate the actual prevalence of TS. Transient and chronic tics may be quite common, with estimates of 10–15 per cent of the general child population. Studies of adults with TS suggest a ten-fold higher rate among children than among

adults, which suggests that for many patients the symptoms abate (Leckman et al. 1998).

ETIOLOGY Although the etiology of OCD is unknown, a frontal lobe–limbic–basal ganglia dysfunction has been implicated (Insel 1992; Wise and Rapoport 1989). Neurotransmitter dysregulation, genetic susceptibility, and environmental triggers may contribute to developing illness (Swedo et al. 1997). Clinical studies showing the efficacy of the serotonin reuptake inhibitors (SRIs) for the treatment of OCD, as well as challenge studies, have led to the ‘serotonin hypothesis.’ It is unlikely that the neurotransmitter dysregulation can be attributed to just one system, and several others (e.g., dopamine) have also been implicated. Evidence supporting neurobiological etiologies of OCD include neuroanatomical, neurophysiological, and neuroimmunological associations and metabolic abnormalities (Insel 1992). Numerous brain insults resulting in basal ganglia damage, including head injury and carbon monoxide poisoning, have been reported to be related to the onset of OCD. Known basal ganglia illnesses also have an increased rate of OCD, including postencephalitic Parkinson’s disease (von Economo 1931) and Huntington’s chorea (Cummings and Cunningham 1992). Neuroimaging studies report that adult OCD patients who had onset of their illness in childhood have decreased caudate size on computed tomography scans (Luxenberg et al. 1988) and abnormal patterns of regional glucose metabolism positron-emission tomography scans compared to controls (Swedo et al. 1989c, 1992). Increasing evidence is consistent with abnormal functioning along specific frontal–subcortical circuitry, with hyperactivity in orbitofrontal–subcortical circuits (Saxena et al. 1998). The etiology of TS currently focuses on genetic susceptibility (Pauls et al. 1986), with other nongenetic factors influencing the manifestation of the disorder (Palumbo et al. 1997; Singer and Walkup 1991). Neurotransmitter dysregulation appears to play a role in the development of TS. Dopaminergic, serotonergic, cholinergic, GABAergic, and opioid systems have all been implicated, yet the mechanisms of causal effects and of aggregate interactions within synaptic systems are inconclusive. Neuroanatomically, the frontal lobe–limbic–basal ganglia circuitry has been postulated to be a locus of dysfunction, but this is at best suggestive, as the exact sites of pathology in TS remain unknown. Functional neuroimaging has provided another tool to study TS, and work continues to focus on the cortico-striato-thalamo-cortical circuits (Jeffries et al. 2002). Palumbo and colleagues (1997) posit that a developmental basal ganglia syndrome (DBGS), which closely resembles TS, can occur as a result of primary (genetic) and/or secondary (nongenetic, including environmental)

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factors which interfere with the normal development of the basal ganglia. Recently, an animal model of TS has been proposed, which may provide new avenues for understanding its etiology and for the development of new treatments (Taylor et al. 2002).

DISCUSSION Recently, a subgroup of children with prepubertal onset of either OCD or tic disorder has been described. This group was described by the term PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection). These children are characterized by:

• • • • •

the presence of OCD and/or a tic disorder; prepubertal onset of symptoms; episodic course (either an abrupt-onset ‘overnight’ or dramatic exacerbations that seem to ‘explode’); association with Group A beta-hemolytic streptococcal infections (GABHS); and association with neurological symptoms (e.g., motoric hyperactivity, choreiform movements).

Only in recent years with parallel studies of Sydenham’s chorea (SC), the neurologic variant of rheumatic fever (Allen et al. 1995; Swedo et al. 1989a, 1993, 1994), was this OCD/TS subgroup noted to have onset of symptoms after GABHS infection (Swedo 1994). There is frequent comorbidity with ADHD, although the exact relationship is unclear. The NIMH group has reported the phenomenology of fifty children who were systematically assessed and met criteria for PANDAS (Swedo et al. 1998). About 50 per cent of the children had OCD as the primary diagnosis, and about 50 per cent had a tic disorder as the primary diagnosis, but 80 per cent had both tics and obsessive–compulsive symptoms. The children had an early onset of symptoms (mean age six years for tics and seven years for OCD) and there were more boys than girls (ratio of 2.6:1). There was a high rate of comorbidity, notably ADHD, depression, separation anxiety, and symptoms of emotional lability and irritability (Swedo et al. 1998). Recently, twelve children with PANDAS were followed prospectively in their pediatric setting; relapses of their OCD or tics were associated with positive throat cultures for GABHS, even though often there were no symptoms of sore throat or pharyngitis (Murphy and Pichichero 2002). Delineation of the subtype of OCD or TS is important as it merits different assessment and treatment. When a child presents with acute onset of OCD and/or tics, or has had an unexplained dramatic deterioration, careful consideration of medical illnesses (including seemingly benign upper pulmonary tract infections) in the preceding

months should take place. Obtaining a throat culture, ASO (antistreptolysin O) titer, anti-DNaseB streptococcal titer, and an antinuclear antibody (which may be nonspecifically positive) may assist in diagnosing such an infection. The studies above suggest that this subgroup of children with OCD or tics, who have previously met the criteria for PANDAS, should be worked up for GABHS in acute exacerbations, even in the absence of sore throat symptoms. The reader is referred to the review by Leonard and Swedo (2001) for a detailed summary of the PANDAS literature to date.

TREATMENT Overview Recent developments in specific pharmacologic agents and behavioral techniques have provided important treatment interventions. With the increasing availability of safer, more effective, and more discriminating pharmacologic agents, pharmacotherapy has often dominated the therapeutic arena. Yet, important nonpharmacologic treatment approaches, such as behavioral therapy, educational interventions, and supportive psychotherapy, provide integral components of multimodal treatment. Additionally, patient advocacy groups can provide important education. Both the Expert Consensus Guidelines and the American Academy of Child and Adolescent Psychiatry Practice Parameters provide excellent references for developing the treatment interventions for children with OCD (King et al. 1998; March et al. 1997).

Behavioral treatment of OCD Although its efficacy is based predominantly on open trials, cognitive behavioral therapy (CBT) has been utilized with much success in the clinical setting (March 1995). Techniques used with adults (Marks 1987) have been adapted to be more developmentally appropriate for children (March et al. 1994, 1995, 1998). For a review of CBT in children with OCD, the reader is referred to Piacentini (1999). The behavioral treatment of choice is exposure with response prevention (ERP), although other techniques, such as anxiety management, are sometimes used as adjuncts (March et al. 1994). Initial reports which described that obsessive adolescents had positive treatment gains (Bolton et al. 1983) have continued (Franklin et al. 1998). Recently, a treatment protocol for children with OCD has been developed into a systematic manual (March et al. 1994, 1995, 1998), which appears to be exportable, practical, and effective. The reader is directed to this treatment manual if interested in implementing

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ERP treatment in the treatment of children with OCD (March and Mulle 1998). On occasion, habit reversal may play a role in the treatment of more repetitive ‘complex tic-like’ rituals (Vitulano et al. 1992). For very young children, noncompliant patients, and ‘pure obsessives’ (those with obsessions only), behavioral modification may be less successful. Cognitive behavioral treatment, specifically ERP, either with or without pharmacotherapy, appears appropriate for children with OCD and should be one of the treatments of choice.

Pharmacologic treatment of OCD The serotonin reuptake inhibitor (SRI) clomipramine, and the selective serotonin reuptake inhibitors (SSRIs) fluoxetine, sertraline, fluvoxamine, and paroxetine have demonstrated efficacy (or are currently under study) in controlled treatment trials in adults with OCD (Piccinelli et al. 1995). Similar results have been reported in trials in younger age groups for most of the SSRIs. Clomipramine has been widely studied in children with OCD and has been shown to be significantly better than placebo in a controlled crossover study (Flament et al. 1985). Clomipramine was superior to placebo for the treatment of OCD in a large multicenter trial (DeVeaugh-Geiss et al. 1992). The SRIs appear to be specifically effective. Leonard et al. (1989) conducted a double-blind, crossover comparison of clomipramine and desipramine (a selective noradrenergic reuptake inhibitor) in order to assess the specificity of the SRI, and found clomipramine significantly better than desipramine in improving symptoms at week 5. Desipramine was no more effective in ameliorating OCD symptoms than placebo had been in the earlier study (Flament et al. 1985). At 3 mg/kg/day dosages both clomipramine and desipramine were well tolerated, and the two medications had similar side-effect profiles. Clomipramine has had a FDA-approved indication for the treatment of OCD in patients aged ten years and up. Baseline and periodic electrocardiographic (ECG) monitoring is recommended as the potential for tricyclic antidepressant (TCA)-related cardiotoxicity exists, although no unexpected adverse reactions were seen in either the NIMH or the multicenter trials (DeVeaugh-Geiss et al. 1992; Leonard et al. 1991). Common side effects include dry mouth, tremor, sedation, dizziness, insomnia, and sweating. The anticholinergic, antihistaminic, and ␣blocking side-effect profile of the TCAs is seen, although anecdotally the younger age group may suffer milder side effects than those generally reported in the adult multicenter trial. With the advent of the SSRIs, and their generally more tolerable side-effect profile, clomipramine is sometimes used for the more treatment-refractory OCD patients (March et al. 1997).

The development of the SSRIs has provided new pharmacotherapeutic agents for the treatment of OCD in children. Sertraline, fluvoxamine and, most recently, fluoxetine, have an approved FDA indication for the treatment of OCD in children, and large systematic studies support their efficacy. March and colleagues (1998) entered 187 children and adolescents with OCD in a twelve-week double-blind placebo-controlled trial of sertraline and reported that sertraline was superior, with this difference being seen as soon as week 3 and continuing throughout the study. Sertraline was titrated to a maximum of 200 mg/day, and the medication was generally well tolerated. Riddle and colleagues (2001) randomized 120 children and adolescents with OCD (after a single-blind placebo lead-in) to double-blind, placebocontrolled design of fluvoxamine (50–200 mg/day) versus placebo for ten weeks. Fluvoxamine was superior to placebo on primary and secondary measures in decreasing the severity of OCD symptoms. Adverse events with a placebo-adjusted rate greater than 10 per cent were insomnia and asthenia (Riddle et al. 2001). A large (n ⫽103) double-blind, placebo-controlled trial of fluoxetine (ranging from 20 to 60 mg daily) versus placebo in seven- to seventeen-year-olds with OCD reported that fluoxetine was effective for the treatment of OCD in the pediatric group, well tolerated, and had a similar rate of discontinuation to placebo (Geller et al. 2001). Fluoxetine was initiated at 10 mg daily and slowly increased to a maximum dose of 60 mg daily. Open studies support the use of paroxetine and citalopram, although controlled trials are needed to systematically test safety and efficacy (Rosenberg et al. 1999; Thomsen 1997). Generally, pediatric side effects commonly reported included nausea, diarrhea, insomnia, anorexia, agitation, hyperkinesia, somnolence, and dyspepsia. When choosing an SRI/SSRI, the clinician should give consideration to pharmacokinetics (long versus short half-life, metabolic pathways with concomitant medications), side-effect profile, comorbidity, and individual response (March et al. 1997). When intent-to-treat metaanalyses are used, clomipramine appears to be more effective than the comparison SSRI, and fewer dropouts were reported on clomipramine, possibly due to its efficacy, although it has the most anticholinergic profile among the agents (Greist et al. 1995). Comorbid diagnoses may also play a role in the selection of the treatment compound, although perhaps of a lesser magnitude than other factors considered here. Adequate dosage for long enough duration is required before response can be determined. Often, it takes six to ten weeks into a trial for patients to have relief. If someone has had no response to a SSRI at ten to twelve weeks, then another SSRI should be considered, and/or CBT should be added. Many experts would recommend clomipramine after two or three failed SSRI trials (March et al. 1997). Augmentation strategies may be considered

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with a partial response. Cognitive behavioral therapy should always be considered as an important treatment for OCD. Haloperidol has been used successfully with a SRI as an augmenting agent in adults with OCD, and patients with a comorbid tic or schizotypal personality disorder seemed to respond best (McDougle et al. 1994). A subsequent controlled study of adults who were partial or nonresponders to SRIs reported that risperidone was superior to placebo SRI augmentation in reducing OCD symptoms, regardless of the patients’ tic or schizotypal personality disorder status (McDougle et al. 2000). There are no controlled reports in the pediatric ages. A case series of children with OCD who were refractory to SRI treatment improved significantly after risperidone was added to an SRI (Fitzgerald et al. 1999). The neuroleptics are the only class of medication with systematic studies of their augmentation role to SSRIs, although the risk–benefit ratio of their side effects, including weight gain, sedation, and the possibility of tardive dyskinesia, must be considered. Although periodic decreasing of dosage should be considered, many need long-term maintenance. A doubleblind desipramine substitution study in adolescents on long-term clomipramine found that eight of nine patients relapsed when switched to desipramine compared to two of eleven who continued to take clomipramine (Leonard et al. 1991). Concomitant behavioral treatment (CBT) should thus be considered, particularly as patients treated with both medications and CBT appeared to show greater improvement and to have lower relapse rates (March et al. 1994). It is not known at this time whether CBT has more ‘durability’ than medication. Combined treatment trials comparing CBT and the SSRIs are under way. A multimodal approach to the treatment of OCD is strongly indicated and merits further systematic study.

Treatment of tic disorders Treatment of tic disorders may involve both pharmacotherapy and psychosocial interventions. Moderately severe tics which are distressing to the child, as well as associated symptomatology such as ADHD or selfinjurious behavior, may merit pharmacotherapy. The decision to treat demands clearly defined target symptoms and appropriate treatment modalities in each individual case. The primary aim in the treatment of tic disorders is reduction of motor and vocal tics. Neuroleptics appear to be effective in the symptomatic treatment of tics, although further systematic studies are needed in the pediatric ages. Difficulties in some of the TS clinical studies have included the disorder’s waxing and waning course; limited availability of validated measures; and confounding associated behavioral problems.

Dopamine antagonists, such as haloperidol, pimozide, and fluphenazine, are the most effective drug treatment of tics and are commonly used. All of the dopamine antagonists may have side effects, including sedation, cognitive blunting, and dysphoria, which cause some patients to discontinue their use. Extrapyramidal side effects (EPS), including drug-induced parkinsonism, akathisia, and tardive dyskinesia (TD), are of concern. Specifically, the risk of TD merits careful consideration and discussion with the patient and family. Neuroleptics have a long half-life; therefore, starting at low doses and titrating slowly can help reduce the risk of such adverse effects. EPS can often be controlled with concomitant anticholinergics such as benztropine mesylate. Sallee and colleagues (1997) found pimozide (3.4 mg/day) superior to haloperidol (3.5 mg/day) (which were equivalent dose formulations) in the treatment of TS in children and adolescents. Pimozide had significantly fewer EPS than haloperidol, but it may cause prolongation of the QT interval on ECG, so patients should be followed with periodic ECGs. The development of the atypical neuroleptics (e.g., risperidone, olanzepine, quetiapine, and ziprasidone), with presumably less risk for EPS, has changed the field in considering which medication to choose. In general, their side-effect profile is felt to be more tolerable, although side effects may include weight gain, sedation, akathisia, and occasional dystonic reactions. Further studies are needed to determine the risk of hyperprolactinemia, hyperglycemia, and significant weight gain. It is unknown whether children and adults differ in their risk for side effects. In general there appears to be a lower incidence of EPS, and probably a lower risk of TD, although there is still a small risk of TD. The atypical neuroleptic risperidone has both serotonin- and dopamine-blocking properties. Open trials of risperidone (cumulative n ⫽ 60) suggest that it may decrease tic severity (Bruun and Budman 1996; Lombroso et al. 1995; van der Linden et al. 1994). An eight-week, double-blind, placebo-controlled trial of risperidone (median dose 2.5 mg/day, range 1–6 mg/day) versus placebo in forty-eight adolescents and adults with TS reported that risperidone was superior to placebo (Dion et al. 2002). On the EPS rating scale, hypokinesia and tremor increased in the risperidone group, although the effect on tremor was largely in those subjects with a high tremor score at baseline. Fatigue and somnolence were the most common adverse effects with risperidone. Interestingly, there were no significant differences in dyskinetic movements, dystonic reactions, parkinsonism, or akathisia (Dion et al. 2002). Sallee and colleagues (2000) reported on twenty-eight children and adolescents with chronic tic disorders or TS who were randomized for eight weeks to either ziprasidone (mean dose 28.2 ⫾ 9.6 mg daily in the last four weeks) or placebo. Ziprasidone was superior to placebo in treating the tics. The most

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common adverse reaction was mild transient somnolence. No clinically significant effects were reported on ratings of EPS, akathisia, or TD. The authors caution that further studies are needed (Sallee et al. 2000). Of note, ECG monitoring is carried out on patients receiving ziprasidone because of the possibility of prolongation of the QT interval. Each of the atypical neuroleptics differs somewhat in its neuropharmacologic action; for example, quetiapine has minimal dopamine blockade in the motor system, and thus may prove to not be that helpful in the suppression of motor tics, although these studies have not been performed. Sulpiride and tiapride, also among the class of atypical neuroleptics, have been reported in Europe to be effective and well tolerated in the treatment of tics but are unavailable in the United States (Eggers et al. 1988; Robertson et al. 1990). Interestingly, dopamine agonists have been tried, and it may prove that their net result may be to decrease tics. Pergolide (300 ␮g/day), a mixed D1-D2-D3 dopamine agonist, was compared with placebo in a double-blind, controlled crossover trial of twenty-four children and adolescents with TS or a chronic tic disorder (Gilbert et al. 2000). Patients received either pergolide (up to 300 ␮g/day) or placebo for six weeks, followed by a twoweek placebo washout, and then received the alternative preparation. Tic scores were significantly lower during the pergolide treatment, and the authors reported that there were no serious adverse events. These small systematic trials are important, though larger trials are needed to assess the risk–benefit ratio of these medications. Clonidine, an ␣2-noradrenergic agonist originally prescribed for hypertension, has become increasingly popular since it may be used to target both the tics and the impulse control symptoms of ADHD, and does not have the EPS adverse effects of the neuroleptics. Concerns about clonidine include its short half-life, which leads to a need for frequent dosages, cardiovascular effects that necessitate monitoring of blood pressure and pulse, and behavioral and cardiovascular rebound effects when dosing has ceased and the medication’s effect wears off. Gaffney and colleagues (2002) reported an eight-week, double-blind comparison of clonidine versus risperidone in twenty-one children and adolescents with TS, who had completed a single-blind placebo lead-in. Risperidone and clonidine were equally effective in treating the tic symptoms. Sedation was the most common adverse event on both drugs. The authors concluded that clonidine and risperidone have equivalent efficacy in this pilot study, but further investigation is needed. Guanfacine, an ␣2-noradrenergic agonist similar to clonidine, has been studied on the basis of its longer halflife (allowing for less frequent dosing across the day compared to clonidine), less sedating side-effect profile, and its more selective binding profile. Open trials of guanfacine in children with ADHD, and ADHD with tic disorders,

have reported a decrease in tic severity and inattentiveness (Chappell et al. 1995; Horrigan and Barnhill 1995; Hunt et al. 1995). Potential side effects include mild sedation, headaches, and hypotension. Scahill and colleagues (2001) reported that guanfacine was effective and well tolerated in an eight-week placebo-controlled trial of thirty-four children and adolescents with both ADHD and a tic disorder. Both tic and ADHD severity were decreased in the children on guanfacine. Patients receiving guanfacine had a clinically insignificant decrease in blood pressure and pulse, and one guanfacine patient withdrew due to sedation. Adequate duration of a drug trial is essential: clonidine, for instance, may take as long as twelve weeks or more to assert its effect. Sufficient doses must also be used, and close monitoring should take place, especially with regard to cardiovascular effects (blood pressure). Indeed, these agents may be contraindicated in patients with pre-existing cardiac conditions. The role of stimulants in the treatment of ADHD symptoms in children with both ADHD and a tic disorder is the subject of debate, and continues to require systematic study. The use of stimulants for the treatment of ADHD in children with tics may potentially exacerbate tics. In a cross-sectional study of 122 children being treated with stimulant medication for ADHD, twelve were found to develop tics or dyskinesias; in general, the tics diminished with discontinuation of the stimulant, although one child developed TS (Lipkin et al. 1994). Clonidine or guanfacine, both of which are ␣2-noradrenergic agonists, may reduce ADHD-like symptoms with low risk of drug-induced exacerbation of tics (Leckman et al. 1991; Scahill et al. 2001; Steingard et al. 1993). Methylphenidate was found to be effective in the treatment of ADHD with no overall effect on tic severity, though the frequency of motor tics increased and that of vocal tics decreased (Gadow et al. 1995). Riddle and colleagues (1995) reported that methylphenidate discontinuation reduced tics, whereas its reinitiation exacerbated both the frequency and severity of tics in children with comorbid TS and ADHD. Most recently, the Tourette’s Syndrome Study Group (2002) reported that methylphenidate and clonidine (particularly in combination) are effective for children with ADHD and comorbid tic disorders. In a doubleblind, randomized trial, 136 children with AHD and a chronic tic disorder were assigned clonidine, methylphenidate, clonidine plus methylphenidate, or placebo. For the ADHD primary outcome measure, significant improvement occurred in those assigned to clonidine and those assigned to methylphenidate. The greatest benefit, when compared to placebo, was in those patients receiving the combination of clonidine and methylphenidate. Methylphenidate was the most helpful for the inattention symptoms, and clonidine was most helpful for the hyperactivity and impulsivity symptoms.

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Tics decreased the most in the combination group, then the clonidine-alone, and then the methylphenidatealone group. Although one would be concerned about a worsening of tics in the methylphenidate group, the proportion of individual subjects having a worsening of tics was not different among the three active treatment groups. The group concluded that ‘prior recommendations to avoid methylphenidate in these children because of concerns of worsening tics are unsupported by this trial.’ Combined pharmacotherapy of ADHD with comorbid tics sometimes (typically methylphenidate and clonidine) has increased in clinical practice, but monitoring of blood pressure and pulse is required especially in the early stages of treatment. Methylphenidate has hypertensive effects on blood pressure, whereas clonidine has hypotensive effects; therefore, proper dosage and taper on discontinuation are imperative to safeguard against large fluctuations in blood pressure (Popper 1995), and the rare case reports of sudden death for a few children on concomitant medications are not well studied. The Tourette Syndrome Association (TSA) has published a review, and in general caution is required for concomitant medications with consideration of regular ECG monitoring. Noradrenergic and dopaminergic antidepressants have been used clinically as second-line medications in the treatment of the ADHD symptoms in children with comorbid tic disorders. Spencer and colleagues (2002) reported that desipramine was associated with a clinically significant reduction in both tic and ADHD symptoms in children and adolescents with ADHD and comorbid tic disorders. Atomoxetine, a noradrenergic reuptake inhibitor, has been reported to be effective for the treatment of ADHD (Michelson et al. 2001) and has recently received FDA approval for this indication. Studies are under way to determine whether atomoxetine might be effective in treating symptoms of ADHD, and not worsen tics. The question remaining is, ‘which medication should be chosen to treat a tic disorder?’ First, functional impairment and distress experienced by the child with TS must be delineated. Moderate to severe symptoms may be treated with clonidine if the patient has responded positively to neuroleptics in the past. Clonidine is slow acting (long latency period), therefore neuroleptics may be the first choice in the treatment of severe, abrupt exacerbation of tics. Work-up of acuteonset tics, as detailed earlier for OCD, should be performed when a case is suspect for infectious triggers, especially those involving GABHS. Clonidine or guanfacine may have a lesser risk of serious adverse effects such as TD, and may improve restlessness and irritability associated with comorbid ADHD symptoms. Pharmacologic treatment of TS is palliative, not curative. The decision to treat must be based on interference, distress, and impairment in the patient’s life – the mere

presence of tics does not mandate pharmacologic treatment. Reduction, rather than elimination, of tics to a ‘socially acceptable’ level should be the focus. Children should be allowed to have more frequent tics at home, making it a ‘tic safe’ place. This attitude is important in helping the youngster cope, especially since anxiety, stress, and fatigue can exacerbate tics. Family therapy may be necessary to help parents cope with the child’s tics. Since tics are often comorbid with OCD, ADHD, and other behavioral difficulties, target symptoms must be identified. Not uncommonly, an SSRI is used to decrease anxiety in the child or adolescent, and this may indirectly result in a decrease of tics. If a child has significant anxiety, and that is treated adequately, then some children do well on a combination of a SSRI and a neuroleptic. In general, the SSRIs are not likely to cause exacerbations of tic symptoms (Scahill et al. 1997). Other behavioral difficulties may be the predominant problem for the patient, in which case a different treatment approach may be utilized (i.e., a different class of drugs, cognitive behavioral therapy first). Different classes of drugs would be expected to reduce tics rather than diminishing behavioral symptoms of ADHD or OCD. One would start at a low dose and slowly titrate medications until improvement occurs or intolerable side effects develop. Generally, one would maintain a patient on medication for the shortest time possible. Clinicians should consider lowering a dose periodically to determine whether tics have remitted over time.

Investigational treatments for OCD and tic disorders Attention has focused on novel therapies for the subgroup of children with OCD and tic disorders who meet the criteria for PANDAS (Swedo et al. 1998). Children with abrupt and dramatic onset of OCD or tics merit a review of recent medical illnesses and a GABHS workup, as detailed earlier in the chapter. If a child were to meet the criteria for PANDAS, would penicillin prophylaxis prevent GABHS infections and thereby relapses of OCD and tic symptoms? Garvey and colleagues at the NIMH (1999) enrolled thirty-seven children in an eightmonth, double-blind, placebo-controlled crossover trial of penicillin V (250 mg twice daily) and placebo. Although there was no difference in OCD or tic severity in the penicillin versus the placebo phase, there were multiple GABHS infections in both phases. Thus, penicillin did not provide adequate prophylaxis in this study. Further studies are needed to develop effective prophylaxis, and then to determine whether the potential risks of antibiotic administration outweigh the study for potential benefit of the neuropsychiatric symptoms (Garvey et al. 1999). Immunomodulatory therapy has been used in the treatment of Sydenham’s chorea (SC). Perlmutter and colleagues (1999) at the NIMH hypothesized that if

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the cause of PANDAS was similar to that of SC, then immunomodulatory therapies might be effective for the neuropsychiatric symptom exacerbations in PANDAS children. Children with severe symptoms of PANDAS were enrolled to receive randomly either plasma exchange, intravenous immunoglobulin (IVIG), or placebo (given in a similar fashion to the IVIG). Twenty-nine children completed the trial, and both IVIG and plasma exchange were effective in decreasing the symptom severity in this group. The authors cautioned that a careful consideration of the risk–benefit ratio is needed, and that immunomodulatory treatments should only be conducted in investigational protocols and in the most severe children (Perlmutter et al. 1999). Hence, further studies are needed in this respect.

FUTURE DIRECTIONS More systematic studies need to be carried out in children to determine the safety and efficacy of pharmacologic agents for the treatment of OCD and TS/tic disorders. Psychosocial and multimodal interventions are often important components of any treatment plan. Further investigations into combined treatments are essential. Educational advocacy is often required for these disorders. With the many treatment modalities available, children and adolescents affected by OCD and/or TS and their families can often significantly improve their symptoms and their overall functioning.

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276 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood Journal of the American Academy of Child and Adolescent Psychiatry 38: 1180–1185, 1999. Sallee, F.R., Nesbitt, L., Jackson, C., et al. Relative efficacy of haloperidol and pimozide in children and adolescents with Tourette’s disorder. American Journal of Psychiatry 154: 1057–1062, 1997. Sallee, F.R., Kurlan, R., Goetz, C.G., Singer, H., Scahill, L., Law, G., Dittman, V.M., Chappel, P.B. Ziprasidone treatment of children and adolescents with Tourette’s syndrome: a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry 39: 292–299, 2000. Saxena, S., Brody, A.L., Schwartz, J.M., Baxter, L.R. Neuroimaging and frontal-subcortical circuitry in obsessive–compulsive disorder. British Journal of Psychiatry (Suppl.) 35: 26–37, 1998. Scahill, L., Riddle, M.A., King, R.A., et al. Fluoxetine has no marked effect on tic symptoms in patients with Tourette’s syndrome: a double-blind placebo controlled study. Journal of Child and Adolescent Psychopharmacology 7: 75–85, 1997. Scahill, L., Chappell, P.B., Kim, Y.S., Schultz, R.T., Katsovich, L., Shepherd, E., Arnsten, A.F., Cohen, D.J., Leckman, J.F. A placebo-controlled study of guanfacine in the treatment of children with tic disorders and attention deficit hyperactivity disorder. American Journal of Psychiatry 58: 1067–1074, 2001. Shapiro, A.K., Shapiro, E.S., Young, J.G., et al. (eds) Gilles de la Tourette Syndrome, 2nd edition. New York: Raven Press, 1987. Singer, H.S., Walkup, J.T. Tourette syndrome and other tic disorders: diagnosis, pathophysiology, and treatment. Medicine 70: 15–32, 1991. Spencer, T., Biederman, J., Coffey, B., Geller, D., Crawford, M., Bearman, S.K., Tarazi, R., Faraone, S.V. A doubleblind comparison of desipramine and placebo in children and adolescents with chronic tic disorder and comorbid attention-deficit/hyperactivity disorder. Archives of General Psychiatry 59: 649–656, 2002. Steingard, R.J., Biederman, J., Spencer, T., et al. Comparison of clonidine response in the treatment of attention-deficit hyperactivity disorder with and without comorbid tic disorders. Journal of the American Academy of Child and Adolescent Psychiatry 32: 350–353, 1993. Swedo, S.E. Sydenham’s chorea: a model for childhood autoimmune neuropsychiatric disorders. Journal of the American Medical Association 272: 1788–1791, 1994. Swedo, S.E., Rapoport, J.L., Cheslow, D.L., et al. High prevalence of obsessive–compulsive symptoms in patients with Sydenham’s chorea. American Journal of Psychiatry 146: 246–249, 1989a. Swedo, S.E., Rapoport, J.L., Leonard, H.L., et al. Obsessivecompulsive disorder in children and adolescents: clinical phenomenology of 70 consecutive cases. Archives of General Psychiatry 46: 335–341, 1989b.

Swedo, S.E., Schapiro, M.B., Grady, C.L., et al. Cerebral glucose metabolism in childhood-onset obsessive– compulsive disorder. Archives of General Psychiatry 46: 518–523, 1989c Swedo, S.E., Pietrini, P., Leonard, H.L., Schapiro, M.B., Rettew, D.C., Goldberger, E.L., Rapoport, S.I., Rapoport, J.L., Grady, C.L. Cerebral glucose metabolism in childhood onset obsessive–compulsive disorder: Revisualization during pharmacotherapy. Archives of General Psychiatry 49: 690–694, 1992. Swedo, S.E., Leonard, H.L., Schapiro, M.B., et al. Sydenham’s chorea: physical and psychological symptoms of St. Vitus dance. Pediatrics 91: 706–713, 1993. Swedo, S.E., Leonard, H.L., Kiessling, L.S. Speculations on antineuronal antibody-mediated neuropsychiatric disorders of childhood: commentaries. Pediatrics 93: 323–326, 1994. Swedo, S.E., Leonard, H.L., Mittleman, B.B., Allen, A.J., Rapoport, J.L., Dow, S.P., Kanter, M.E., Chapman, F., Zabriskie, J. Identification of children with pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections by a marker associated with rheumatic fever. American Journal of Psychiatry 154: 110–112, 1997. Swedo, S.E., Leonard, H.L., Garvey, M., et al. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. American Journal of Psychiatry 155: 264–271, 1998. Taylor, J.R., Morshed, S.A., Parveen, S., et al. An animal model of Tourette’s syndrome. American Journal of Psychiatry 159: 657–660, 2002. Thomsen, P. Obsessive–compulsive disorder in children and adolescents. Acta Psychiatrica Scandinavica 88: 212–217, 1993. Thomsen, P. Child and adolescent obsessive–compulsive disorder treated with citalopram: findings from an open trial of 23 cases. Journal of Child and Adolescent Psychopharmacology 7: 157–166, 1997. Tourette’s Syndrome Study Group. Treatment of ADHD in children with tics: a randomized controlled trial. Neurology 58: 527–536, 2002. Valleni-Basile, L.A., Garrsion, C.Z., Waller, J.L., et al. Incidence of obsessive–compulsive disorder in a community sample of young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 35: 898–906, 1996. van der Linden, C., Bruggeman, R., Van Woerkom, T. Serotonin-dopamine antagonist and Gilles de la Tourette’s syndrome: an open, pilot, dose-titration study with risperidone. Movement Disorders 9: 687–688, 1994. Vitulano, L.A., King, R.A., Scahill, L., et al. Behavioral treatment of children and adolescent with trichotillomania. Journal of the American Academy of Child and Adolescent Psychiatry 31: 139–146, 1992.

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Suggested reading de Hann, E., Hoogduin, K.A.L., et al. Behavior therapy versus clomipramine for the treatment of

obsessive–compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry 37: 1022–1029, 1998. Jenike, M.A. Psychotherapy of obsessive–compulsive disorder. In Jenike, M.A. (ed.), Obsessive-Compulsive Disorder: Practical Management. Chicago: Mosby-Year Book, 1998, pp. 611–624. Leonard, H.L., Topol, D., Bukstein, O., et al. Clonazepam as an augmenting agent in the treatment of childhood onset obsessive compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry 33: 792–794, 1998. March, J. Current status of pharmacotherapy for pediatric anxiety disorders. In Beidel, D. (ed.), Treating Anxiety Disorders in Youth: Current Problems and Future Solutions (ADAA/NIMH). Washington, DC: Anxiety Disorders Association of American, 1999, pp. 42–62.

5.3 Anxiety disorders during adolescence MOHAMMAD HAERIAN, GLORIA REEVES, AND SUSHMA JANI

INTRODUCTION Anxiety disorders in adolescence are often misdiagnosed and overlooked. Inherent in making these diagnoses are several difficulties. First, the distinction between normal and pathological anxiety may be unclear, since adolescent development is marked by many anxiety-provoking experiences. Worries over ‘fitting in’ with peers, nervousness about dating, and fears about becoming independent are examples familiar to most adolescents. When anxiety symptoms become more pervasive and troublesome, they may still be misattributed to ‘normal’ adolescent experience until prominent behavioral symptoms manifest, such as complete school refusal. Second, adolescent anxiety disorders have high rates of psychiatric comorbidity. Disruptive behavior problems, such as hyperactivity, may be more readily apparent than internalized anxiety symptoms. Agitation and dysphoria from untreated anxiety disorders may also be misattributed to a comorbid condition, such as depression or Attention Deficit Hyperactivity Disorder (ADHD). A final challenge is that the diagnostic classification of anxiety disorders has undergone major revisions. Syndromes such as Overanxious Disorder and Avoidant Disorder of Childhood were eliminated from DSM-IV because of specificity concerns and efforts to reconsider diagnoses such as Generalized Anxiety Disorder on a developmental spectrum. Diagnostic criteria may need further modification to address differences between adult and childhood presentations, and thus improve the sensitivity and specificity of the criteria.

THEORETICAL CONSIDERATIONS Despite the above difficulties, our understanding of anxiety disorders continues to evolve. Theories about etiology

involve biologic, psychological, and even evolutionary factors. Anxiety is closely related to the primitive experience of fear, a feeling of hyperarousal that signals potential threats or dangers. The adaptive value of fear or anxiety lies in the anticipation or detection of true dangers, which are not always external. For example, hypoglycemia and other metabolic disturbances may cause a physiologic induced state of anxiety. Darwin (1873) noted that physical signs, including dilated pupils, labored breathing, and pale skin tone, were evident when fear progressed to terror. He questioned the adaptive value of such intense fear because it seemed to reduce the efficiency and effectiveness of an organism’s response. Similarly, anxiety is considered pathologic when it negatively affects biologic, social, or psychological functioning. Anxiety is also maladaptive when it signals dangerousness in nonthreatening situations, such as a social gathering. Psychoanalytic theorists focused on the unconscious, psychological roots of anxiety. Freud (1926) hypothesized that anxiety resulted from conflict between an instinctual drive and an internal inhibition. For example, the failure of the ego to repress or modulate aggressive impulses may generate emotional tension, and anxiety would be the conscious experience of this underlying conflict. Otto Rank (1924) emphasized birth trauma as a basis for anxiety experiences, suggesting that separation from the all-gratifying womb caused what he termed ‘primal anxiety,’ the template for anxiety experiences. Cognitive behavioral theories implicated the role of thought distortion in creating distress. Beck (1967) theorized how all-or-nothing, catastrophic, and overexaggerated thinking can negatively distort a person’s world view and generate feelings of anxiety and depression. Imaging studies have implicated some neuroanatomic sites in the modulation of fear and anxiety responses. The amygdala contains primitive neural circuits involved in fear conditioning. A functional magnetic resonance

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imaging (MRI) study of adults with Social Phobia showed enhanced amygdala response during observation of facial expressions (Pine and Grun 1994). Also, a preliminary MRI study of children and adolescents revealed significantly larger right and total amygdala volumes than in matched control subjects (De Bellis et al. 2000). The locus coeruleus may also modulate anxiety responses. Some medications that decrease hyperarousal (e.g., clonidine) decrease neural activity in that area (Kashani et al. 1991). Anxiety is also associated with dysregulation of neurotransmitter and neuroendocrine systems. Growth hormone response to clonidine challenge is blunted in patients with Generalized Anxiety Disorder, and central benzodiazepine receptor function is reduced in Panic Disorder and Generalized Anxiety Disorder patients (Nutt 2001). Kagan et al. (1987) suggested that youth with behaviorally inhibited temperaments are prone to increased arousal via the limbic–sympathetic axes. Inhibited temperament has been associated with increased noradrenaline (norepinephrine) levels (Kagan et al. 1988) and increased risk of anxiety disorders compared with nonbehaviorally inhibited children (Rosenbaum et al. 1991). Familial studies indicate significant heritability of anxiety disorders. In a community sample, Panic Disorder in a parent was associated with a three-fold increase in the risk of separation anxiety in the child (Woodward and Fergusson 2001). Also, a heritability estimate of 30 per cent has been reported for Generalized Anxiety Disorder (Wagner 2001). Finally, 70 per cent of children with selective mutism have a first-degree family member with a history of social anxiety disorder (Moutier and Stein 1999).

EPIDEMIOLOGY Community studies have reported anxiety disorders as the most prevalent psychiatric diagnoses (Benjamin et al. 1990). Epidemiologic studies suggest a high prevalence of anxiety disorders in adolescence, ranging from 5 to 17 per cent (Woodward and Fergusson 2001). Hayward et al. (1989) studied 95 ninth-graders and found a lifetime prevalence of 11.6 per cent for panic attacks, while Anderson et al. (1987) reported a one-year rate of 3.5 per cent for Separation Anxiety Disorder and 2.9 per cent for Generalized Anxiety Disorder for a population of over 700 eleven-year-olds. Half of these anxiety disorder cases had at least one comorbid diagnosis.

SEPARATION ANXIETY DISORDER The essential features for the diagnosis of Separation Anxiety Disorder are excessive distress when away from home or main attachment figures, as well as persistent worry about one’s safety or a parent’s safety during that

separation (DSM-IV). Adolescents with this disorder may refuse to attend school, avoid social activities, or have difficulty going to sleep away from a major attachment figure. They may have nightmares or prominent somatic complaints during periods of separation. Onset of symptoms must occur by age eighteen years, and must last for a duration of at least four weeks. Prevalence in adolescence has been reported as 0.7 to 2.4 per cent (Benjamin et al. 1990). Separation anxiety can be particularly challenging during adolescence since the normal developmental task is to achieve some independence from parents and a stronger affiliation with peers.

PANIC DISORDER Separation anxiety has been theorized as a predecessor or risk factor for adult panic disorder (Biederman 1990). Panic Disorder is defined as the presence of recurrent, unexpected panic attacks followed by persistent concerns of having an attack, worries about the consequence of the attacks, or behavior changes related to the attacks (DSM-IV). Panic attacks are discrete episodes of intense fear and distress. Physical symptoms include palpitations, diaphoresis, and tremulousness; and psychological symptoms include fear of dying or going crazy and feelings of depersonalization. Patients often describe the experience as feeling like a heart attack, and they may undergo extensive testing in emergency rooms and primary care clinics because of the severity of the distress. Panic Disorders are further classified by whether or not agoraphobia symptoms are present. Thus, the anticipation of panic attacks is an important and potentially disabling feature of this illness. Panic Disorder is rare in pre-pubertal development. In a study by Hayward et al. (1992) of middle-school students, 5.3 per cent of sixth and seventh grade students reported at least one panic attack. However, none of the Tanner stage I students (n ⫽ 94) reported experiencing a panic attack.

GENERALIZED ANXIETY DISORDER Generalized Anxiety Disorder, in contrast, may present with more internalized and pervasive symptoms. DSM-IV criteria define General Anxiety Disorder as excessive anxiety and worry that occurs over the majority of at least six months. Anxiety is associated with at least three of the following symptoms: restlessness, fatigue, poor concentration, irritability, muscle tension, or sleep disturbance. Only one symptom is required in children. Youth with this disorder are often characterized as overly mature, perfectionistic, and sensitive to criticism. Adolescents are more likely than children to report brooding, and children are more likely than adolescents to report need for reassurance

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(Wagner 2001). Symptoms of sleep disturbance, fatigue, and irritability overlap with symptoms of depression, so it is important for the clinician to probe carefully for prominent anxiety and worries to distinguish these syndromes. It is equally important to interview the adolescent individually since parents and teachers may not be aware of these internalized symptoms.

SOCIAL PHOBIA Social Phobia, or Social Anxiety Disorder, gained increased public attention through television advertisements that promote medication treatment options. An essential feature of this disorder is the persistent and distressing fear of humiliating oneself in a social or performance situation. Social or performance situations are avoided or else they cause great distress. Children may express anxiety by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people. Also, the anxiety must occur in the presence of peers as well as adults, and youth must have the capacity for age appropriate social relationships (DSM-IV). Mean onset typically occurs during adolescence, between thirteen and twenty years, and onset after twenty-five years is rare (Moutier and Stein 1999). In evaluating an adolescent, it is important to assess for other factors that may contribute to social anxiety, such as speech disorders, hearing problems, and learning disabilities, which frequently cause stress in a variety of social and school settings. Detection and management of these problems usually helps to reduce excessive fears of embarrassment. Also, it is important to consider external factors, such as abuse or neglect, as a source for the anxiety symptoms since it may be difficult to distinguish Post Traumatic Stress Disorder from other anxiety disorders if information about abuse is not forthcoming.

SPECIFIC PHOBIA Specific Phobia is defined as persistent and excessive fear cued by a specific object or situation. The avoidance, anxious anticipation, or distress in the feared situations interferes significantly with functioning. For children and adolescents, symptoms must persist for at least six months (DSM-IV). Stimulus for anxiety seems to evolve with development; for example, children are more likely to report fears of the dark, whereas adolescents are more likely to report fear of heights or public speaking. Adolescents are also more likely than pre-adolescents to worry about blushing or feeling more self-conscious (Bernstein et al. 1996). The manifestation of these fears may become more prominent as the developmental tasks of adolescence focuses on social skills and peer acceptance.

PSYCHIATRIC COMORBIDITY Comorbidity of anxiety disorders with other psychiatric conditions is quite common. Approximately one-third of patients with ADHD have a comorbid anxiety disorder, and studies have shown high comorbidities of anxiety and affective disorders (Biederman 1990). Community samples of children and adolescents report a 32–75 per cent comorbidity between depression and anxiety disorders (Kutcher et al. 1992). Comorbidity among the anxiety disorders themselves is reported to be as high as 50 per cent or more in other clinical studies (Last et al. 1987). An important developmental issue that affects comorbidity is that adolescence often is a period of experimentation with alcohol or drugs. Anxiety symptoms may be associated with or caused by cannabis, stimulants, caffeine, or other substances of abuse. For example, heavy cigarette smoking during adolescence is associated with increased risk for agoraphobia, General Anxiety Disorder, and Panic Disorder during early adulthood (Johnson et al. 2000). Kendall et al. (2001) investigated the impact of psychiatric comorbidity on anxiety treatment outcomes in children aged eight to thirteen years old with Separation Anxiety Disorder, General Anxiety Disorder, or Social Phobia. A large majority (79%) of subjects with a primary anxiety disorder had at least one comorbid diagnosis, most commonly another anxiety disorder. Comorbidity, however, did not moderate response to a cognitive behavioral treatment program. The authors suggest that treatments geared towards anxiety disorders might also have secondary benefits on non-anxiety conditions. For example, relaxation training may help reduce fidgeting in ADHD, and reduction of anxious mood may decrease disruptive behavior in Oppositional Defiant Disorder. Manassis and Monga (2001) described the importance of increasing structure for anxious children with comorbid conditions. Since these children may be particularly reactive to minor changes, the implementation and reminders of routines may help alleviate worries and prevent further exacerbations of anxiety.

COURSE OF ILLNESS Current research has already started to address the question of how anxiety symptoms may persist or evolve over time. A prospective study by Pine et al. (1998) followed a randomly selected cohort of over 700 subjects aged nine to eighteen years. Initial diagnostic evaluations were reassessed at two- and nine-year intervals. Results indicated some specificity for Simple and Social Phobia over time: that is, adolescent social phobia predicted primarily adult Social Phobia and adolescent Simple Phobia predicted primarily adult Simple Phobia. General Anxiety Disorder, in contrast, was less specific over time.

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Woodward and Fergusson (2001) conducted a twentyone-year longitudinal study of 1265 New Zealand children from birth. These children were evaluated at ages fifteen and sixteen years for anxiety disorders by using DSM-IIIR criteria, and 11 per cent met criteria for Generalized Anxiety Disorder, 2.9 per cent for social phobia, and 1.7 per cent for Separation Anxiety Disorder. The children were divided into four groups based on the number of anxiety disorders present (zero to three). Follow-up evaluations at ages eighteen and twenty-one years assessed for depression, anxiety, substance abuse, educational outcomes, employment, and parenting status. From the original sample, 964 subjects were retained through age twentyone years. The presence of anxiety disorders at ages fifteen and sixteen significantly increased the risk for anxiety disorder, major depression, and substance dependence in young adulthood, as well as failure to attend a university.

TREATMENT Treatment options for anxiety disorders include an array of pharmacologic agents and a variety of therapies. A fundamental treatment objective is to help the patient regain a sense of mastery or control. This objective is particularly important for adolescents who are struggling with their normal developmental challenge of becoming more independent from their family. Adolescents should always be involved in decision making about treatment options, and they should be asked directly for feedback and input. Clinicians can help manage transference reactions of authority defiance by describing their role as an information provider, to enable the adolescent to make an informed decision about treatment options. This approach can help accomplish a few important objectives. It helps facilitate good rapport since the adolescent’s input is valued. Also, it role models for the patient a health coping strategy for dealing with anxiety-provoking situations. The adolescent is encouraged verbally to express concerns and seek out information that may reduce their worries. This method should not diminish the role of families or clinicians in making treatment decisions, but rather it should elevate the adolescent to the important status of an integral member of the treatment team. Several types of medication are useful in the treatment of adolescent anxiety disorders. The mainstay of pharmacologic treatment are antidepressant medications. Geller et al. (1999) examined double-blind, placebo-controlled studies of tricyclic medications in the treatment of Separation Anxiety Disorder and School Phobia. Of the three studies reported in the literature, one showed benefit of imipramine over placebo, one showed no significant benefit of imipramine over placebo, and one study showed negative effect of clomipramine over placebo.

A difficulty of interpreting these results is that School Phobia or refusal does not equal separation anxiety. The medication may have been effective for this target symptom, but it is unclear if it was enough to ameliorate the disorder. A review by Wagner (2001) reported that there are no published studies of the use of tricyclic antidepressants in the treatment of Generalized Anxiety Disorder. Concerns about using tricyclic medications include lethality in overdose and case reports of unexplained, sudden death in children treated with desipramine (Varley and McClellan 1997). Furthermore, adherence to electrocardiogram (ECG) monitoring or blood levels may be particularly challenging with adolescents. Selective serotonin reuptake inhibitor (SSRI) antidepressants are another option in the medication treatment of anxiety disorders. Fluoxetine has been the most extensively studied SSRI in the treatment of children and adolescents, but large placebo-controlled studies have been conducted mainly for the treatment of Major Depressive Disorder and Obsessive–Compulsive Disorder (Emslie et al. 1999). Significant improvement of social and separation anxiety symptoms has been shown in open-label studies of fluoxetine (Birmaher et al. 1994) and sertraline (Compton et al. 2001), and paroxetine is FDA-labeled for the treatment of Social Phobia in adults. Fairbanks et al. (1997) conducted an open-label study of fluoxetine in the treatment of mixed anxiety disorders. Eleven of the subjects had coexisting anxiety disorders, and the mean daily dose of fluoxetine for all subjects was 35 ⫾ 17.1 mg. Among the six patients with a diagnosis of Generalized Anxiety Disorder, only one patient was rated as significantly improved, although four showed some benefit. Difficulties in using SSRI antidepressants include the potential for drug–drug interactions via the cytochrome P450 system, sexual side effects, behavioral dysinhibition, and akathisia. Other types of antidepressants such as mirtazapine, nefazodone, and buproprion, need to be studied further to determine if there is any benefit of their use in the treatment of anxiety disorders in children and adolescents. Benzodiazepines, which can be quite effective in treating adult anxiety disorders, may be somewhat more problematic in treating children and adolescents. In one study of 130 children aged from seven to seventeen years, 10 per cent of patients experienced a paradoxical response to chlordiazepoxide, namely hyperactivity, behavioral dysinhibition, and rage (Kraft 1965). An advantage of using benzodiazepines is that they generally alleviate anxiety symptoms more quickly than other anxiolytic medications. A thorough substance abuse history should be assessed prior to starting the medication, and information should be provided on potential for withdrawal if the medication is stopped abruptly. Buspirone, a serotonin agonist, is an alternative treatment that is not a controlled substance. Some open-label trials of buspirone in the treatment of Generalized Anxiety Disorder have shown

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significant reduction in Hamilton Anxiety Scale Scores (Kutcher et al. 1992). Although side effects are generally benign, adherence to the regimen may be challenged by the need for multiple dosing throughout the day. Nonpharmacologic treatment of anxiety disorders may involve a variety of therapeutic approaches, including individual, group, or family therapy. Kendall (1993) described the cognitive behavioral approach to anxiety disorders as a collaborative, problem-solving interaction. In the treatment of children and adolescents, he emphasized the need to distinguish between cognitive deficiencies, or absence of thought, and cognitive distortions. The interventions may need to be geared towards developing basic cognitive awareness and developing conscious thought response to stress before being able to challenge distorted or faulty thinking. Behavior therapy may be particularly helpful for the treatment of specific phobias. Systematic desensitization involves graduated exposure to the fearful stimulus so that the patient can master the experience over time. Psychodynamic and psychoanalytic approaches help the adolescent identify underlying conflicts which may cause or exacerbate their anxiety. Consistent and predictable availability of the therapist can help to decrease the patient’s anxiety about treatment and facilitate transference development. Nonindividual therapy approaches include family and group therapy. Family therapy has several advantages. First, parents or family members may be inadvertently reinforcing avoidant or anxious behavior. For example, a parent may allow their teenager to stay home from school and social activities in order to distract from marital or other family difficulties. Second, the high degree of heritability of anxiety disorders suggests that parents of anxious children may also be experiencing panic or anxiety symptoms. Although the adolescent may be the designated patient, parents may also be suffering with disabling anxiety. Group therapy may benefit socially anxious adolescents by providing an ‘in-vivo’ experience of their difficulties. It allows for a safe environment to experience social interactions, and allows adolescents to get feedback on their social skills from peers. From a developmental perspective, adolescents may place greater weight and trust in the perception of other teenagers.

CONCLUSION Anxiety disorders can cause significant distress during adolescent development. Internal experiences of worry or panic combined with behavioral inhibitions, such as school refusal or agoraphobia, can interfere with social, psychological, and academic functioning. Further research is needed to elucidate how anxiety symptoms

may present differently from childhood to adulthood as well as a need for well-controlled studies of medications used to treat adolescent anxiety disorders. Long-term follow-up of children and adolescents is needed to assess both vulnerability and protective factors towards expression of anxiety symptoms in adulthood.

REFERENCES Anderson, J.C., Williams, S., McGee, R., Siva, P.A. DSM-III disorders in preadolescent children: prevalence in a large sample from the general population. Archives of General Psychiatry 44: 69–76, 1987. Beck, A.T., Rush, A.J., Shaw, B.E., et al. Cognitive Therapy of Depression. New York: Harper & Row, 1967. Benjamin, R.S., Costello, E.J., Warren, M. Anxiety disorders in a pediatric sample. Journal of Anxiety Disorders 4: 293–316, 1990. Bernstein, B.A., Borchardt, C.M., Perwien, A.R. Anxiety disorders in children and adolescents: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 35: 1110–1119, 1996. Biederman, J. The diagnosis and treatment of adolescent anxiety disorders. Journal of Clinical Psychiatry 51: 20–26, 1990. Birmaher, B., Waterman, G.S., Ryan, N., et al. Fluoxetine for childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry 33: 993–999, 1994. Compton, S.N., Grant, P.J., Chrisman, A.K., et al. Sertraline in children and adolescents with social anxiety disorder: an open trial. Journal of the American Academy of Child and Adolescent Psychiatry 40: 564–571, 2001. Darwin, C. The Expression of Emotions in Man and Animals. New York, NY: Appleton, 1873. De Bellis, M.D., Casey, B.J., Dahle, R.E., et al. A pilot study of amygdala volumes in pediatric generalized anxiety disorder. Biologic Psychiatry 48: 51–57, 2000. Emslie, G.J., Walkup, J.T., Pliszka, S.R., Ernst, M. Nontricyclic antidepressants: current trends in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 517–528, 1999. Fairbanks, J.M., Pine, D.S., Tancer, N.K., Dummet, E.S., III, et al. Open fluoxetine treatment of mixed anxiety disorders in children and adolescents. Journal of the American Academy of Child and Adolescent Psychopharmacology 7: 17–29, 1997. Freud, S. Inhibitions, symptoms, and anxiety. In Strachey, J. (ed,), The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 20. London: Hogarth Press, 1959, pp. 75–174.

Anxiety disorders during adolescence 283 Geller, B., Reising, D., Leonard, H.A., Riddle, M.D., Walsh, B.T. Critical review of tricyclic antidepressant use in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 513–516, 1999. Hayward, C., Killen, J.D., Taylor, C.B. Panic attacks in young adolescents. American Journal of Psychiatry 146: 1061–1062, 1989. Hayward, C., Killen, J.D., Hammer, L.D. Pubertal stage and panic attack history in sixth- and seventh-grade girls. American Journal of Psychiatry 149: 1239–1243, 1992. Johnson, J.G., Cohen, P., Pine, D.S., et al. Association between cigarette smoking and anxiety disorders during adolescence and early adulthood. Journal of the American Medical Association 18: 2348–2351, 2000. Kagan, J., Reznick, J.S., Gibbons, J. The physiology and psychology of behavioral inhibition in children. Child Development 56: 1459–1473, 1987. Kagan, J., Reznick, J.S., Gibbons, J. Biological bases of childhood shyness. Science 240: 167–171, 1988. Kashani, J.H., Dandoy, A.C., Orvaschel, H. Current perspectives on anxiety disorders in children and adolescents: an overview. Comprehensive Psychiatry 32: 481–495, 1991. Kendall, P.C. Cognitive-behavioral therapies with youth: guiding theory, current status, and emerging developments. Journal of Consulting and Clinical Psychology 61: 235–247, 1993. Kendall, P.C., Brady, E.U., Verduin, T.L. Comorbidity in childhood anxiety disorders and treatment outcome. Journal of the American Academy of Child and Adolescent Psychiatry 40: 787–794, 2001. Kraft, I. A clinical study of chlordiazepoxide use in psychiatric disorders of children. International Journal of Neuropsychiatry 1: 433–437, 1965. Kutcher, S.P., Reiter, S., Gardner, D.M., Klein, R.G. The pharmacotherapy of anxiety disorders in children and adolescents. Psychiatric Clinics of North America 15: 41–63, 1992.

Last, C.G., Strauss, C.C., Francis, G. Comorbidity among childhood anxiety disorders. Journal of Nervous and Mental Disease 175: 726–730, 1987. Manassis, K., Monga, S. A therapeutic approach to children and adolescents with anxiety disorders and associated comorbid conditions. Journal of the American Academy of Child and Adolescent Psychiatry 40: 115–117, 2001. Moutier, C.Y., Stein, M.B. The history, epidemiology, and differential diagnosis of social anxiety disorder. Journal of Clinical Psychiatry 60: 4–8, 1999. Nutt, D.J. Neurobiological mechanisms in generalized anxiety disorder. Journal of Clinical Psychiatry 62: 22–27, 2001. Pine, D.S., Grun, J. Childhood anxiety: integrating developmental psychopathology and affective neuroscience. Applied and Developmental Psychology 15: 345–365, 1994. Pine, D.S., Cohen, P., Gurley, D., et al. The risk for early adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General Psychiatry 55: 56–64, 1998. Rank, O. The Trauma of Birth. New York: Harcourt, Brace, 1924. Rosenbaum, J.F., Biederman, J., Hirschfeld, D.R., et al. Further evidence of an association between behavioral inhibition and anxiety disorders: results from a family study of children from a non-clinical sample. Journal of Psychiatric Research 25: 49–65, 1991. Varley, C.K., McClellan, J. Case study: two additional sudden deaths with tricyclic antidepressants. Journal of the American Academy of Child and Adolescent Psychiatry 36: 390–394, 1997. Wagner, K.D. Generalized anxiety disorder in children and adolescents. Psychiatric Clinics of North America 24: 139–153, 2001. Woodward, U., Fergusson, D.M. Life course outcomes of young people with anxiety disorders in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry 40: 1086–1093, 2001.

5.4 Mood disorders and suicide in children and adolescents PARAMJIT T. JOSHI AND JAY A. SALPEKAR

INTRODUCTION Depressive disorders and suicide are known to contribute significantly to serious psychiatric disturbance in childhood and adolescence. Studies indicate that both the incidence of depressive disorders and the rate of suicide in children and adolescents may be increasing. In particular, the suicide rates in young males have increased. Epidemiological studies show that major depression exists in children from preschool ages through adolescence, and that stressful life events are associated with severe depressive symptoms. The incidence of major depression in clinical populations varies widely, from 3 to 33 per cent as described by Robins (1979). The increase in the prevalence of depression as children get older has been reported by several investigators who found a tripling of the rate of depression among ten- to fourteen-year-olds. The prevalence of major depression has been reported to be 4.7 per cent in younger children and 20.8 per cent in middle school and high school students. In addition, the total suicide rate almost doubled between 1947 and 1991 in both sexes. Among children undergoing psychiatric treatment, the prevalence of suicidal ideation and of suicide attempts has been found to be 20.5 per cent and 12.8 per cent respectively, in outpatients (Pfeffer et al. 1980), and 52.3 per cent and 26.2 per cent in inpatients (Pfeffer et al. 1982). These numbers suggest that anyone working with children and adolescents will most likely encounter youngsters who are depressed and possibly suicidal. Epidemiological studies in adults have clearly demonstrated a preponderance of depressive illness in females versus males. However, studies to date do not report a similar preponderance of depressive disorders in young

girls. Yet, overall suicide rates have increased for boys and girls, especially by violent methods, which further contributes to the high suicide mortality rate among the young. These methods, except for firearms, are often hard to restrict. The male:female ratio of suicide rate widened from 6:1 to 8:1 in fifteen- to nineteen-year-olds, while that of twenty- to twenty-four-year-olds narrowed slightly, from 6:1 to 5:1. Prevalence studies in adults have found increased rates of Major Depression in African-Americans as compared to Caucasians. Although there are no definitive studies in young children, there are some reports of increased depressive symptoms in African-American middle school students. However, these reports may have been confounded by the marked disparity in the socioeconomic status of the populations studied. Socially and economically disadvantaged youngsters, identified demographically by paternal education, maternal occupation and family income, have been found to be at increased risk for depression and suicide. Many studies dealing with the suicide methods of the young come from the United States, where the use of firearms is the most common method of committing suicide for both sexes (Shaffer and Fisher 1981). Because the availability of firearms in the homes is a risk factor, especially for adolescent suicide, the removal of guns is recommended in homes with youngsters at high risk (Brent et al. 1995). Furthermore, the restriction of handguns is presumed to reduce suicide mortality in fifteento twenty-four-year-olds. Studies examining the risk factors for suicide in adolescents with depression or alcohol abuse have found that interpersonal separations and difficulties regarding discipline or the law were common recent stressors among the alcohol-abusing adolescents.

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However, interpersonal conflicts and somatic illness were the stressors among those with depressive disorders (Marttunen et al. 1994). The natural history of depressive disorders has been examined extensively in adults since Kraepelin (1921) first described the phenomenology of ‘Manic–Depressive Insanity and Paranoia.’ However, there is a paucity of literature studying the natural course of mood disorders in children and adolescents. Youngsters who have dysthymia and/or major depression often have protracted episodes, are at high risk for further episodes of depression, may spend 50 per cent of their young lives being depressed, and may exhibit suicidal behaviors (Kovacs 1985, 1992). These characteristics, including the fact that 30–50 per cent of young patients with major depression also have underlying dysthymia, are very similar to findings reported in adults, suggesting that these disabling conditions continue across the life span. Adding to this concern is evidence that childhood depression significantly disrupts normal emotional development and academic progress. It seems important that there is integration of various preventative measures of cooperation between mental health professionals and other authorities in the recognition and care of young people at high risk for suicide. Therefore, it is imperative to recognize and identify depressive disorders in youngsters and institute appropriate treatments in order to minimize the morbidity and mortality in the form of suicide that can result.

CLASSIFICATION OF MOOD DISORDERS There are three types of mood disorders described in the DSM-IV. There are no separate criteria for any of the following disorders in children and adolescents, and therefore they are subsumed under the adult criteria: 1 Depressive Disorders: Major Depressive Disorder (MDD), Dysthymic Disorder (DD) and Depressive Disorders not otherwise specified. 2 Bipolar Disorders: Bipolar I Disorder, Bipolar II Disorder, Cyclothymic Disorder and Bipolar Disorder not otherwise specified. 3 Mood Disorder due to a medical condition and Substance-induced Mood Disorder. Mania has been well documented in children and adolescents, although the actual occurrence and presentation remain controversial. Just as with the DSM-IV diagnostic criteria for major depression, there are no separate criteria for Bipolar Disorder in adolescents. However, in the pre-pubertal age groups, patients diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) and additional symptoms of marked irritability, extreme fluctuation of mood and behavior problems have been

assessed by some as having Bipolar Disorder. The older the adolescent, the more likely are symptoms to mirror presentation of adult bipolar patients. The focus of this chapter is primarily on major depressive disorder and suicide in children and adolescents. The diagnostic criteria for MDD in children and adolescents are based on distinct clinical phenomena, which are similar to those applied in adult Affective Disorders. Mood disorders are seen on a continuum through the life span and the core phenomenology and symptom description are similar for children, adolescents and adults (DSM-IV; American Psychiatric Association 1995). However, recent data suggest that the prominence of characteristic symptoms may change with age. Symptoms such as somatic complaints, irritability, and social withdrawal are particularly common in depressed children and adolescents, whereas psychomotor retardation, hypersomnia, and delusions are less common, especially in pre-pubertal children. Despite limitations posed by the criteria in the DSM, those criteria allow uniformity in describing key Affective Disorder symptoms in pre-pubertal children and adolescents. More rigorous criteria allow youngsters to be included in more sophisticated research studies, thereby avoiding the methodologic difficulties encountered in earlier studies where the criteria used were much more vague. Ideally, to validate psychiatric diagnoses, follow-up studies along with family and treatment studies have to be carried out over time. Then, any recurrent episodes of mood disorder in children and adolescents will lend validity and support for the original diagnosis as it continues into adulthood. The DSM-IV diagnostic criteria for a major depressive episode are as follows: 1 Depressed mood, irritability and/or pervasive anhedonia of at least two weeks’ duration, by either subjective report or objective observation by others. These changes should represent a change from previous level of functioning. 2 Five out of the following nine symptoms also of at least two weeks’ duration, by either subjective report or objective observation: Depressed mood and/or irritability; the irritability being the most common affective state seen in children and adolescents almost every day or nearly every day. Appetite disturbance, usually a decrease in appetite with or without weight loss. Failure to make expected weight gains in children and adolescents is considered significant. Infrequently there is an increase in appetite resulting in weight gain. Sleep disturbances seen in children and adolescents are similar to those reported in adults, i.e., initial insomnia, middle-of-the-night awakening, and terminal insomnia or early morning awakening

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occurring nearly every day. Parents are often not aware of sleep changes in their adolescents, but are more so if they occur in the younger children, as parents are much more involved in bedtime rituals with a younger child. Motor restlessness, fidgetiness and trouble sitting still are suggestive of motor agitation; conversely, moving and talking slowly is reflective of motor retardation. The symptoms of motor agitation are often misdiagnosed to be symptoms of an ADHD, and symptoms of motor retardation may be considered a sign of laziness and oppositional behavior. Loss of interest in activities that the youngsters usually engage and participate in is readily observed by parents and teachers. Youngsters tend to become withdrawn, isolated and retreat into themselves. These changes are often of great concern to the parents, teachers, and friends. Loss of energy and lethargy almost daily are often evident in children and adolescents suffering from major depression. Youngsters complain of feeling tired, resist getting up to go to school, tend to nap during the day, lie around and complain of feeling exhausted. This feeling of tiredness and low energy is often puzzling to the youngster and to the parents. It often leads to seeking a medical etiology for the low energy. When this happens, the child is often first seen by a pediatrician. The feelings of guilt and self-reproach often seen in depressed adults can also be a symptom of depression in children and adolescents. However, the concept of guilt is an abstract one and therefore developmentally is often not readily elicited in very young children. Academic impairment secondary to a decrease in the ability to concentrate is a symptom that is readily noticed by teachers and parents as well as the youngsters themselves. Grades tend to drop, or the student may have to work much harder in order to keep up. Often, youngsters describe their mind to be blank and empty or find themselves day-dreaming excessively. Recurring thoughts of death and suicide often occur in young children. It is important to ask about such painful thoughts. Most children, regardless of their age and cognitive abilities, have some concept of death, even if very simple or concrete. These thoughts are of three types: passive death wishes such as ‘I wish I was never born,’ or ‘ I wish I was dead’; active death wishes where the youngster actually thinks of a method to put an end to his/her life, such as ‘taking an overdose’; and lastly proceeding with a suicidal attempt or gesture. 3 The DSM-IV includes exclusionary criteria for the diagnosis of a major depressive episode. These include schizophrenia, direct physiological effects of a substance

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(e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism) and uncomplicated bereavement. 4 Functioning in social, occupational, school or other areas is significantly impaired and causes serious distress as a result of the depressive episode. The symptoms do not meet criteria for a mixed episode, which is characterized by a period of time lasting at least one week in which the patient meets criteria for both a manic episode and a major depressive episode. It is important to keep in mind that very often children will have one or more of the above symptoms during the course of their childhood. However, one should be suspicious of the development of a mood disorder when there is clustering of these symptoms over a given period of time.

ETIOLOGICAL CONSIDERATIONS The argument about nature versus nurture continues to be an important one in the etiology of depression in humans. The issue may not be so much of one or the other; rather, it may be the lack of nurture and the presence of environmental stress and learned helplessness. These factors could be viewed as precipitating or potentiating depressive symptoms in a patient who has the genetic vulnerability for developing major depression. The frequency of psychiatric disorders in the child and adolescent members of extended pedigrees identified through bipolar probands is five-fold higher than in the offspring of healthy parents. In writing about the etiologic aspects of child and adolescent mood disorders, McCracken (1992) has described an interactional approach to understanding depression. The three-factor approach consists of the provoking agents, vulnerability factors, and symptom-formation factors. The provocative factors that have been associated with the development of depression in children and adolescents have been bereavement, impairment of relationship with parents, physical illness and use of certain medications. These provocative factors may interact with vulnerability factors such as positive family history of major depressive disorder, maladaptive cognitive-behavioral patterns and maternal dysfunction. The provoking agents and vulnerability factors then interact with symptom formation influences, which in children and adolescents may include the presence of phobias, anxiety symptoms, and especially separation anxiety. In addition, epidemiological studies have shown a higher risk of suicidality in children and adolescents who experience high levels of perceived family stress. However, it remains unclear how these various forces interact with each other to precipitate a depressive episode in children and adolescents, particularly as these interactions change and as the child gets older.

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There is a growing body of knowledge suggesting that genetic factors play an important role in Affective Disorders. The life-time risk in first-degree relatives is 25 per cent and 20 per cent respectively for bipolar and unipolar Affective Disorder. Concordance studies also show an increase of monozygotic over dizygotic twins for bipolar and unipolar Affective Disorder, with a ratio of 4:2.8 (Weissman and Boyd 1985). There remains a scarcity of genetic studies in children and adolescents, but there are reports of increased history of depression in parents of depressed children. The most systematic longitudinal studies examining the natural course of mood disorders have been carried out by Kovacs (1985). The results of these longitudinal studies reveal that the average length of an untreated major depressive episode is 32 weeks, and 92 per cent of patients recover within eighteen months from the start of the episode. Kovacs also reported that the younger the child at the time of the onset of the episode, the longer it would take for recovery. Therefore, there is an inverse relationship between the length of the depressive episode and the age of the child. A disturbing finding reported by Kovacs was a recurrence rate of major depression in 70 per cent of the children within five years from the onset of the first episode. Kovacs also reported that 40 per cent of children will have a second episode within two years from the time the child recovers from the first episode. The only predictors and risk factors for a second episode that the Kovacs study identified was the concurrence of a diagnosed dysthymic disorder, otherwise referred to as ‘double depression.’ Others have concluded that there is continued risk for recurrence of major depressive disorder into adulthood, with a rate of up to 69 per cent over a period of seven years.

DIAGNOSIS Diagnosis is always based on clinical information obtained from the family and the patient, along with a thorough mental status examination. However, diagnosis can be aided by the use of standardized checklists and questionnaires designed to measure depressive symptomatology in children and adolescents. Commonly used measures include the Beck Depression Scale (Beck et al. 1961), the Children’s Depression Inventory (Kovacs 1985), and the Johns Hopkins Depression Checklist for Children (Joshi et al. 1990). Unlike the latter system, the first two systems are subjective rating scales relying on self-report from the patients with no input from the parents. Children’s selfratings may be much more affected by immediate life circumstances than is so with adults, and therefore may be more variable over time. Structured and semi-structured interviews, such as the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS; Chambers et al.

1985), Diagnostic Interview for Children and Adolescents (DICA-R; Herjanic and Reich 1982), and the Diagnostic Interview Schedule for Children (DISC; Costello et al. 1984), are rigorous diagnostic tools used for clinical and research purposes. In addition to the various diagnostic instruments that are available, clinicians often rely on other methods to help support clinical impressions. Some of these include cognitive and projective testing, such as responses on the Rorschach cards or the Thematic Apperception Test (TAT) stories. Themes indicative of depression, self-blame, undue guilt, hopelessness/helplessness, abandonment, and self-harm or suicide are often prevalent in depressed children. Scores on the cognitive tasks related to memory and concentration are often negatively affected, though usually abate after the child gets well. Artwork is often useful in reflecting the mental state of children and adolescents. Depressed children and adolescents typically draw ill-defined, sad-appearing figures, with decreased intensity of lines, lacking color and organization. Interviewing suicidal children can often pose a challenge to child and adolescent psychiatrists and other mental health professionals. In assessing a depressed and/or suicidal youngster, several factors must be borne in mind. These include the patient’s age, cognitive and emotional maturity, developmental lags such an expressive or receptive language disorder, concept of death, and the impact of parents and their understanding of the suicidality of their child or adolescent. Rating scales based on the severity of the suicidal ideation and attempts can be helpful to measure suicidality. This measure rates suicidality on a scale of one to five: 1 Nonsuicidal. 2 Suicidal ideation: which includes verbalization of a suicidal intention, e.g., ‘I want to kill myself.’ 3 Suicidal threat: includes verbalization of impending suicidal action, which if carried out would lead to harm, e.g., ‘I am going to jump out of a high window or run in front of a car.’ 4 Mild attempt: which includes actual self-destructive action which does not necessarily endanger life, e.g., putting superficial scratches on the arm with a blunt knife or ingesting a few nonlethal pills. 5 Serious attempt: where the youngster actually engages in a suicidal attempt which realistically could have led to death and necessitated intensive medical care, e.g., carbon monoxide poisoning, hanging attempt, or gunshot wound.

BIOLOGICAL MARKERS Several biological markers, such as cortisol secretion and sleep electroencephalogram (EEG) changes, have been associated with depression in adults. In children, the one

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marker that has been studied fairly extensively has been cortisol secretion, using the dexamethasone secretion test (DST). As with most of the adult studies with DST, the results in children and adolescents are generally inconclusive. Growth hormone secretion tests have also been conducted and showed a blunting of the growth hormone secretion after administration of five units of insulin in patients with major depression compared to normal controls. However, as none of these tests has proved to be specific or conclusive, they are not currently being routinely administered in children and adolescents with major depression.

DIFFERENTIAL DIAGNOSIS The issue of major depression occurring in a ‘pure’ form has been examined by several investigators. Studies suggest that at least one-half of pre-pubertal children who meet DSM criteria for major depression have a comorbid psychiatric diagnosis, particularly anxiety disorders and conduct disorders. It is unclear if there is a difference in the clinical presentation, treatment response and longitudinal outcome in those patients with a ‘pure depressive illness’ versus those with additional psychiatric comorbidity. The differential diagnosis should include the following disorders:

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Anxiety disorders, which can often be a comorbid diagnosis. Often, children can have symptoms of separation anxiety disorder presenting clinically with school refusal. It is important to identify children with school refusal secondary to a mood disorder and those without a mood disorder. This differentiation is important in order to make the most appropriate treatment interventions. Mood disorder secondary to a medical condition such as hypothyroidism. Some symptoms of hypothyroidism are identical to those found with a mood disorder, for example, low energy, tiredness, sleep, appetite and weight change, and a decrease in concentration. It is therefore important to obtain thyroid function tests. Another medical condition that can simulate a mood disorder is Chronic Fatigue Syndrome, which may or may not result from infectious mononucleosis. The most salient feature of this syndrome is very low energy level and the inability to function. Infectious mononucleosis can be diagnosed by obtaining a mono screen, which is positive if the Epstein–Barr virus is present. A third medical condition, which can have some of the symptoms of a major depression, is neurally mediated hypotension. This usually causes lethargy, and somatic symptoms such as headaches and a decrease in concentration. This condition can be readily diagnosed by obtaining a ‘tilt test.’ Treatment of this condition often relieves the symptoms.

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Affective changes can also be caused by various medications. The most notorious medications causing such mood changes are steroids. It is remarkable how often parents fail to mention at the original interview if their child is taking steroid medication.

Suicidality can be viewed either as a symptom of a depressive illness – and hence formulated in the ‘disease perspective’ (what the patient has); or as is often seen especially in adolescents, as a behavior, and thus formulated in the ‘behavioral perspective’ (what the patient does) (McHugh and Slavney 1998). The presentation, phenomenology and management of suicidality in these two instances are somewhat different. It is therefore imperative that suicidal ideation and attempts be clearly understood in any given patient with the above two perspectives in mind. Suicidal ideation or attempt in a depressed youngster is secondary to the hopelessness and helplessness experienced, and therefore is part of the constellation of the depressive symptomatology, with the youngster seeing no point in living or even deserving to live. On the other hand, suicidal behavior is often seen in a youngster who may have poor coping skills or is attention-seeking, and exhibits suicidality as a dangerous way to seek help and get attention. In many instances it is an impulsive act at a time of humiliation or acute stress. This behavior is even more dangerous if it occurs in the context of substance abuse. There is also a group of patients who have a combination of the above two factors: that is, have both a depressive illness and a predisposition to being impulsive and resorting to extreme measures such as suicidality. Substance abuse, either in conjunction with a mood disorder and/or a conduct disorder or alone, carries a higher risk of suicide.

TREATMENT Treatment of children and adolescents with major depressive disorders can perhaps be more complicated because of the variables that are often encountered, for example, developmental issues, cognitive immaturity, dependence on the adults in their lives, resistance from the adolescent patient and often lack of clarity of the diagnosis. As mentioned above, the biopsychosocial approach to treatment perhaps best encompasses the three aspects of treatment that should be emphasized: (i) education and illness teaching once the patient has been diagnosed to have major depression; (ii) pharmacotherapy; and (iii) psychotherapy. Depending on the individual needs of a particular patient, some may need more emphasis on the biological aspects of treatment, others the psychosocial, and others may need all three. Education involves an open discussion with the child and his/her parents about the general nature of the disorder, its clinical presentation, prognosis, and specific

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aspects, as it applies to the particular patient in question. Since major depressive illness is usually episodic, the patient and the family should be educated to better recognize recurrences, and to seek treatment in a timely manner. The adolescent and the parents can often be referred to important readings on the subject, seminars, Internet websites, support groups, and other materials available from their child’s treating psychiatrist. Pharmacotherapy in the treatment of childhood depression includes the use of anti-depressants, mood stabilizers, and anti-convulsants (Bostic et al. 1999). Though most of the open studies have shown antidepressants to be effective in the treatment of major depression in the young, most of the rigorous, double-blind, placebocontrolled studies have repeatedly been unable to demonstrate any superiority of antidepressants over placebo. Most of the patients in these studies had a chronic, unremitting course of depressive illness, with a very high degree of comorbidity. In adults, the same drugs have been shown to be efficacious in the treatment of depression, though not to the same degree in those patients who have a high degree of comorbidity. However, compared to the number of adult studies that have included thousands of subjects, there have been very few randomized placebocontrolled studies in children; indeed, participating subjects number just a few hundred.

citalopram in children are generally 5–10 mg/day. The starting dose for fluvoxamine is 10–25 mg/day, and for sertraline is 25–50 mg/day. Fluoxetine in particular – and SSRIs in general – may lead to psychomotor activation early in treatment. Some patients were reported to become disinhibited, impulsive, hyperactive and even self-destructive when treated with higher dosages, as are often required for obsessive–compulsive disorder. Sexually active adolescents sometimes complain of sexual dysfunction that may interfere with medication compliance. Antidepressants in general can sometimes precipitate or induce a manic or hypo-manic episode, especially in those youngsters who are predisposed to developing a bipolar course of the disorder. The advantages of SSRIs are their minimal cardiac, anticholinergic and antihistaminic side effects, and efficacy even with once-daily dosing. They are also generally nonlethal, even when taken in large overdoses.

NEWER ANTIDEPRESSANTS During the past few years, several new antidepressants have been developed that are now being used in children and adolescents. These include venlafaxine (Effexor), bupropion (Wellbutrin), buspirone (Buspar), nefazodone (Serzone), and remeron (Mirtazapine):

• Antidepressants Antidepressants that have been used in the treatment of depression in children and adolescents include the selective serotonin reuptake inhibitors (SSRIs), the relatively newer non-serotonin reuptake inhibitors (NSRIs), the tricyclic antidepressants (TCAs) and the mono-amine oxidase inhibitors (MAOIs). The latter two groups are used far less frequently since the advent of the SSRIs, which are considered to be much safer.

SSRIs These are commonly used for the treatment of major depression in children and adolescents, and include fluoxetine (Prozac), sertraline hydrochloride (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), and citalopram hydrobromide (Celexa). These SSRIs have been shown to be efficacious in the treatment of major depression and obsessive–compulsive disorder in adults. Sophisticated studies in children have been performed with fluoxetine, paroxetine and fluvoxamine. Fluoxetine was the first SSRI to be studied in children, and is still the most commonly used, having been shown to be efficacious in a doubleblind control trial using an ‘intent to treat’ model (Emslie et al. 1997). Fluoxetine has a long half-life and a cumulative effect over time, so dose increases should be made very slowly, and even a low starting dose may prove therapeutic. Starting dosages for fluoxetine, paroxetine, and

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Venlafaxine (Effexor): this strongly inhibits the uptake of both norepinephrine (NE) and 5-hydroxytryptamine (5-HT) and, to a lesser extent, also dopamine. It has a rapid onset of action that makes it unique among the antidepressants. To date, no studies have been conducted in children and adolescents, except for anecdotal reports and clinical experience. The dosage ranges from 25 mg to not more than 200 mg/day in divided doses. Plasma levels are not available. No pretreatment laboratory work-up is recommended. Adverse effects include somnolence, dizziness, insomnia, nervousness, dry mouth, nausea, loss of appetite and weight loss. Bupropion (Wellbutrin): this has been shown to be superior to placebo in randomized, double-blind, placebo-controlled trials in adults. It is a weaker inhibitor of the neuronal uptake of serotonin and NE, and also inhibits the neuronal re-uptake of dopamine to some extent. Bupropion is an attractive alternative to the tricyclic antidepressants in those patients who are unable to tolerate the side effects of the tricyclic antidepressants. There are anecdotal reports and a few open studies describing its efficacy in the treatment of major depression in children and adolescents. The usual starting dose is 75 mg/day, not to exceed a total of 450 mg/day in divided doses. (No single dose of bupropion should exceed 150 mg.) Plasma levels are not available, and pretreatment work-up may include evaluation of the liver function tests, since hepatocellular damage has been reported in animal studies.

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Adverse effects include akathisia, agitation, sedation, insomnia, headaches and tremors. The risk of seizures is four in 1000 patients; this is a four-fold increased risk compared to other antidepressants. Predisposing factors are a history of seizure disorder, head injury, central nervous system (CNS) tumor and sudden and large increments in the dose of bupropion. Buspirone (Buspar): this is an anxiolytic agent with antidepressant properties. It is considered an effective and relatively safe alternative to the benzodiazepines in the treatment of anxiety disorders. There are case reports of its use in the treatment of depression and anxiety disorder in adolescents. The recommended dose is 15–30 mg/day in divided doses. No pretreatment work-up is recommended. There is no established use of plasma levels. The side-effect profile is reported to be relatively benign with a wide margin for safety and low abuse potential. The more commonly reported side effects are insomnia, dizziness, headaches, and gastrointestinal complaints. Nefazodone (Serzone): this is one of the newest antidepressants, and is structurally different from the TCAs, SSRIs and MAOIs. There are no specific laboratory tests recommended. There are no case reports of its use in children and adolescents, though it has been prescribed to youngsters. No plasma levels are available. The starting dose in adults is 100 mg/day in divided doses, with suggested increments of 100 mg/day weekly. The average dose is 300–600 mg/day. Adverse effects are infrequent with doses of less than 300 mg/ day. The side effects are usually gastrointestinal, with dryness of the mouth, nausea and constipation. Headaches, somnolence, dizziness and blurred vision have also been reported. More recently, a few cases of hepatotoxicity have been reported. Because of this, abdominal pain or other gastrointestinal complaints should be promptly assessed. Mirtazapine (Remeron): this is a ‘designer drug,’ in the sense that it was purposely developed with a chemical structure resembling those of known antidepressants. Mirtazapine, however, has a unique mechanism of action, different from that of the TCAs, SSRIs and MAOIs, and could be best described as a noradrenergic and specific serotonergic antidepressant, abbreviated as ‘NaSSA.’ It enhances both noradrenergic and serotonergic transmission. Mirtazapine is not an SSRI, but it can achieve the effects of an SSRI without the side effects. It acts on three of the many types of serotonin receptors, stimulating one and blocking two. It is the blocking action of mirtazapine that reduces the SSRI’s side effects of lowered libido, gastrointestinal discomfort, and increased anxiety. Mirtazapine’s own side effects include sedation and increased appetite, resulting in weight gain. The sedation is a benefit for patients with insomnia. In addition to acting on serotonin, mirtazapine also affects

levels of NE; this property helps some patients for whom solely increasing the serotonin level is not enough. Mirtazapine has also been used clinically with youngsters, though there are no case reports at the present time. The initial dose recommended is 15 mg, usually at bedtime. After about two weeks the dose can be titrated up wards to a maximum recommended dose of 45–60 mg/day.

TRICYCLIC ANTIDEPRESSANTS The most commonly prescribed are imipramine (Tofranil), desipramine (Norpramine) and nortriptyline (Pamelor or Aventyl). As one of the serious side effects of the tricyclic antidepressants is cardiotoxicity, it is important to assess baseline cardiac status, including an electrocardiogram, heart rate, and orthostatic blood pressure recordings. Several studies have demonstrated lengthening of the PR and QRS intervals at imipramine doses of 5 mg/kg. More recently, there have been case reports of sudden death occurring in children treated with desipramine. Therefore, the use of therapeutic blood levels has become part of the normal practice when administering tricyclic antidepressants to children and adolescents. The blood level guidelines are similar to those in adults, namely 150–250 ng/ml desipramine, or a combination of desipramine and imipramine. In the case of nortriptyline, a blood level of 50–150 ng/ml should be sought. Blood level ‘windows’ are well established for tricyclic antidepressants, and dosing should attempt to achieve a middle of the therapeutic range. The advantages of obtaining blood levels is three-fold, namely, to guide dosing regimen, to determine compliance, and to identify the approximately 10 per cent of patients who are rapid metabolizers. Doses should be administered twice daily in children, who tend to metabolize these drugs more efficiently than adults. Besides cardiotoxicity, the other side effects of tricyclic antidepressants include dryness of the mouth, constipation, postural dizziness and occasional weight gain.

MONOAMINE OXIDASE INHIBITORS The monoamine oxidase inhibitors are infrequently used in the treatment of major depression in children and adolescents, and only one study has been published describing the efficacy of MAOIs in adolescents (Ryan et al. 1988). The use of MAOIs in the young is perhaps limited by potentially life-threatening side effects of hypertensive crises in patients who do not follow a tyramine-free diet. These dietary restrictions are difficult to monitor in children and adolescents, especially those who have problems with compliance and reliability. In general, the MAOIs should only be considered for the treatment of depression in children and adolescents after all other pharmacologic agents and combinations have been discussed.

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Mood stabilizers LITHIUM Lithium is a naturally occurring salt, which has been used in children and adolescents to treat a variety of disorders and symptoms. Lithium is effective in the treatment of bipolar disorders, organic mood disorders, management of aggression, and also as an adjunct to tricyclic and SSRI antidepressants in the treatment of major depression. The dosing of lithium in children and adolescents follows the same guidelines as in adults, although in younger patients it is wise to start on a low dose of 150 mg twice daily, and then gradually titrate the dose to obtain therapeutic blood levels of 0.7–1.2 mEq/L. The annoying and early side effects are usually gastrointestinal in nature, including nausea, abdominal cramps, and diarrhea. These usually subside in the first few days of treatment and are sometimes alleviated by prescribing an enteric-coated lithium preparation (e.g., Lithobid, Eskalith). Some of the later-onset side effects include hand tremors, which can be problematic for students when trying to write or do other academic work. Polyuria and polydipsia are signs of nephrogenic diabetes insipidus, which can cause an emergence of enuresis that leads in turn to embarrassment and patient noncompliance. The risk of potential lithium toxicity demands careful monitoring. At lithium levels above 1.2 mEq/L, symptoms such as impairment in cognitive functioning, lethargy, stupor and cardiac arrhythmia can occur.

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ANTICONVULSANTS Several anticonvulsants have been shown to be effective in the treatment of major depression and manic–depressive illness in children and adolescents. Medicines such as carbamazepine (Tegretol) and valproic acid (Depakote) have been used for decades, with good success. Over the past few years there has been an explosion in the development of new anticonvulsant medications, many of which appear to have good efficacy for mood stabilization. Newer medications that seem beneficial include gabapentin (Neurontin), oxcarbazepine (Trileptal), topiramate (Topomax), and lamotrigine (Lamictal). These medications are often used effectively either as standalone agents or synergistically in combination with antidepressants, or even with other anticonvulsants.

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Carbamazepine (Tegretol) has been shown to be prophylactic in mania and depression in adult patients who are resistant to lithium. Several reports have shown carbamazepine to decrease impulsivity, agitation and affective lability in children and adolescents. The usual dose ranges from 300 to 800 mg/day in divided doses, with a plasma level of 6–12 (g/ml. Combination with the MAOIs is not recommended because of potentially toxic increases in plasma levels of carbamazepine. Potential

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side effects include an allergic skin rash, initial lethargy and drowsiness, dysarthria and ataxia. Other side effects include a decrease in the white cell count. Therefore, it is important to obtain baseline blood counts, including differential and platelet count. Carbamazepine has been used in combination with antidepressants and with lithium. Valproic acid (Depakote) is usually started at 250 mg/day in divided doses, depending on the age of the child (15 mg/kg per day). The dose should be titrated in order to obtain a therapeutic plasma level of 50–100 ␮g/ml, but the maximum recommended dose should not exceed 60 mg/kg per day. Potential side effects include skin rash, gastrointestinal upset and lethargy. Elevated liver enzyme activities can result, and these should be monitored regularly. There have also been some case reports of female patients developing polycystic ovaries. Valproic acid can be used as an adjunct to most antidepressants and lithium or carbamazepine, for those patients requiring double mood stabilization. Topiramate (Topomax) is increasingly used as an off-label treatment for Bipolar Disorder. It has a well-established indication for treatment of epilepsy. Starting dosage is generally 25–50 mg/day, with an increase of 25 mg/day on a weekly basis. Potential side effects include difficulty concentrating, somnolence, weight loss, and kidney stones (1.5%). Blood level monitoring is not required, but very slow dosage increases are necessary to avoid undue cognitive and psychomotor slowing. Topiramate is a particularly attractive choice for those patients who suffer weight gain with alternative anticonvulsant medications. Lamotrigine (Lamictal) is an anticonvulsant that seems to have additional antidepressant effects. For children under 12 years of age the starting dose is 25 mg/day or 0.6 mg/kg per day, increasing every one to two weeks, with a maximum total dose of 400 mg per day. For adolescents, the starting dose is 50 mg per day, increasing to a target maximum dose of 500 mg per day in divided doses. If valproic acid is used concomitantly, the lamotrigine dosage should be halved. Dosages should be increased slowly, and particular caution should be used in children or if used with valproic acid, as cases have been identified of a fatal epidermal necrolysis. Initial clinical signs may include a skin rash or Stevens–Johnson reaction. Other side effects include dizziness, somnolence, and nausea. Despite this potential toxicity, lamotrigine seems to be very effective in treating mood disorders. Oxcarbazepine (Trileptal) is structurally related to carbamazepine, but seems to be better tolerated and is particularly effective for manic states. The starting dosage is generally 600 mg/day in divided doses, and increases of 300–600 mg per week can be used. Therapeutic plasma levels range from 12 to 30 ␮g/ml,

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and dosage may be best titrated in terms of clinical response. Potential side effects include sedation, dizziness, diploplia, and hyponatremia. Of note, leukopenia does not seem to be associated with oxcarbazepine. Gabapentin (Neurontin) is renally metabolized and therefore a more prudent choice for patients with hepatic disease. It is very well tolerated, and the common side effects are somnolence, ataxia and dizziness. The starting dose is 300 mg, which is gradually titrated upward to between 900 and 1800 mg/day. It is not necessary to monitor therapeutic blood levels. Common side effects are somewhat similar to those seen with other anticonvulsants.

Psychotherapy COGNITIVE BEHAVIORAL THERAPY Cognitive behavioral therapy (CBT) is a widely researched empirically based treatment for depression (Kendall 1993). CBT represents an integration of cognitive and behavioral approaches to psychotherapy utilizing information processing and social-learning theories. Cognitive behavior therapy emphasizes cognitive dysfunction and directs the patient to identify cognitive distortions. The focus is on troublesome and difficult situations rather than on a difficult individual. An important part of CBT is to help the youngster recognize how he or she thinks, and then to develop and practice new ways of thinking. This process requires several strategies, including affective education, relaxation training, social problem solving, cognitive restructuring and attribution retraining, contingent reinforcement, modeling and role playing.

INTERPERSONAL PSYCHOTHERAPY Interpersonal psychotherapy for depressed adolescents (ITP-A) is a promising treatment modality (Moreau and Mufson 1997). It is a brief and focused twelve-week therapy based on the premise that historic difficulties in the interpersonal relationship lead to a predisposition for the development of depression, and conversely that depression itself affects current interpersonal relationships. The goals of ITP-A are to relieve depression and improve current interpersonal relationships.

PREVENTIVE AND SAFETY MEASURES It is crucial to identify and address specific psychosocial stressors in the evaluation and treatment of a suicidal adolescent. Disruptions and changes in the adolescent’s interpersonal relationships, excess accumulation of stress, and lack of support from the family may be warning signs that must be identified and addressed in therapy. It is important to identify any potential for suicide and indications for additional social support, for possibly more intensive treatment, or even a change in the treatment

setting, such as hospitalization. Therefore, family functioning is important to consider when assessing and treating adolescents for suicidal behavior.

SUPPORTIVE TREATMENT Supportive therapy includes illness teaching to the families and the patients, especially the adolescents. Denial of the depressive illness is a common occurrence, not only with the young patient but also with their family. Many times the patient and their family feel stigmatized and need supportive counseling to help with their feelings of inadequacy, anger and despair. This can be done in supportive individual therapy, family therapy, or sometimes referring them to local support groups, especially focused for those suffering from depressive disorders. Supportive treatment in the young may also include talking with the school counselors and the child’s teacher to better acquaint them with the signs and symptoms of the disorder, and to get them involved in helping the child or adolescent in the school setting. Given the fact that there is often a strong family history of depressive disorders, there can be other family members who may be identified as having a mood disorder and require psychiatric intervention and appropriate treatment. Treatment with the young also includes helping the child see himself/herself in context with his/her friends, school, and future goals and aspirations. With adolescents it is important to help them gradually take responsibility for their own care, as they prepare to move into the adult world and away from the confines of their immediate family.

CONCLUSION Millions of children and adolescents suffer needlessly from undiagnosed depression and other mood disorders, putting them at much increased risk for becoming suicidal. It is therefore imperative that we recognize depressive disorders in the young and identify those children and adolescents who are at risk. It is equally important to identify the disorders correctly and initiate comprehensive and efficacious treatment. Mood disorders are, by and large, treatable and early identification and treatment can make a significant difference in the lives of children, adolescents and their families. It can also lead to saving precious lives in those who would otherwise succumb to suicide, feeling that their lives are meaningless as a result of the perils of these disorders. Research efforts in the areas of understanding mental illness in children and adolescents, especially in the area of mood disorders, hold exciting possibilities. The inseparable roles of genes and the environment are being further clarified. Well-designed prospective longitudinal studies and genetic family studies hold the key to answering

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questions related to the risk, protective factors, and outcome of major depression and other child and adolescent mental illness.

REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: American Psychiatric Association, 1995. Beck, A.T., Ward, C.H., Mendelson, M. An inventory foe measuring depression. Archives of General Psychiatry 4: 561–571, 1961. Bostic, J.Q., Wilens, T., Spencer, T., Biederman, J. Pharmacologic treatment of Juvenile Depression. Psychiatric Clinics of North America; Annals of Drug Therapy 6: 175–191, 1999. Brent, D.A. Risk factors for adolescent suicide and suicidal behavior: mental and substance abuse disorders, family environmental factors, and life stress. Suicide and Life Threatening Behavior 25: 52–63, 1995. Chambers, W.J., Puig-Antich, J., Hirsh, M., et al. The assessment of affective disorders in children and adolescents by semi-structured interview. Archives of General Psychiatry 42: 696–702, 1985. Costello, A.J., Edelbrock, C.S., Kalas, R., Dulcan, M.D., Klaric, S.H. Development and testing of the NIMH diagnostic interview schedule for children in a clinical population (Contract No. RSP-DB-81/0027), Rockville, MD. Center for Epidemiologic studies, NIMH, 1984. Emslie, G.J., Rush, A.J., Weinberg, W.A., Kowatch, R.A., Hughes, C.W., et al. A double-blind, randomized, placebo-controlled trail of fluoxetine in children and adolescents with depression. Archives of General Psychiatry 54: 1031–1037, 1997. Herjanic, B., Reich, W. Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms. Journal of Abnormal Child Psychology 10: 307–324, 1982. Joshi, P.T., Capozzoli, J.A., Coyle, J.T. The Johns Hopkins Depression Scale: normative data and validation in child psychiatry patients. Journal of the American Academy of Child and Adolescent Psychiatry 29: 283–288, 1990. Kendall, P.C. Cognitive Behavior Therapies with youth: guiding theory, current status and emerging developments. Journal of Consulting and Clinical Psychology 61: 235–247, 1993. Kovacs, M. The natural history and course of depressive disorders in children. Psychiatric Annals 15: 387–389, 1985. Kovacs, M., Gatsonis, C., Pollock, M., Parrone, P.L. A controlled prospective study of DSM-III Adjustment disorder in childhood: short term prognosis and long term predictive validity. Archives of General Psychiatry 51: 535–541, 1994.

Kraepelin, I. Manic-Depressive Insanity and Paranoia. Edinburgh: E&S Livingston, 1921. McCracken, J.T. The epidemiology of child and adolescent mood disorders. Child and Adolescent Clinics of North America 1: 53–72, 1992. McHugh, P.R., Slavney, P.R. The Perspectives of Psychiatry. Baltimore, London: The Johns Hopkins University Press, 1998. Moreau, D., Mufson, L. Interpersonal psychotherapy for depressed adolescents. Child and Adolescent Psychiatry, Clinics of North America 6: 97–110, 1997. Pfeffer, C., Conte, H.R., Plutchik, R., Jerrett, L. Suicidal behavior in latency age. An outpatient population. Journal of the American Academy of Child and Adolescent Psychiatry 19: 703–710, 1980. Pfeffer, C., Solomon, G., Plutchik, R., Mizruchi, M., Weiner, A. Suicidal behavior in adolescent psychiatric inpatients: a replication and cross validation. Journal of the American Academy of Child and Adolescent Psychiatry 21: 564–569, 1982. Robins, L.N. Longitudinal methods in the study of normal and pathological development. In Kisker, K.P., Meyer, J.E., Muller, C., et al. (eds), Psychiatric der Gegenwart, Band I, Forscchung und Praxis, Grundlagen und Methoden der Psychiatrie Teil I. Heidelburg: Springer-Verlag, 1979, p. 627. Ryan, N.D., Puig-Antich, J., Rabinovich, H., et al. MAOIs in adolescent major depression unresponsive to tricyclic antidepressants. Journal of the American Academy of Child and Adolescent Psychiatry 27: 755–758, 1988. Shaffer, D., Fisher, P. The epidemiology of suicide in children and young adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 20: 545–565, 1981. Weissman, M.M., Boyd, J.H. Affective disorders: epidemiology. In Kaplan, H.I., Sadock, B.J. (eds), Comprehensive Textbook of Psychiatry. Volume 4. Baltimore: Williams & Wilkins, 1985, pp. 764–769.

Suggested reading Beardslee, W.R., Keller, M.B., Seifer, R., Lavori, P.W., et al. Prediction of adolescent affective disorder: effects of prior parental affective disorders and child psychopathology. Journal of the American Academy of Child and Adolescent Psychiatry 35: 279–288, 1977. Beardslee, W.R., Versage, E.M., Wright, E., et al. Examination of preventive interventions for families with depression: evidence of change. Developmental Psychopathology 9: 109–130, 1997. Birmaher, B., Ryan, N.D., Williamson, D.E., Brent, D.A., et al. Childhood and adolescent depression: a review of the past 10 years. Part I. Journal of the American Academy of Child and Adolescent Psychiatry 35: 1427–1439, 1996.

294 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood Birmaher, B., Ryan, N.D., Williamson, D.E., Brent, D.A., Kaufman, J. Childhood and adolescent: depression. A review of the past 10 years. Part II. Journal of the American Academy of Child and Adolescent Psychiatry 35: 1575–1583, 1996. Geller, B., Luby, J. Child and adolescent bipolar disorder: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1168–1176, 1997. Geller, B., Williams, M., Zimerman, B., Frazier, J., Beringer, L., Warner, K.L. Prepubertal and early adolescent bipolarity differentiate from ADHD by manic symptoms, grandiose delusions, ultra-rapid or ultradian cycling. Journal of Affective Disorders 51: 81–91, 1998. Emslie, G.J., Walkup, J.T., Plizka, S.R., Ernst, M. Nontricyclic antidepressants: current trends in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 517–528, 1999. Hughes, C.W., Emslie, G.J., Crimson, M.L., Wagner, K.D., Birmaher, B., Geller, B., et al. The Texas Consensus Conference Panel on medication Treatment of Childhood Major Depressive Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 38: 1442–1454, 1999. Kaufman, J., Birmaher, B., Brent, D., et al. Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version

(K-SADS-PL): initial reliability and validity data. Journal of the American Academy of Child and Adolescent Psychiatry 36: 980–988, 1997. Kowatch, R., Suppes, T., Carmody, T., et al. Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder. Journal of the American Academy of Child and Adolescent Psychiatry 39: 713–720, 2000. Lewinsohn, P.M., Rohde, P., Seeley, J.R., Klein, D.N., Gotlib, I.H. Natural course of adolescent major depressive disorder in a community sample: predictors of recurrence in young adults. American Journal of Psychiatry 157: 1584–1591, 2000. Marttunen, M.J., Aro, H.M., Henriksson, M.M., Lovnquist, J.K. Psychosocial stressors more common in adolescent suicide with alcohol abuse compared with depressive adolescent suicides. Journal of the American Academy of Child and Adolescent Psychiatry 33: 490–497, 1994. Rao, U., Hammen, C., Daley, S.E. Continuity of depression during the transition to adulthood: a five year longitudinal study of young women. Journal of the American Academy of Child and Adolescent Psychiatry 38: 908–915, 1999. Ryan, N.D., Bhatara, V.S., Perel, J.M. Mood stabilizers in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 529–536, 1999.

5.5 Eating disorders and disordered eating LYNN E. PONTON

INTRODUCTION Adolescents and their parents commonly use both ‘disordered eating’ and ‘eating disorder’ as terms to describe any perceived fluctuation from what they view as normal eating. ‘Disordered eating’ clinically refers to any abnormal pattern, from the most mild to the most severe. The term ‘eating disorder’ represents an extreme of severity and is applied to diagnostic syndromes or a constellation of symptoms regularly found to occur together, such as atypical binge disorder (Spitzer et al. 1993). The term ‘eating disorder’ is also used to refer to specific diseases such as anorexia nervosa (American Psychiatric Association 1994); these are relatively well-defined disorders that have been shown to have regularly recurring psychopathological correlates, a clear genetic basis, a distinctive etiology, physical pathology, and shared prognosis. The term ‘eating disordered’ is also used to refer to a condition of chronic disability when multiple relapses have occurred. Acknowledging the wide range of disordered eating behavior in adolescents, this chapter focuses primarily on the epidemiology, prevention, and treatment of anorexia nervosa and bulimia nervosa, the areas addressed by most studies. Obesity and atypical binge disorder are covered briefly.

DEFINITIONS The diagnostic criteria for anorexia nervosa as defined by DSM-IV (American Psychiatric Association 1994) are: 1 Refusal to maintain body weight over a minimal normal weight for age and height (⬍85% of what is expected) or failure to make expected weight gain during a period of growth (again ⬍85% of what is expected). 2 Intense fear of becoming fat, even though underweight.

3 Disturbance in the way in which one’s body or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight. 4 Amenorrhea in postmenarcheal females, i.e., the absence of at least three consecutive menstrual cycles. The DSM-IV specifies two types of anorexia nervosa: (i) restricting, where the individual does not engage in bingeing or purging; and (ii) the subtype categorized as binge eating/purging, where the individual regularly engages in binge eating or purging behavior during the current episode of anorexia nervosa. The diagnostic criteria for bulimia nervosa as defined by the DSM-IV are: 1 Recurrent episodes of binge eating characterized by eating an amount of food that is definitely larger than most people would eat during a similar period of time and a sense of lack of control over eating during the episode. 2 Engaging in a method to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, and other medications; fasting; or excessive exercise. 3 Behavior (both bingeing and compensatory behavior) occurs, on average, at least twice a week for two months. 4 Self-evaluation is unduly influenced by body shape and weight. 5 The disturbances do not occur exclusively during episodes of anorexia nervosa. There are two designated subcategories of bulimia nervosa: purging type and nonpurging (e.g., use of fasting or excessive exercise) type. The DSM-IV lists a third diagnostic disorder, atypical binge eating, in a provisional category proposed for

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further study. The proposed criteria include: 1 Recurrent episodes of binge eating characterized by eating an amount of food that is definitely larger than most people would eat during a similar period of time and a sense of lack of control over eating during the episode. 2 Binge eating episodes include three of the five symptoms: eating more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because one is embarrassed by the amount; and feeling self-disgust, depression, or guilt after the eating. 3 The individual feels markedly distressed about the binge eating. 4 The binge eating occurs at least two days a week for at least six months. 5 The binge eating is not associated with regular use of inappropriate compensatory mechanisms (e.g., vomiting, laxative use). The validity of atypical binge eating disorder has been supported by its strong association with impairment in work and social functioning, overconcern with body shape and weight, general psychopathology, significant amount of time spent on diets, and an associated history of depression, drug and alcohol use, and periods of psychiatric treatment (Spitzer et al. 1993). Thinness is much admired in Western cultures, including among adolescents (Stunkard et al. 1972), and obese adolescents are frequently stigmatized (Canning and Meyer 1967) as well as suffering increased risk for a variety of medical conditions (Tobias and Gordon 1980). Obesity in adolescents is defined by a triceps fat fold thickness greater than the 95th percentile (Kleinman 1987). Obesity is believed to be connected more strongly with environmental factors, particularly diet, lack of physical activity, and family patterns of feeding (Serdula et al. 1993). The psychiatric diagnoses of anorexia nervosa and bulimia nervosa are now recognized as important but relatively uncommon syndromes or disease processes within a wide spectrum of disordered eating. Within this spectrum, concern about weight (Killen et al. 1996), dieting, and in particular unsupervised and unhealthy dieting patterns in adolescents, may be one of the most important pathways to eating disorders. Key influences may operate to initiate dieting rather than eating disorders specifically. As dieting appears to be a commonly reported behavior among adolescents and represents a risk factor that could be targeted in prevention programs (e.g., programs focused on healthy eating habits or life-style), understanding its role within the spectrum of disordered eating is particularly important. Adolescent dieting is clearly not well understood. Studies indicate that dieting alone does not directly lead to the more severe findings of anorexia or bulimia nervosa. Schleimer’s longitudinal follow-up of 111 pathological

dieters indicated that girls who diet in adolescence do not go on to develop an eating disorder without having been presented with some of the criteria for an eating disorder early in adolescence (Schleimer 1984). Patton (1992) found that a rise in self-reported depressive symptoms correlated with the development of eating disorders in a group of adolescent dieters.

EPIDEMIOLOGY Incidence and prevalence Several studies have reported a varying incidence and prevalence of eating-disordered behavior among adolescents. Most of the studies in this area have focused on the most severe symptomatology, the psychiatric diagnoses of anorexia nervosa and bulimia nervosa. Reported prevalence rates for anorexia nervosa in adolescent females vary from 1 in 100 females to 1 in 800 (American Psychiatric Association 1987). Halmi and colleagues (1973) reported the prevalence to be 1 in 100 adolescent girls and noted a bimodal pattern of onset with two risk periods, early adolescence (13–14 years of age) and late adolescence (17–19 years of age). Bulimia nervosa is more common and is reported to affect between 4 and 10 per cent of adolescent college-age women (Pyle et al. 1983). Varying prevalence rates for bulimia nervosa are reported for female adolescents (Yates 1989). Obesity has been shown to have prevalence rates of 6 to 13 per cent for all adolescents (Kleinman 1987). Many adolescents do not meet the diagnostic criteria for the psychiatric diagnoses or the medical criteria for obesity, but exhibit some form of disordered eating consisting of preoccupation with food or weight that seriously interferes with their daily lives. Here again, reported prevalence varies based on the adolescent population sample, but 30–70 per cent of adolescent females report that they are dieting (Felts et al. 1992; King 1989). Data from a self-report adolescent risk behavior survey given to 3437 high-school students revealed that 25 per cent of that population believed that they were ‘too fat’ (Felts et al. 1992), with adolescent girls constituting 75 per cent of this group. Some 68 per cent of the adolescents in the study reported currently being on a diet. Within the past ten years, there has been disagreement about the reported incidence of anorexia nervosa and bulimia nervosa. Several researchers have reported a doubling of the incidence of anorexia nervosa, and possibly bulimia nervosa, between 1960 and 1980 (Jones et al. 1983; Willi and Grossmann 1983). Williams and King (1987) questioned the increased incidence of eating disorders, and attributed the perceived increase to a large number of young women in the population. Lucas et al. (1991) explored the question of increased incidence in a

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population-based study in Minnesota. This study, focusing on the fifty-year period from 1935 to 1984, found that while the overall incidence of anorexia nervosa had not increased, a significant temporal increase had occurred for fifteen- to twenty-four-year-olds. The ten- to nineteen-year-old age group, which included premenarcheal girls, reported a high rate of anorexia nervosa during the 1930s, a lower rate in the 1950s, and a gradually increasing rate from 1964 until the end of the study in 1984. Lucas classified anorexia nervosa into two subtypes: Type I, a chronic, severe form of the illness with a largely biological etiology; and Type II, a less severe form with a more benign course. He believed that the increase in the incidence of anorexia nervosa among adolescent females is probably an increase in the more mild Type II (Lucas 1992). This is consistent with Yates’ hypothesis (Yates 1989, 1990) that sociocultural pressures have played an important role in the increasing incidence among adolescent females. Although the presentation, history, and family dynamics of male and female patients with diagnosed eating disorders are reported to be remarkably similar (Lerner et al. 1976), the epidemiology for males with eating disorders does not reflect the increases noted for young females during the past twenty years. For males in the Rochester, Minnesota, study (Soundy et al. 1994), the incidence of anorexia nervosa for the fifty-year period from 1935 to 1984 was found to be 1.6 per 100 000, in contrast to the overall reported incidence for females of 13.5 per 100 000. Soundy and colleagues reported that the incidence of bulimia nervosa among males was rare: 0.8 per 100 000 compared with 26.5 per 100 000 for females. The suspected underlying pathology also appears to be different. Lerner and colleagues (1976) found that physical attractiveness predicts self-concept and self-esteem in adolescent girls, whereas physical effectiveness predicts self-concept in boys. Therefore, it is not surprising that male patients with eating disorders present with unconventional psychosexual development and gender identity issues. Male anorexia nervosa patients are reported to be more extroverted and score superfeminine on many of the personality scales. Yeager et al. (1988) found a high prevalence of binge eating problems, terror of being fat, and diuretic use in homosexual male college students, indicating another male group at higher risk for eating disorders.

PATHOGENESIS Complex biopsychosocial and cultural factors have affected both the development of eating disorders and disordered eating themselves, as well as our current understanding and treatment of them. The initial work on pathogenesis and theoretical perspective in this area

focused on a specific illness, anorexia nervosa, so a historical review of theoretical perspective regarding this illness is useful. It mirrors changes in thinking which have also affected the broader field of disordered eating. The best historian is Alexander Lucas. Lucas reviews the development of the field of eating disorders in his historical papers (Lucas 1981; Ponton 1993; Ponton et al. 1994), wherein he underscores the need for an integrative approach. He describes six eras in which controversial data led to polarized and dogmatic positions. The first, from 1868 to 1914, marks the discovery and acknowledgement of eating disorders in the literature and is titled, ‘the descriptive era.’ The biological era followed in 1914 when Simmond, a pathologist, described ‘pituitary cachexia.’ The etiology developed from the autopsy of a young woman who died of cachexia with pituitary failure. Lucas describes the third era, from 1930 to 1961, as a period of rediscovery. It included the end of Simmond’s disease when extensive pathological reports did not substantiate the diagnosis. This era also sparked the recognition of a certain psychopathological component in patients with eating disorders. The fourth era, that of the psychoanalytic perspective, followed the period of rediscovery. The lingering effect of Helene Deutsch’s work (1944, 1981), characterized by descriptions of fears of impregnation and delayed adolescent sexuality, still hovers over the field. Lucas describes the fifth era of eating disorders from 1961 to 1980 and highlights the importance of the work of Hilde Bruch, a clinical theoretician who worked to define the diagnoses, develop clinical strategies, and educate patients and their families. He introduces the sixth era in the study of eating disorders crediting the biopsychosocial model and the importance of a developmental approach. He details the complex interactions and genetic determinants that lead to a variable degree of biological vulnerability in persons who are at risk for experiencing the illness. Although Lucas is one of the great theoretical and clinical integrationalists in the field of eating disorders, much has happened since he wrote his thoughtful and predictive descriptions, and his historical perspective can also be expanded upon. During the 1980s, there was a growing awareness of the importance of cultural factors in eating disorders and other illnesses. At the end of that decade the model could more aptly be described as a biopsychosocial and cultural model. According to a recent review by Steiner and Lock (1998), research in the area of eating disorders has progressed during the past ten years, but definitive longitudinal data are still missing from the literature; research specific to the treatment of child and adolescent eating disorders remains rare; and normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods are still needed.

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TREATMENT Although there is a whole spectrum of severity, from mild to severe, in patients presenting with disordered eating, many of those with anorexia nervosa and bulimia nervosa are extremely difficult to treat and respond best to combined modalities. In addition, although many papers are written about treating adults with eating disorders, Wachsmuth and Garfinkel (1983) underscore the point that there are only a limited number of articles available on the treatment of adolescents. They emphasize the importance of the treating physician or therapist being able to set and prioritize clear treatment goals for this age group. The goals they outline include establishing and maintaining a treatment alliance based on trust; weight restoration or a cessation of bingeing, vomiting, or other unhealthy weight-reduction methods; improvement in eating behavior; and improvement in social behavior.

Assessment The treatment of these difficult patients responds best to an approach that integrates several modalities, including physical assessment and laboratory testing, nutritional assessment, and evaluation of individual psychopathology and family functioning. Ideally, the treatment team should have considerable experience working together and should be able to address each of these important areas. A possible combination for members of the treatment team would include a pediatrician or primary care physician, a nutritionist, and a psychiatrist or other trained mental health professional, all with expertise in this area. The basic history and physical examination gathered and conducted by the physician should include a weigh-in, vital signs, and evaluation of daily activities including exercise, eating, and sports and school activities (Kreipe and Uphoff 1992). Baseline collaborating data would include a complete blood count, a serum electrolyte determination, urinalysis, an electrocardiogram, thyroxine (T4) and thyroid-stimulating hormone (TSH), luteinizing hormone (LH) and follicle-stimulating hormone (FSH) (Fisher 1992). When the diagnosis is unclear, additional tests such as a magnetic resonance imaging (MRI) brain scan may be prescribed, in order to rule out other clinical entities. All members of the team should question the patient about weight loss, examining methods and signs and symptoms. The nutritionist should begin an educational program explaining methods of weight reduction or weight maintenance and, emphasizing the keeping of a daily food journal, should help the patient to initiate a healthy dietary plan. A nutritional assessment includes an assessment of daily nutritional intake combined with eating attitudes, behaviors, and habits, and an anthropoietic assessment, which might include skinfold caliper measurements of subcutaneous

body fat (Schebendach and Nussbaum 1992). Evaluation by the mental health professional should include an individual assessment and evaluation of the family, which covers developmental issues and makes psychiatric diagnoses such as anorexia or bulimia nervosa as well as other comorbid diseases. If a psychiatrist is not on the team, the mental health professional should also consider referral regarding the utility of psychopharmacologic agents if indicated. Once the initial assessment has been conducted, the treatment team should meet, share recommendations, and establish or refer to an ongoing treatment program. Team members (physician, nutritionist, and psychiatrist or psychologist) should continue to collaborate at regular intervals (Kreipe and Uphoff 1992). Inpatient treatment is determined by the presence of specific criteria that Herzog and Copeland (1985) define as: weight loss greater than 30 per cent over a three-month period; metabolic disturbances manifested by vital sign changes, or changes in the potassium or bound urea nitrogen; suicidal risk; severe purging with a risk of aspiration; or the presence of psychosis and the existence of a family crisis that puts the adolescent’s physical health or safety in jeopardy. A combined methodologic approach to inpatient treatment should be adopted, including the implementation of an eating disorder protocol to restore eating, and a combined approach utilizing individual, family, group, nutritional, and biological therapy. The inpatient hospitalization might begin with a behavioral modification plan that reinforces weight gain by offering a levels system with increasing responsibility and privilege. Nasogastric feeding is also frequently employed if the severity of the weight loss mandates it (Larocca and Goodner 1986). The inpatient unit also offers an opportunity for intensive education about faulty eating behaviors and can utilize group, milieu, family, and individual therapy; diet and exercise counseling; and psychoeducational material to promote changes in eating and social behavior. It is important that all treatment teams understand the biological, psychological, social, and cultural components of these illnesses.

Biological assessment and treatment modalities Physiological changes with eating disorders are well summarized in the review articles by Herzog and Copeland (1985), Halmi et al. (1983), and Yates (1990). Here, some of the areas important to focus on clinically will be highlighted. Biological theories are most frequently based on studies that have been conducted on individuals maintained on semi-starvation diets. These report that starving individuals undergo sleep disturbance, impaired concentration, indecisiveness, withdrawal, mood lability, anxiety, and depression (Garfinkel and Kaplan 1985). There are a

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host of abnormal neuroendocrine axes in anorexic patients who are self-starved, and, in fact, the whole endocrine axis is very much affected by the starvation process. In starvation, the hypothalamus secretes a larger amount of corticotropin-releasing factor that stimulates the adrenal cortex. The degree of elevation of corticotropin-releasing hormone in the cerebrospinal fluid (CSF) of anorexic patients correlates with the degree of their depression (Gold and Rubinow 1987). Anorexia nervosa in many ways parallels other ‘starvation states.’ There are many changes consistent with this, including differences in total sodium, potassium loss, and decreased tri-iodothyronine (T3) and T4. Decreased production of blood cells of all types is a frequent phenomenon. Anemia, leukopenia, and thrombocytopenia are associated with changes in the bone marrow. The anemia may contribute to fatigue. In patients with bulimia nervosa, hypokalemic alkalosis is one of the most serious physical problems. Careful monitoring of serum creatinine and blood urea nitrogen (BUN) is important. Also quite serious are electrocardiogram changes increased by electrolyte abnormalities. Most remarkable are flattening of the T wave, ST segment depression, and lengthening of the QT interval. Long-term presence of anorexia nervosa may lead to cardiac changes, including thinning of the wall of the left ventricle. Electroencephalographic (EEG) changes are also notable, revealing moderate to marked slowing. For bulimics, many gastrointestinal abnormalities – tears from vomiting, erosion of dental enamel, and gastric dilation with the risk of rupture – present significant risk. Renal changes that reflect dehydration and a reduced glomerular filtration rate may also be present, and the incidence of renal calculi is also increased. Hormonal abnormalities are also found with these disorders. If amenorrhea, one of the diagnostic criteria for anorexia nervosa, is present, it may appear associated with hypothalamic abnormalities even before weight loss. Amenorrhea in anorexia nervosa is associated with a revision of gonadotropin secretion to the prepubertal pattern (Boyer et al. 1974). Other hormonal changes include a change in growth hormone, which is elevated in response to the decreased levels of somatomedin C, and abnormal temperature regulations that occur regularly secondary to the loss of body fat and/or a hypothalamic defect. The complexity of physiological changes in adolescent patients with eating disorders necessitates that the treating therapist be informed about the condition and either be fully trained or work with someone who is fully trained in the medical aspects of these illnesses. Psychotropic therapy may be an important component, but should be carefully integrated with the use of other therapies. Anorexic patients who are depressed have lowered urinary excretion of 3-methoxy-4-hydroxyphenylglycol, which suggests a greater responsiveness to norepinephrine-reuptake blockers such as imipramine or desipramine (Herzog and Copeland 1985). However, there

are to date no published controlled trials of the use of tricyclic antidepressants in adolescents with eating disorders (Wachsmuth and Garfinkel 1983). Imipramine and phenelzine have been found to be superior to placebo in reducing depressive and bulimic symptoms in the treatment of bulimia (Bond et al. 1986), but more controlled studies are needed in the pharmacotherapy of eating disorders. In general, restrictor anorexics experience more side effects than bulimics with medications. Therefore, careful attention must be paid to the side-effect profile when treating that population. Medications that have some utility in treating patients with eating disorders include antidepressants, phenothiazines, anxiolytics, cyproheptadine (marketed as Periactin), clonidine, naloxone, and lithium. Tricyclics and other newer antidepressant agents are frequently used in the treatment of bulimia nervosa and are recommended in the treatment of anorexia nervosa when a concomitant affective disorder has been diagnosed. Treating adolescents diagnosed with anorexia nervosa with tricyclic medication necessitates a careful monitoring of cardiac function with serial electrocardiograms. The greater proclivity of adolescents for cardiac changes makes the consideration of alternatives to tricyclic antidepressants such as fluoxetine important. The use of fluoxetine and other serotonergic agents is also important in patients with bulimia nervosa, when they have been shown to decrease bingeing and associated cravings. It is believed that fluoxetine accomplishes this by increasing serotonin levels in the brain. Patients who respond successfully claim that they feel full faster and crave binge foods less. It is important to note that antidepressant medication may decrease either depressive symptoms or bingeing patterns. Current understanding indicates that there is an independent relationship between the two factors so that one, both, or neither may improve.

Psychological treatment modalities Recent studies (Agras et al. 1992; Fairburn et al. 1993; Gardner et al. 1993) indicate that a structured psychotherapy designed specifically for the treatment of bulimia nervosa is most beneficial in comparative studies. Fairburn and colleagues compared cognitive behavioral therapy (CBT), interpersonal therapy (ITP), and behavioral therapy (a modified program separate from CBT) and found that patients in the groups receiving CBT and ITP respectively made the most substantial and long-lasting changes across all symptom areas at a twelve-month follow-up point. Although CBT and ITP achieved roughly equivalent results, it is believed that they work through different mediating mechanisms with clear temporal differences in areas of response. A further comparison of CBT and ITP would be beneficial. Gardner and colleagues compared the effectiveness of four months of CBT and supportive expressive therapy

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for bulimia, and found it to be effective in leading to significant improvement in specific eating disorder symptoms and psychosocial disturbances. CBT was found to be more effective, however, in promoting long-term abstention from vomiting. These authors recommend further refinement of the psychotherapy treatment modalities for eating disorders, repeat studies that clearly differentiate diagnostic groupings (anorexia nervosa versus bulimia nervosa versus subclinical but symptomatic and normals), and longer-term follow-up. Family therapy may be an important component of both inpatient and outpatient treatment. It is particularly important in the treatment of adolescents. In a randomized study of discharged inpatients with eating disorders (Russell et al. 1987), family therapy was found to be most effective in patients whose illness was not chronic and where the onset of the illness occurred at nineteen years of age or younger. Family therapy also appears to be particularly helpful if the patient needs to attain autonomy from the family. The cornerstone of treatment for individuals with anorexia nervosa and bulimia nervosa continues to be individual psychotherapy focusing on both the individual’s symptoms and underlying psychological problems associated with the illness. Bruch (1982) introduced the importance of this type of work, which focuses on building individual autonomy in contrast to analytically uncovering psychological issues. Therapists working with these patients actually perform several roles. One role is clearly that of providing education about the impact of social expectations regarding body image, but equally important – and often more difficult – is to help the young patient understand how societal expectations and the patient’s own issues result in a pattern of disordered eating. Also, the individual therapist should help the patient see the disordered eating behavior as risk-taking, and then help him or her develop an internal process of risk assessment (Ponton 1993). These are complex functions which require individual therapists with medical knowledge, societal awareness, psychological understanding, and an ability to address risk-taking behavior in the adolescent population.

PREVENTION Although there are only a limited number of existing prevention programs, several conclusions can be made from both general and specific studies. First, developing targeted programs for adolescents at risk (e.g., school-girls, university students, athletes, and girls visiting general practice clinics) is an important idea. Nonspecific studies of high-risk populations (Benson et al. 1990; Herzog and Copeland 1985; King 1989; McDonald and Thompson 1992; Schotte and Stunkard 1987; Taub and Blinde 1992; Whitehouse et al. 1992) suggest this, and the intervention

developed by Killen and colleagues (1993) found the greatest benefit with the girls at higher risk. Second, the interface between dieting and disordered eating bears further investigation and development. Adolescent dieters may be a high-risk population that would benefit from targeted intervention. There is also a need to develop methods for sending adolescents the important prevention message that dieting is not a strategy for weight control that is likely to prove successful. As puberty itself appears to be a risk factor for disordered eating, girls who are pre- and peripubertal should be assessed and monitored for manifestations of disordered eating. A second important prevention message to deliver is that pubertal development in girls is normally accompanied by changes in body composition, including body fat composition. The need for this reality to become accepted and acceptable underscores the negative effects of current sociocultural media messages. Specific intervention studies suggest other important strategies for future prevention efforts. Interventions need to be reproducible and effected with sufficiently large intervention and control groups. Paxton’s (1993) study, which utilized a control population of twenty-nine subjects from a different school, illustrates potential problems in this arena. One session or cluster of sessions may not be adequate, and the idea of ‘booster sessions’ at a later point to build on the positive effects, as proposed by Moreno and Thelan (1993), should be considered. Intervention measures have to be very carefully considered. Including measures that assess more than change in knowledge or attitudes such as measures of behavioral intention (Moreno and Thelan 1993) or monitoring the body mass index (Killen et al. 1993) is valuable. Refining and utilizing existing measures would offer uniformity and help standardize prevention efforts. Attaching and integrating prevention programs with treatment is also important. Shisslak and colleagues’ (1987) failure to have treatment offers accepted in the high school population indicates that the marketing of treatment and prevention efforts for adolescent girls must be carefully considered. Prevention components targeted at behavior patterns and future episodes should also be attached to all treatment services to decrease chronicity. Detecting middle school girls – the population most at risk for disordered eating – and tracking them into well-marketed, specialized interventions in the school setting appears to be valuable. Fully-fledged disorders have not yet developed or are in the early stages at this point, and the school site allows greater accessibility to the intervention rather than requiring that the girls attend a treatment setting.

SUMMARY AND CONCLUSIONS Many review articles address the diverse and rapidly developing field of disordered eating, but far fewer

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articles address the at-risk population of adolescents. Social contributors (e.g., the media’s affirmation of a desire for thinness) to this behavior and associated illnesses are considerable, and affect all adolescent and latency-age girls to some degree. Understanding the full range of behavior and those at high risk to develop pathology is important. Developing prevention programs that target adolescent girls, their families, schools, and the relevant media is also important. Prevention has been much neglected within the field of eating disorders. Adolescent psychiatrists can play an important role in treatment and prevention. Understanding the spectrum of ‘disordered eating’ and the manifestations of the diagnoses is an important first step. Recognizing that treatment of adolescents with the diagnoses is complex, requiring both a comprehensive theoretical (biopsychosocial and cultural) modal and a multimodality treatment approach, is also crucial. Ongoing collaboration with pediatricians, adolescent medicine physicians, dieticians, and teachers is an important part of treatment. Adolescent psychiatrists can and should advocate for teenagers by recognizing that disordered eating is a serious risk behavior; by educating parents, teachers, and others who work with adolescents; and by helping to develop effective, widespread prevention.

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Deutsch, H. Anorexia nervosa. Bulletin of the Meninger Clinic 45: 499–511, 1981. Fairburn, C.G., Jones, R., Peveler, R.C., Hope, R.A., O’Connor, M. Psychotherapy and bulimia nervosa: Longer term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Archives of General Psychiatry 50: 419–428, 1993. Felts, M., Tavasso, D., Chenier, T., Dunn, P. Adolescents’ perceptions of relative weight and self-reported weight loss activities. Journal of School Health 62: 372–376, 1992. Fisher, M. Medical complications of anorexia and bulimia nervosa. Adolescent Medicine State of the Art Reviews 3: 487–502, 1992. Gardner, H.M., Freeman, C.P., Jesinger, D.K., Collins, S.A. Fluoxamine: an open pilot study in moderately obese female patients suffering from atypical eating disorders and episodes of binging. International Journal of Obesity 17: 301–305, 1993. Garfinkel, P.E., Kaplan, A.S. Starvation based perpetuating mechanism in anorexia nervosa and bulimia. International Journal of Eating Disorders 4: 661–665, 1985. Gold, D.W., Rubinow, D.R. Neuropeptide function in affective illness. In Meltzer, H.W. (ed.), Psychopharmacology: The third generation of progress. New York: Raven Press, 1987, 1–13. Halmi, K., Broadland, G., Loney, J. Prognosis in anorexia nervosa. Annals of Internal Medicine 78: 907–909, 1973. Herzog, D.B., Copeland, P.M. Eating disorders (a review). New England Journal of Medicine 313: 295–303, 1985. Jones, D.J., Fox, M.M., Babigian, H.M., Hutton, H.E. Epidemiology of anorexia nervosa in Monroe County, New York, 1960–1976. Psychosomatic Medicine 42: 551–558, 1983. Killen, J.D., Taylor, C.B., Hammer, L.D., et al. An attempt to modify unhealthful eating attitudes and weight reduction practices of young adolescent girls. International Journal of Eating Disorders 13: 369–384, 1993. Killen, J.D., Taylor, C.B., Hayward, C., et al. Weight concerns influence the development of eating disorder: a 4-year prospective study. Journal of Consulting and Clinical Psychology 64: 936–940, 1996. King, M.B. Eating disorders in a general practice population: prevalence, characteristics, and follow-up at 12–18 months. Psychological Medicine (Suppl.): 14, 1989. Kleinman, R.E. Obesity. In Rudolph, A. (ed.), Pediatrics. Los Altos, CA/Norwalk, CT: Appleton and Lange, 1987, 205–208. Kreipe, R.E., Uphoff, M. Treatment and outcome of adolescents with anorexia nervosa. Adolescent Medicine State of the Art Reviews 3: 519–540, 1992.

302 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood Larocca, F.E., Goodner, S.A. Tube feeding: is it ever necessary? New Directions for Mental Health Services 31: 87, 1986. Lerner, R.M., Orlos, J.B., Knapp, J.R. Physical attractiveness, physical effectiveness, and self-concept in late adolescents. Adolescence 11: 313–316, 1976. Lucas, A.R. Toward the understanding of anorexia nervosa as a disease entity. Mayo Clinic Proceedings 56: 254–264, 1981. Lucas, A.R. The eating disorder ‘epidemic’: more apparent than real. Pediatric Annals 21: 746–751, 1992. Lucas, A.F., Beard, M., O’Fallon, W.M., Kurland, L.T. 50-year trends in the incidence of anorexia nervosa in Rochester, Minnesota: a population-based study. American Journal of Psychiatry 148: 917–922, 1991. McDonald, K., Thompson, J.K. Eating disturbance, body image dissatisfaction, and reasons for exercising: gender differences and correlational findings. International Journal of Eating Disorders 11: 289–292, 1992. Moreno, A.M., Thelan, M.H. A preliminary prevention program for eating disorders in a junior high school population. Journal of Youth and Adolescence 22: 109–124, 1993. Patton, G.W. Eating disorders: antecedents, evolution, and course. Annals of Medicine 24: 281–285, 1992. Paxton, S.J. A prevention program for disturbed eating and body dissatisfaction in adolescent girls: one-year follow-up. Health Education Research 8: 43–51, 1993. Ponton, L.E. Issues unique to psychotherapy with adolescent girls. American Journal of Psychotherapy 47: 353–372, 1993. Ponton, L.E., Gruber, E., DiClemente, R. Reported symptoms of eating disorders among Native American adolescents contrasted with white and black youth. Proceedings of the Society for Adolescent Medicine 1994: 25–26, 1994. Pyle, R.L., Mitchell, J.E., Eckert, E.D., Halvorson, P.A., Newman, P.A., Goff, G.M. The incidence of bulimia in freshman college students. International Journal of Eating Disorders 2: 75–85, 1983. Russell, G.F.F., Szmukler, G.L., Dare, C. An evaluation of family therapy in anorexia and bulimia nervosa. Archives of General Psychiatry 44: 1047, 1987. Schebendach, J., Nussbaum, M.P. Nutrition management in adolescents with eating disorders. Adolescent Medicine State of the Art Reviews 3: 541–558, 1992. Schotte, D.E., Stunkard, A.J. Bulimia vs. bulimic behaviors on a college campus. Journal of the American Medical Association 258: 1213–1215, 1987. Schleimer, K. Dieting in teenage girls. Acta Pediatrica, Supplement: 312, 1984.

Serdula, M.K., Ivery, D., Coates, R.J., Friedman, D.S., Williamson, D.F., Byers, T. Do obese children become obese adults? A review of the literature. Preventive Medicine 22: 167–177, 1993. Shisslak, C.M., Crago, M., Neal, M.E. Prevention of eating disorders among adolescents. Journal of Consulting and Clinical Psychology 55: 660–667, 1987. Soundy, T.J., Lucas, A.R., Suman, V.J., Melton, L.J. Bulimia nervosa in Rochester, Minnesota, 1980–1990. Personal communication, 1994. Spitzer, R., Yanovski, S., Wadden, T., Wing, R., Marcus, M.D., Stunkard, A. Eating disorder: its further validation in a multisite study. International Journal of Eating Disorders 13: 137–153, 1993. Steiner, H., Lock, J. Anorexia nervosa and culimia nervosa in children and adolescents: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 37: 352–359, 1998.. Stunkard, A., d’Aquile, E., Fox, S., Filion, R. Influence of social class on obesity and thinness in children. Journal of the American Medical Association 221: 579–584, 1972. Taub, D.E., Blinde, E.M. Eating disorders among adolescent female athletes. Adolescence 27: 833–848, 1992. Tobias, A., Gordon, J. Social consequences of obesity. Journal of the American Dietetic Association 76: 338–342, 1980. Wachsmuth, J.R., Garfinkel, P.E. The treatment of Anorexia Nervosa in young adolescents. In Lewis, M., Woolston, J.L. (eds), Child and Adolescent Psychiatric Clinics of North America. Philadelphia: Saunders Co., 1983. Whitehouse, A.M., Cooper, P.J., Vize, C.V., Hill, C., Vogel, L. Prevalence of eating disorders in three Cambridge general practices: hidden and conspicuous morbidity. British Journal of General Practice 42: 57–60, 1992. Willi, J., Grossmann, S. Epidemiology of anorexia nervosa in a defined region of Switzerland. American Journal of Psychiatry 140: 564–567, 1983. Williams, P., King, M. The ‘epidemic’ of anorexia nervosa: another medical myth? Lancet 1: 205–207, 1987. Yates, A. Current Perspectives on the eating disorders: I. History, psychological and biological aspects. Journal of the American Academy of Child and Adolescent Psychiatry 28: 813–828, 1989. Yates, A. Current perspectives on the eating disorders: II. Treatment, outcome, and research directions. Journal of the American Academy of Child and Adolescent Psychiatry 29: 1–9, 1990. Yeager, J., Kurtman, F., Landsverk, J., Wiesmeier, E. Behaviors and attitudes related to eating disorders in homosexual male college studies. American Journal of Psychiatry 145: 495–497, 1988.

5.6 Personality disorder in adolescence GLEN T. PEARSON

HISTORY AND BACKGROUND For the first three-quarters of the twentieth century, official psychiatric nosology determinedly ignored most of the disorders of both childhood and adolescence. The neglect of children’s psychiatric disturbances in the official nomenclature began to be redressed in 1980 with the publication of the Third Edition of the Diagnostic and Statistical Manual (DSM-III; American Psychiatric Association 1980 in which appeared for the first time an entire section of categories devoted to disorders usually first evident in childhood or adolescence. There soon followed what was to become a flood of nosological and epidemiological research focusing on disorders of childhood, conducted mostly by pediatric psychopharmacology workers (Rapoport and Ismond 1990). The burgeoning literature of childhood psychopathology which has resulted from this floodtide has, for the most part, preferentially addressed disorders of childhood, once again relegating adolescence to an unenviable position of nosological neglect. If adolescence is the stepchild of psychiatric nosology, so too are personality disorders the stepchildren of adolescent psychiatry. The issue of whether a child should be given a diagnosis implying chronically enduring maladaptive characteristics, in an age period when personality cannot be said to have completed its development, has been argued by academicians on empirical grounds and by clinicians on ethical ones (Pearson 1997a). Nevertheless, an empirical literature is emerging which, when framed by the rich antecedent formulations of attachment, object relations, and self-psychological theories, point compellingly to the existence of personality disorder in adolescence. After all, the diagnosis of personality disorder in adulthood requires a retrospective judgement that the behavioral symptoms were present no later than in adolescence.

This chapter provides an overview of personality disorder as an important morbid condition affecting adolescents. Not only do personality disorders occur, but they also most commonly present in adolescence. Personality disorders can be reliably diagnosed in adolescent patients, and adolescence as a developmental phase presents us with unique opportunities for the effective treatment of these disorders.

EPIDEMIOLOGY Estimates of the prevalence of personality disorders in the adolescent population range from a low of 5 per cent (Samuels et al. 1994) to a high in excess of 30 per cent (Korenblum et al. 1987). The Toronto Longitudinal Study of Golombek and Marton (1992) placed the prevalence of severe personality dysfunction in early adolescence at 16 per cent of their community sample. Personality dysfunction is more prevalent in early and middle adolescence; rates in late adolescence fall to approximate those in the adult population (Bernstein et al. 1993). Moreover, any number of comorbidity studies of clinical populations (e.g., Westman et al. 1987; Eppright et al. 1993; McManus et al. 1984) confirm a high prevalence of comorbid personality pathology in adolescents referred for such disparate problems as learning disabilities, mood disorders, and conduct disturbances. In epidemiological terms, adolescent personality disorder is an important morbid condition – a public health problem of considerable magnitude (Pearson 1997b). These kids are out there: they are terrorizing our neighborhoods and schools; and they are clogging our public mental healthcare system, our private psychiatric hospitals, and – most particularly – our juvenile justice system. Untreated, they will go on to lifelong careers as adult character disorders. It is crucial that these cases be

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identified and treated during the formative developmental years of adolescence, before maladaptive patterns of relating and behaving have become permanently entrenched; because, with effective treatment, we can spare both the child and ourselves the misery that he will otherwise both experience within himself and inflict upon society.

DIAGNOSIS DSM-IV provides criteria for diagnosis that can be used for any age period. Although many clinical workers do not believe it, these criteria can be applied to both children and adolescents in order to diagnose personality disorders. These purely descriptive criteria (really just lists of behavioral symptoms) form the basis of classification in our official psychiatric nosology. The descriptive diagnosis of psychiatric disorder is one level of assessment and is generally necessary for uniform reporting for statistical and research purposes (not to mention billing to thirdparty payers). However, descriptive diagnosis is of little or no help to the clinician in understanding the patient or in planning and carrying out treatment. For these purposes, a psychodynamic formulation, including a structural assessment of personality, is needed. Psychodynamic and structural assessments rely upon theoretical formulations which will be discussed below; the concept presented here is simply that descriptive diagnosis alone is inadequate. To the DSM IV diagnosis must be appended a detailed analysis of the intrapsychic forces that shape the structure of the patient’s personality. DSM-IV lists ten personality disorders, grouped in three typological clusters, as shown in Table 5.6-1. Not only because of the lack of strong evidence for the validity of these clusters, but also because of their insistence upon a particular theory of pathogenesis, Masterson and Klein (1989) proposed an alternative grouping of the personality disorders, which assumes most of the DSM disorders under Borderline Personality Disorder, reserves Narcissistic and Antisocial Personality Disorders each a category of its own, and leaves the Odd/Eccentric cluster intact, as shown in Table 5.6-2. This is clinically a very relevant classification; that is, actual patients fit into its categories more nearly neatly than into any other. We are unlikely to see such a useful Table 5.6-1 DSM-IV Personality Disorders: clusters of typology. A. Odd/Eccentric B. Dramatic/Emotional/ Erratic C. Fearful/Anxious

Paranoid, schizoid, schizotypal Borderline, narcissistic, histrionic, antisocial Avoidant, dependent, obsessive–compulsive

classification made part of our official nomenclature in our lifetime, because it has two fatal nosological flaws: etiological assumptions, and a taxonomic basis other than phenomenology. Since 1980, the various DSMs have attempted to address the problem of diagnosing adolescent personality dysfunction by providing categories for children and adolescents that are in some ways counterparts to the adult personality disorders. For example, we are forbidden to diagnose antisocial personality disorder in patients under the age of eighteen years (even though the behavioral symptoms of the disorder must by definition have become well established by the age of fifteen), but a child who is clearly on the pathway leading to that diagnosis at age eighteen can be diagnosed with conduct disorder at any age. Although all adult antisocial Personality Disorders will have had Conduct Disorder by adolescence, not all children with Conduct Disorder will go on to develop Antisocial Personality Disorder in adult life. In DSM III and DSM III-R, borderline Personality Disorder also had a counterpart in adolescence: identity disorder. Its construct validity was a matter of some controversy and it was not retained in DSM IV. Many psychiatrists, particularly those in college health settings, maintain that identity disorder is a valid diagnosis and is quite common in their clinical caseloads; however, it seems unlikely that identity disorder is related to borderline Personality Disorder in the same way that conduct disorder is related to antisocial Personality Disorder. Except for borderline and narcissistic Personality Disorders, most DSM-IV personality disorder diagnoses are seldom made in adolescents. Most teenagers who qualify for a personality disorder diagnosis are in Cluster B (dramatic/emotional), and it is these same youths who claim the lion’s share of public and therapeutic attention. Odd and eccentric children may meet the criteria for schizoid or schizotypal Personality Disorder. A few of these are seen in outpatient settings, where they are more likely to be described as showing ‘traits’ of these disorders, rather than to be given an Axis II ‘diagnosis.’ Many of them probably never come to clinical attention. Structurally borderline or narcissistic adolescent males often present with paranoid features, although they seldom meet the criteria for paranoid Personality Disorder. Histrionic features frequently dominate the clinical Table 5.6-2 Alternative classification of Personality Disorders (Masterson and Klein 1989). I. Borderline

II. Narcissistic III. Antisocial IV. Paranoid/schizoid

Borderline, histrionic, avoidant, dependent, obsessive– compulsive Exhibitionistic, internalizing (‘closet’) subtypes Antisocial Paranoid, schizoid, schizotypal

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picture in borderline and narcissistic adolescent females, to the point that many of them will meet the criteria for both Personality Disorder diagnoses. Avoidant Personality Disorder has a corresponding Axis I diagnosis in the disorders, first appearing in childhood and adolescence. Adolescents with this disorder are occasionally seen in outpatient practice. Although obsessive–compulsive illness and other anxiety disorders (on Axis I) are fairly common in childhood and adolescence, children and adolescents probably rarely if ever meet the criteria for Obsessive–Compulsive Personality Disorder. The fact that the criteria for Passive– Aggressive Personality Disorder (in DSM-III and DSMIII-R) could be used to describe the average teenager underscored the lack of developmental considerations and led to the exclusion of the category from DSM-IV. From the foregoing, we see that the utility of DSM-IV personality disorder criteria is limited principally to borderline, and, to a lesser extent, narcissistic Personality Disorders. Adolescents who qualify for other personality disorders are usually, if not always, psychodynamically and structurally similar to the borderlines. Most adolescents with personality disorders will have at least five of the eight symptoms on the DSM-IV borderline list (Table 5.6-3). However, one’s understanding of the patient and treatment approach will be based on the psychodynamic formulation and structural assessment, which depend, in turn, upon the clinician’s ability to organize clinical data meaningfully. In addition, the extraction of meaning from clinical data requires some kind of organizing principle, or theory; thus, it will be necessary for the clinician to step beyond the realm of the empirically verifiable. One shudders to think that we must somehow apologize Table 5.6-3 DSM-IV criteria: borderline Personality Disorder. Five of the following: 1 Frantic efforts to avoid real or imagined abandonment 2 A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation 3 Identity disturbance: markedly and persistently unstable self-image or sense of self 4 Impulsivity in at least two areas that are potentially selfdamaging (e.g., spending, sex, substance abuse, reckless driving, binge eating) 5 Recurrent suicidal threats, gestures, or behavior; or selfmutilating behaviors 6 Affective instability due to a marked reactivity of mood (e.g., intense episodic dsyphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days) 7 Chronic feelings of emptiness or boredom 8 Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights)

for this step, even if only to reassure the younger students of the field that, despite the determinedly atheoretical framework of DSM, this is not only an acceptable, but an indispensable thing to do.

THEORETICAL FORMULATIONS OF ADOLESCENT PERSONALITY DISORDER In order to accomplish the deeper level of diagnostic assessment which will support and guide treatment planning and implementation, we must make explicit our beliefs about human behavioral science, development, and psychopathology. The atheoretical premise of the DSMs over the past two decades was necessary in order to begin accumulating an empirical database which may eventually lead to discoveries about the etiology and pathogenesis of psychiatric disorders; meanwhile, we must acknowledge, with DSM IV, that we do not know how normal personality development unfolds, or what factors cause disordered development (Rutter and Tuma 1988). Unfortunately, the phenomenological approach to diagnosis has allowed – and perhaps even encouraged – too many clinicians to stop thinking theoretically altogether. A clinical worker without a framework for organizing and understanding the vast varieties of clinical material which provide the subject matter for therapeutic work is lost at sea, lacking navigational skills and knowledge, and without charts. It is not necessary (in fact would be undesirable) for the worker to ‘believe’ in the ‘absolute truth’ of a particular theory. But it is necessary for the worker to have some way of understanding patient feelings, behaviors, and relationships, that will allow the therapist to generate and test some hypotheses about behavioral causes and effects, to therefore see the patient as predictable in some ways, and to communicate ideas about therapeutic change to the patient. To theorize we must, with two caveats: 1 Remember that we do not actually know how personality develops; our theories are best thought of as ‘a variety of helpful concepts, which still fall far short of explaining how personality is organized’ (Rutter and Tuma 1988). 2 One should never put all one’s conceptual eggs into one theoretical basket. It is never a question of whether Kohut’s view is more correct than Kernberg’s: it is always a question of what aspects of each way of thinking are most relevant and helpful in understanding a particular child in a particular context at a particular point in time. Theoretical masters can only help us to organize and understand what our patients are trying to teach us. Over the past twenty to thirty years, two major schools of psychoanalytic thought have influenced theoretical

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formulations of personality development and disorder: object-relations theory and self-psychology, whose principal advocates are, respectively, Otto Kernberg and Heinz Kohut. In the following brief overview, the salient features of each of their formulations are highlighted, and a more recent synthesis of the two schools of thought, formulated by James Masterson and coworkers, is presented.

Object-relations theory Kernberg holds that all personality disorders are the phenomenological expression of an underlying personality structure which he calls borderline, because it is intermediately pathological between psychotic and neurotic structures. Two principal risk factors lead to the development of borderline personality organization: a high level of constitutionally endowed pregenital aggression in the infant, and the libidinal unavailability of the mother (‘object’) during the rapprochement subphase of separation– individuation. The disorder is characterized by the persistence of primitive mechanisms of defense, such as splitting, projection, and projective identification, in order to protect the good maternal object from the destructive effects of the child’s innate aggression and the child himself from the abandonment depression caused by libidinal unavailability of the object. Among the diagnostic implications of this formulation is that one must differentially diagnose the underlying structure of the patient’s personality; and Kernberg (1984) gives explicit guidelines for delineating neurotic, borderline, and psychotic personality structures. Concerning treatment, Kernberg insists upon technical neutrality (don’t we all), and holds that successful treatment depends absolutely upon the accuracy and timeliness of the content of interpretations of the patient’s defenses, the underlying instinctual wishes, and his pathological ties to objects.

Self-psychological theory Heinz Kohut’s careful attention to his patients caused him to question the orthodox psychoanalytic concepts he had been taught (we should all learn a lesson from this). He, and eventually a legion of coworkers and followers, ended by approaching the problem of personality disorder from the perspective of the development of the self. In Kohut’s account of early personality development, the child’s needs for nurturing, soothing, and various kinds of personal validation are met psychologically by a network of self-object structures. Empathically attuned parents and care-givers meet both mirroring and idealizing self-object needs, and the capacity to meet those needs for himself is internalized by the developing child. If the parent persistently rejects the child’s attempts to

idealize the parent (that is, if the child’s idealizing selfobject needs are frustrated), the child will suffer narcissistic developmental arrest in idealizing, will continue to long for a perfectionistic image of the parent, and may tend throughout life to search for someone to fulfill that image. If the child’s mirroring self-object needs are not adequately met (that is, if he experiences continuous rejection of, or lack of support for, his proud feelings of accomplishment and importance) a developmental arrest in the primitive grandiose self occurs. The clinical picture in this case can present in two ways depending on the defensive strategy directed against the primitive grandiose self. If repressed, a horizontal split occurs, the person negates his grandiosity, and presents with low self-esteem, depression, and impaired enthusiasm. If denial or disavowal is used, a vertical split occurs, the person gives full expression to his exhibitionistic desires but without awareness either that he is doing so or of the consequences, especially for others, and the clinical presentation is more like the narcissistic personality disorder as behaviorally defined in DSM IV (insensitive, uncaring). Primary self structures develop naturally in an empathically attuned self-object environment. Compensatory self-structures develop in response to defects in the naturally developing primary structures. A defective structure means that there has been inadequate internalization of one or more essential self-object functions. Overinvestment in idealizing functions may compensate for defective mirroring, and vice versa. Kohut’s criteria of a healthy self are: a capacity for empathy, the capacity for love, creativity, humor, and wisdom. Wisdom is achieved by very few people. In its highest form it encompasses coming to terms with one’s own mortality... a kind of existential authenticity. Kohut also developed a classification of psychopathology of the self. Self-disturbances were first classified as primary or secondary. Secondary self-disturbances occur in the context of a well-established cohesive self-system, and range from nonpathological vicissitudes of self-esteem in response to life stressors to the psychoneuroses. The primary self-disturbances, in order of decreasing severity, are: psychoses, borderline states, narcissistic personality disorder, and narcissistic ‘behavior disorders.’ Kohut believed that both psychoses and borderline states reflected permanent and irreparable damage to the self, although the central defect of the borderline patient was covered over by an effective defensive structure. He would upgrade borderline patients to narcissistic if they showed evidence in treatment of beginning to develop self-object transferences. But he basically believed that truly borderline patients, like psychotic patients, were not analyzable. In Narcissistic Personality and Behavior Disorders, the self is not permanently damaged and has some flexibility and resilience. Reactions of enfeeblement or fragmentation are more temporary, and the patient can form self-object

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transferences and so, for Kohut, is at least potentially analyzable. The difference between what Kohut calls Narcissistic Personality Disorder and the Behavior Disorder is basically whether the surface clinical presentation is internalizing or acting out. Kohut’s Personality Disorder is hypersensitive, depressed, empty, apathetic, and hypochondriacal; his Behavior Disorder is delinquent, perverse, promiscuous, alcoholic, and/or chemically dependent.

Synthesis of object relations and self psychology approaches In an attempt to synthesize the contributions of self psychology and object-relations theories, Masterson has proposed that a logical classification of personality disorders would regroup the ten DSM disorders into only four categories: borderline, narcissistic, antisocial, and paranoid/schizoid (see Table 5.6-3.) Most of the DSM personality disorders would be diagnosed as Borderline. The assumption is that in those four types, in addition to Borderline Personality Disorder per se, the same structural and dynamic configurations are in place, and the choice of defensive style determines the clinical presentation. Narcissistic Personality Disorder is a category to itself, with the internalizing or closet and externalizing or exhibitionistic subtypes, depending on the choice of defense against the emergence of the primitive grandiose self (vertical split/disavowal or horizontal split/repression). Antisocial Personality Disorder is also a category unto itself, and the Odd/Eccentric cluster is left intact. The differentiating principle in this classification is the way in which the self relates to the object. In the borderline, the self clings to or distances the object. In the narcissistic, the self co-opts the object. In the truly psychopathic antisocial personality disorders, the self remains totally emotionally detached and uninvolved with objects. In the schizoid disorders the self distances the object, and in the paranoid there is major use of projection. Masterson comes closest to synthesizing self psychology and object relations when he talks about self-theory as the flip side of the object relations coin. Instead of ‘cohesive self,’ he uses the term ‘libidinal self constancy,’ in parallel with the object relations term ‘libidinal object constancy.’ Masterson does not get into the detailed analysis of self-object functions and their internalization. He postulates a ‘false self’ which defends the patient against awareness of his ‘impaired true self.’ For Masterson, the false self seems to be made up of a composite of pathological part-self images (which are related to corresponding part-object images), and the constellation of primitive defenses that go along with the disorder. Underlying everything is still the famous abandonment depression, caused by libidinal unavailability of the object during rapprochement.

In the differential diagnosis of personality disorders, Masterson and Klein (1989) assume that the presenting clinical picture is that of the defensive false self, and relies heavily on the assessment of intrapyschic structure (that is, the self ’s characteristic way of relating to the object), and the nature of the therapeutic relationship. This correlates with Kohut’s assessment of the ability to form self-object transferences, which is the sine qua non of analyzability. Masterson’s main point is that the focus of object relations theory has been on the ways the self differentiates from and attaches to the object in the course of development; while the focus of self-psychological theory has been on the ways the self becomes individuated and autonomous. The flip sides of the same coin are separation and individuation. The end result of normal development on the one side is libidinal object constancy; on the other, libidinal self-constancy, or self-cohesiveness. Masterson and Klein (1989) conceptualize the normal functions of the unimpaired Real Self as divided between the two sides of the separation/individuation coin. Normal functions of the Separate Real Self include sharing, commitment, intimacy, empathy, and acknowledgement of others; those of the Individuated Real Self are comprised of self-soothing, self-acknowledgement, spontaneity, selfactivation, aliveness of affect, and creativity. Impairments in the Real Self will be manifested by difficulties in the normal functions of separation and individuation listed here. In the Borderline states, impairments of the Real Self show up clinically as impairments in functions associated about equally with both separation and individuation. In Narcissistic disorders, the manifest symptoms are those of failure of separation. Narcissistic disorders also have failures of individuation, but they tend to be latent, and show up only under the stress of acute narcissistic disappointment, or in treatment.

TREATMENT Principles of treatment The principles of treatment discussed here were first enunciated in the latter half of the 1980s, and were first published as recently as 1997 (Pearson 1997b). As originally formulated, these principles reflected the author’s extensive experience in long-term hospital treatment of severely disturbed adolescents, complemented by a unique opportunity for very long-term follow-up in the community (Pearson 1987). The decade that has passed since the first iteration of these treatment principles has seen epochal changes in the way psychiatric services are funded and delivered, with the result that it is no longer feasible for severely disturbed adolescents to receive

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long-term hospital, residential, or any other out-of-home treatment. Yet the principles of treatment discussed herein are still valid and perhaps even more important than they were ten years ago, if vastly more difficult to apply. In this section, treatment principles are enumerated and discussed with emphasis on translating their application from inpatient/residential to community-based outpatient settings, and some of the attendant difficulties.

his therapeutic experience in the real world over a period of months and years, after the formal treatment has stopped. Many patients have found it helpful to be told by the therapist, at each nodal separation point in treatment, that ‘Although I won’t be your therapist any more, I’ll still be your friend. I’ll always be your friend.’ Patients should be encouraged to call or write, and each contact must be faithfully answered by the therapist.

CONTEXT

CONTROL

A secure context is essential for treatment of adolescents with severe personality disorder (Rose 1987). In the days of long-term residential care, such a context was offered by the inpatient or residential treatment program itself, together with an alliance with the family. Even then, context was a bigger issue than the ability to restrain the adolescent; it has always involved an explicit understanding among multiple systems of care and authority (family, treatment team, school, and community) as to the shared responsibilites of treatment. In the current environment, the therapist must construct context by engaging the child, family, school, and others in the community in a shared understanding of the adolescent’s problems, the means of addressing them, and the goals of treatment. Brief hospitalization, respite care, ‘wraparound’ services, and home- and school-based services will all be used at different times in the treatment; the umbrella of context must be provided by the uniquely committed relationship of the therapist to the child and family.

In the much-lamented days of long-term residential treatment, many controls were available to apply to patients’ symptomatic behaviors. Locked units, strict behavioral programs, personal and mechanical restraint procedures were all used not only to assure safety, but to deprive the adolescent of action as a mechanism for externalizing his or her inner pain. In today’s treatment milieu, very few controls are available to the therapist. One must conceptualize the adolescent’s entire living situation as a system offering contingent possibilities to be utilized therapeutically (both behaviorally and interpretively): brief hospital admission, or even arrest and incarceration in a juvenile justice facility could be considered analogs of restraint. The use of real-life contingencies as therapeutic controls depends upon the therapist’s commitment to and engagement with the patient: detention at juvenile hall is not to be interpreted as a disruption of treatment, but rather as a part of the treatment program which must be understood and utilized in the service of learning and growth.

ENGAGEMENT The therapist must somehow understand ‘where’ the child is and ‘meet him there.’ Empathically processing verbal and (more importantly) nonverbal communications from the adolescent, the therapist sorts out issues of relevance from the youngster’s perspective, and by identifying himself with those issues, evokes or provokes an interest on the adolescent’s part in the therapist as a person and in the process of treatment. Engagement is an opening gambit which must be continually addressed throughout the course of treatment. It is a necessary but not a sufficient condition for alliance development. The establishment and maintenance of engagement with a severely disturbed adolescence call for creativity, flexibility, and a willingness to relinquish traditional professional role behaviors.

REGRESSION AND RECONSTRUCTION

COMMITMENT

CONTINUITY

The therapist must be palpably committed to the patient early on and for as long as the patient needs the therapist, typically for several years. If treatment is successful, the adolescent will internalize the therapist as his or her first whole-object image, and will then need to be able to check back with the therapist as the patient generalizes

Continuity means continuity of care. The therapist must be a constant object in the child’s life from the beginning of treatment until the child can relinquish the therapist (if ever). Treatment of adolescent personality disorder is not analagous to repairing an automobile, and therapists are not interchangeable parts.

If real-life situational ‘controls’ succeed in depriving the adolescent of his characteristic mechanisms for avoiding pain, he or she regresses. The therapist must then intensify engagement, meet the patient where he or she is (at that regressed level) and, by clarification, interpretation, and working through, reconstruct the adolescent’s personality development along healthier lines. In the longterm residential treatment environment, opportunities for more normative and corrective developmental experience were routinely provided by the milieu; in the outpatient community-based environment of today, the therapist must partner with the youngster and family to seek such opportunities in the real world.

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SYSTEMS INVOLVEMENT Treating severely disturbed adolescents requires the therapist to be involved with a variety of social systems (Pearson 1991). First and foremost of these is the child’s family; and the interface and boundaries between the treatment of the child and the management of the family constitute an issue of some magnitude, one which by itself can predict either success or failure (Pearson 1997b). In the present-day environment, the therapist must conceptualize the whole of the adolescent’s day-to-day living as the milieu in which treatment is carried out, and opportunities to turn daily events and routine processes to therapeutic advantage must be sought in every sector: family, school, and community. All of these children will be involved in school; many of them will also be involved with other community agencies, such as juvenile probation, child protective services, police departments, and the like.

Treatment modalities INPATIENT/RESIDENTIAL TREATMENT Once considered the treatment of choice for severely disturbed adolescents, inpatient treatment is now almost universally limited to brief episodes of crisis management; while residential treatment programs which formerly could extend over eighteen months to two years (or even longer) are limited to three months (or less) of behavior modification. The inpatient crisis unit is useful in today’s environment as a controlling intervention for suicidal or destructively acting-out adolescents, but it must be merged with a system of other alternatives in the community since it is unlikely to be funded for more than a few days of crisis care at a time. The challenge of today’s psychiatric healthcare environment is to find ways to translate the well-established inpatient/residential milieu therapy into community-based interventions. The interested reader is referred to the author’s discussion of milieu therapy (Pearson 1997, pp. 278–281).

INNOVATIVE ALTERNATIVE TREATMENTS The public mental health sector, together with other child-service agencies such as juvenile justice, child protective services, and public educational systems, has pioneered a number of approaches which show great promise for the severely disturbed adolescent. Among these are wraparound services, therapeutic foster care, family preservation services and other home-based interventions, and school-based mental health services. Wraparound services and therapeutic foster care represent comprehensive, stand-alone treatment programs which, properly planned and delivered, could substitute for, or even improve upon, traditional hospital or residential treatment for personality-disordered adolescents.

Family preservation (in-home therapeutic services) and school-based mental health services should be thought of as part of the continuum of services available to the therapist of outpatient adolescents with personality disorder.

PSYCHOTHERAPIES A rich literature on the individual outpatient psychotherapy of adult borderline patients informs the treatment of personality-disordered adolescents. Group psychotherapy In the days of residential treatment, psychoanalytic conceptualizations of psychotherapeutic principles were incorporated into the milieux of treatment units; individual and group psychotherapies were prescribed, and most of the early work of confrontation, clarification, and working through of resistances was done in the group setting. Group dynamics are a powerful influence on adolescent emotionality and behavior, and, in the author’s opinion, the loss of the group as a treatment modality is the chief – if not the only – reason to grieve the loss of the residential treatment unit from our armamentarium against personality disorder in adolescents. In outpatient practice, the establishment and maintenance of an intensive, protreatment, progrowth, prodevelopment therapeutic group is an impossible task. On the other hand, in community settings, we are not aggregating youth with emerging characterological psychopathology; thus, there is less of a naturally antitreatment group process to be countered. Therapists should be constantly aware of the adolescent’s propensity to identify with groups, and alert for opportunities to turn real-life group memberships to therapeutic advantage (Pearson 1991). Individual psychotherapy There is a rich literature on the analytically oriented psychotherapy of borderline adults; many of these principles apply to the psychotherapy of adolescents with personality disorder. The guidelines for therapist activity discussed in this section are extracted from the writings of Kernberg (1984), Masterson (1976), Rinsley (1980, 1982, 1989), Masterson and Klein (1989), Campbell (1982), and Lewis (1987), and from the author’s personal experience treating the target population. The following principles should be kept in mind when treating personalitydisordered adolescents:

•

Technical neutrality: Kernberg insists upon it, and so should we. Technical neutrality does not mean being passive or reflective, like the stereotype of the psychoanalyst behind the couch. It does mean keeping oneself equidistant from the opposing forces that determine the patient’s conflicts (Campbell 1982). This means, in turn, taking in with equal interest and acceptance both the libidinal and the aggressive derivatives with which the child invests the therapist.

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•

•

•

•

Control of relationship: Based upon a well-thoughtout analysis of the state of object relationship in early adolescence, Owen Lewis (1987) proposes that an adolescent cannot be expected to be meaningfully engaged in therapy if he or she has no control over the relationship. Adolescent patients referred for therapy should be advised to evaluate the therapist, just as the therapist is evaluating them. If the therapist concludes that he or she can be helpful to a particular child, an offer to become the therapist should be made, but it should be entirely up to the adolescent to accept the offer. Furthermore, the patient should have the power to fire the therapist at any time. (If a patient threatens to discharge later in treatment, as a resistance, the therapist should insist that the wish be understood, like anything else, rather than immediately gratified; but this also should be explained to the child at the beginning. A therapist who has successfully engaged a child in the early going is extremely unlikely to be fired later on.) Giving the adolescent control over the relationship also extends to how the hours are spent, what kind of material is valued, and how material is handled by the therapist. Therapist activity level: Adolescent patients do not tolerate long silences. One cannot sit back and wait for a teenager to talk; the therapist must be more active with adolescents than with adults. Experience treating young children in the playroom is very helpful to therapists: it sensitizes them to how much of a child’s communication is behavioral rather than verbal. It is often indicated to respond to an adolescent’s behavioral communications in kind rather than by immediately translating them into verbal content. As every therapist of young children knows, words tend to be overvalued by adults in their attempts to communicate with children. Responding behaviorally to behavioral communications, whenever possible, has the advantage of maintaining or enhancing one’s engagement with the child, and, as clarification proceeds, the material can be translated into words. Emphasis on confrontation: The classic technique of calling to therapeutic attention the patient’s behavior, emotional reactions, and intrapsychic processes is central to the therapeutic process with adolescents. This activity is at the expense of efforts to understand and reconstruct. One might compare the confrontations of this treatment process with the behavioral events of behavior modification therapy: there is no such thing as one-trial learning; one must repeat, and repeat, and repeat again. We are not looking for a sudden ‘Aha!,’ but persisting in hope of a cumulative learning process (‘There I go again…’). Limitations on interpretation and analysis of defense: Not every truth which may become clear to the therapist need be shared with the adolescent patient; and defense operations should be explicitly addressed

•

only to the extent that they cause the patient difficulty in living (as is almost always the case with the more primitive, pathological mechanisms, such as splitting and projective identification). Personality disorder in adolescence is characterized by object relationship impairment which severely restricts the applicability of traditional psychotherapeutic procedures. Support for reality testing: The therapist has an important role as an arbiter between the adolescent and the real world. Specific interventions which may be called for include giving advice, setting limits, acknowledging the child’s parents’ mistakes (and the therapist’s), and clarifying the difference between what a given situation ‘feels like’ to the child and what it ‘really is’.

Family therapy The adolescent’s family is one of the most important parts of his or her living milieu; the context which the family provides for its children’s experience can either facilitate or inhibit healthy change and growth. Dynamics in the family must be thought of as treatment variables to be addressed, and the family itself considered an integral part of the treatment team (Jones et al. 1989). It is frequently necessary to employ a specialist in family therapy other than the adolescent’s therapist, in order to preserve the unique and confidential relationship that the therapist must maintain with the child. Pharmacotherapy Treatment with psychoactive drugs is appropriate for specific target symptoms and for diagnosed comorbid conditions in adolescents with personality disorder. One should bear in mind that most of the commonly prescribed psychotropics, including the new generations of antidepressants, have not been studied or proved effective in young people; and we must resist the temptation to view pharmacotherapy as a solution. Mood stabilizers and antidepressants are useful in bipolar disorder and major depression; stimulants and tricyclic antidepressants in attention deficit hyperactivity disorder; and lowdose potent neuroleptics may be prescribed to address the transient psychotic or chronic low-grade paranoid symptoms in the borderline adolescent. Behavior therapy Behavior modification programs have always been central to the residential treatment of personalitydisordered youth. In order to treat these adolescents in the outpatient setting, it is essential to enlist the family, school, and if possible other aspects of the child’s living context to provide consistent contingent reinforcements of targeted behaviors. Otherwise well-intentioned families often have no experience or tradition of providing positive reinforcement on a routine basis; some coaching and reinforcement of parental behaviors in this particular regard are essential. Another common obstacle to providing consistent therapeutic behavioral intervention

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in families is the difficulty a concerned and loving parent has taking a step back from his or her intense affection for the child, and fulfilling a more mundane role as a reinforcer of behavior. There are many opportunities for the patient to learn from experiencing the natural consequences of his behavior at school and in the community; all of these, including such examples as disciplinary actions at school and arrest and detention by the police, should be conceptualized as part of the overall treatment program rather than as an interruption of treatment.

phase-adequate emotional, behavioral, and social functioning, supported by a meaningful renegotiation of the child’s separation–individuation and the establishment of whole-object-relations, in Margaret Mahler’s term, ‘object constancy’ (Fraiberg 1969). This enables the child to view himself and others realistically, to tolerate ambivalence, and, ultimately, to integrate his identity.

Treatment of comorbid conditions In addition to concurrent mood disorders, psychotic symptoms, and attention deficit hyperactivity disorder (ADHD), there are a number of other psychiatric disorders which frequently occur concurrently in adolescents with personality disorder. Learning disorders call for special education and behavioral therapeutic approaches which are available in most public schools. Adolescents with comorbid substance abuse and dependence present an especially difficult problem, in that twelve-step recovery programs which are proven effective with adults present developmental obstacles for many teenagers, who seem to keep tripping over Steps One and Two. Some older adolescents are able to make a commitment to recovery in Alcoholics Anonymous or Narcotics Anonymous and receive great benefit from the network of positive peer relationships and mentoring provided by these organizations.

There are no controlled studies of treatment outcome in adolescents with personality disorder. Those that have been carried out emphasize the importance of continuity of care and long-term treatment in determining a favorable outcome (e.g., Gossett et al. 1983; Masterson and Costello 1980; Pearson 1987, 1997).

Collaboration with community agencies Adolescents with Personality Disorder are frequently involved with such child service agencies as juvenile probation and child protective services. Therapy with multiagency-involved children requires collaboration among the care-givers, and the therapist should take a leadership role in this collaboration, while paying careful attention to issues of boundaries and confidentiality. Adolescents who have histories of delinquent behavior should be advised that the therapist’s role is not to get them out of trouble but to help them understand their need to get into trouble, so they can change the behavior that gets them there.

Goals of treatment Successful treatment of emerging personality disorder in adolescence involves offering the child a committed, stable, predictable relationship as a context for the continual examination and reworking of issues of attachment, separation, idealization, devaluation, dependency, autonomy, hate, and love. Repeated confrontation of primitive psychopathological defenses, such as splitting, denial, projection, projective identification, and omnipotence, sets the stage for internalization of the therapist as a whole object. The ultimate goal is developmentally

Outcome of treatment

APPROACHING THE ADOLESCENT WITH PERSONALITY DISORDER: TECHNICAL CONSIDERATIONS It is perhaps uniquely important to adolescent patients that they be acknowledged as a person (adults may take it for granted that they are; younger children may take it for granted that they are not). Because of the developmental tasks with which the teenager is struggling, he or she is exquisitely sensitive to the inquiring authority of the psychiatrist. Any approach which obviously probes for symptoms is likely to be taken as evidence that the psychiatrist is seeing the patient as a ‘case’ and not as a person. The adolescent needs to experience the psychiatrist as a person who is interested in knowing him as a person and not simply as a bearer of psychopathology. A sincerely interested, respectful approach to the youngster sets the stage for accurate diagnosis, careful clinical formulation and understanding, and, ultimately, effective treatment. Treatment depends upon the relationship between psychiatrist and patient, and an adolescent patient who is not engaged in a relationship with his therapist will defeat any and all attempts at therapeutic intervention. The effectiveness of almost any treatment approach depends much more on the personal characteristics of the patient and the quality of the therapist–patient relationship than on the nature of the disorder. A psychiatric diagnosis is necessary but not sufficient information on which to base a treatment plan. A clinical formulation, in which data about the disorder are integrated with one’s understanding of the patient as a person (Shapiro 1989), as a participant in the therapeutic relationship, and as a member of his family and other relevant social systems (Pearson 1991) forms the foundation upon which effective treatment can be based. The clinical formulation combines categorical, dimensional, developmental, and functional models of diagnosis in

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organizing a broad range of information about the adolescent and his world, gathered by the psychiatrist in the process of participating in a relationship with the youngster. Shapiro (1989) has called for a renewal of attention to the psychodynamic formulation and its central importance to any therapeutic endeavor. To formulate a case requires the clinician to hold, at a minimum, four fundamental convictions:

• • • •

There is unconscious mental functioning. Symptoms may be driven by internalized conflict or developmental deviance. Symptoms have meaning to the child and affect his adaptation to the environment. The therapeutic relationship (transference) plays a critical role in undoing maladaptive behaviors and symptoms.

The psychodynamic formulation is constructed from the viewpoints of ego psychology, development, self psychology, and object-relations theory; thus, it portrays the child in depth in terms of temperament, drives, defenses, coping mechanisms, developmental attainments, and relatedness to others. This detailed portrait of the patient must then be placed in the context of his real relationships with family, peers, adults, authorities, and others in the community. Adolescence is characterized by a geometric expansion of the individual’s social horizon, and the therapist of adolescent patients must enlist the youngster’s help in identifying the social systems in which he lives and moves. Therapist and patient together sketch the boundaries, interfaces, and rule of interaction in and among these systems; the therapist may then listen to the patient’s material with a ‘fourth ear,’ attuned not only to evidence of impact on the adolescent of family or peer-group systems issues, but also to opportunities for the adolescent to become the agent of beneficial changes in his family, peer group, or community systems (Pearson 1991). The initial task of therapeutic work with an adolescent is to engage the patient in a relationship in which he experiences respect for and interest in himself as a person. In the context of such a relationship, the adolescent allows access to his psychological and social worlds. Participation in the relationship permits the psychiatrist to formulate a comprehensive understanding of the adolescent and his social systems, which in turn sets the stage for helping interventions. The diagnostic process is not limited to clinical understanding and treatment planning: it incorporates measured steps of relationship-building activity by the therapist which initially engages the adolescent, then holds him or her in a deepening attachment, and finally goes on to establish a working therapeutic alliance. It is important to distinguish between engagement, attachment, and alliance, because the concept of ‘alliance’

has been invoked so often for such a long time that it is increasingly misused to refer to attachments, and even to compliant resistances. Alliance means that the patient has, by identification with the nonjudgmental, inquiring, and examining functions of the therapist, established his or her own self-examining functions (‘observing ego’), which can then ‘ally’ with those of the therapist in the work of treatment. Developmental variables in adolescence strongly influence the form and stability of the alliance. Attachment simply means a state of affectionate regard by the adolescent for the psychiatrist. In the steps one takes toward encouraging attachment, both positive and negative feelings must be acknowledged and accepted. If the attachment is to be useful for therapeutic purposes, it must be secure enough to contain the patient’s ambivalence toward the therapist. Engagement is the initial process of involving the adolescent in an interactional dialectic, an opening gambit in the diagnostic process. One engages the adolescent by evoking, provoking, or otherwise attracting his interest in the psychiatrist and the process. Engagement is obviously prerequisite to attachment, which, in turn is a necessary, but not a sufficient, condition for an alliance eventually to develop. It is engagement that concerns us in the diagnostic process. How does the psychiatrist engage an adolescent? Concisely put, one must somehow understand ‘where’ the child is, and ‘meet him there.’ ‘Somehow’ encompasses empathically processing verbal and nonverbal communications from the adolescent and using clinical intuition to identify the issues which are most salient from the youngster’s point of view, and then communicating that understanding in a context of interest and respect. An explanation of how this is done is a formidable, perhaps impossible, task. Nevertheless, there are some features of the psychiatrist’s approach to the adolescent, and to the process, which it can be helpful to consider.

Personal style Some adults, including some psychiatrists, are ‘child’ people. They like adolescents, enjoy working with them, and naturally and spontaneously convey their respect and appreciation of them as people. If such an orientation can be learned, it would behoove psychiatrists who work with adolescents to learn it. If not, one must remind oneself that genuineness and honesty are the cardinal virtues for an adult working professionally with teenagers. Genuineness extends to letting the child know one as a person, not only as an adult professional (we are after all asking the child to let us know him as a person). This means acknowledging the feelings one has concerning the adolescent and his issues in the treatment relationship, not disclosing one’s personal life outside the treatment; although, occasionally, the judicious use of self-disclosure based on one’s relevant past experience can enhance the

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youngster’s sense of the importance of the relationship, and of feeling understood (Pearson 1991).

Control of the relationship Most adolescents will not engage meaningfully in a relationship in which they feel they have no control. Ideally, the teenager should feel that he has chosen his doctor or therapist. This is a goal to work toward even when, as is usually the case, the youngster had no part in the decision to begin treatment. One earns the job of chosen therapist by respecting the autonomy of the adolescent in any way that does not jeopardize treatment, often by actively removing oneself from the medical authoritative role, and by honestly acknowledging one’s limitations. Giving the adolescent control of the relationship also extends to how the treatment time is spent, what kind of material is produced, and how the material is to be responded to by the therapist (Lewis 1987).

Technical neutrality The therapist must keep himself equidistant from the opposing forces that codetermine the adolescent patient’s conflicts. Neutrality does not mean passivity or a remote, distant, unemotional attitude. It means tolerating both poles of the youngster’s ambivalence; taking in with equal interest and acceptance both the libidinal (loving) and the aggressive (hating) derivatives with which the child invests the therapist.

Transference Once an adolescent is engaged and is beginning to attach to his therapist, as the transference develops it should be handled in a way that allows for a real relationship. It is not necessary or desirable to ‘safeguard’ the transference; transferences are ubiquitous, robust, and sturdy. One must remain genuine, forthcoming, and active; and there will remain more transference than one could ever hope to clarify or interpret (Lewis 1987).

CONCLUSION Disorders of personality are diagnosable and effectively treatable in adolescence. Successful treatment depends on early recognition, establishment of a caring, committed relationship over an indefinitely long period of time, limitless flexibility, uncommon skill, and tenacity on the part of the therapist. The challenges and difficulties are great, but even greater are the rewards of healthy growth into prosocial adult functioning, relief of suffering,

and prevention of the future social costs of behavioral disability.

REFERENCES American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM III). Washington, DC: American Psychiatric Association, 1980. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised (DSM III-R). Washington, DC: American Psychiatric Association, 1987, pp. 335–358. Bernstein, D.P., Cohen, P., Velez, C.N., Schwab-Stone, M., Siever, L.J., Sinsato, L. Prevalence and stability of DSM III R personality disorders in a community-based survey of adolescents. American Journal of Psychiatry 150: 1237–1243, 1993. Campbell, K. The psychotherapy relationship with borderline personality disorders. Psychotherapy Theory, Research, and Practice 19: 166–193, 1982. Eppright, T.D., Kashani, J.H., Robison, B.D., Reid, J.C. Personality disorders in an incarcerated juvenile population. American Journal of Psychiatry 150: 1233–1236, 1993. Fraiberg, S. Libidinal object constancy and mental representations. Psychoanalytic Study of the Child 24: 9–47, 1969. Golombek, H., Marton, P. Adolescents over time: a longitudinal study of personality development. Adolescent Psychiatry 18: 213–284, 1992. Gossett, J., Lewis, J.M., Barnhart, D. To find a way: the outcome of hospital treatment of disturbed adolescents. New York: Brunner/Mazel, 1983. Jones, J., Pearson, G., Dimperio, R. Treatment of the hospitalized adolescent and family: an integrated systems-theory approach. Adolescent Psychiatry 16: 449–472, 1989. Kernberg, O.F. Severe Personality Disorders: Psychotherapeutic Strategies. New Haven: Yale University Press, 1984. Korenblum, M., Marton, P., Golombek, H., Stein, B. Disturbed personality functioning: patterns of change from early to middle adolescence. Adolescent Psychiatry 14: 407–416, 1987. Lewis, O. The paranoid-schizoid position and pathologic regression in early adolescence. Journal of the American Academy of Psychoanalysis 15: 503–519, 1987 Masterson, J.F. Psychotherapy of the Borderline Adult. New York: Jason Aronson, 1976. Masterson, J.F., Klein, R. (eds) Psychotherapy of Disorders of the Self. New York: Brunner/Mazel, 1989. Masterson, J., Costello, J.L. From borderline adolescent to functioning adult: the test of time. New York: Brunner/Mazel, 1980.

314 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood McManus, M., Lerner, H., Robbins, D., Barbour, C. Assessment of borderline symptomatology in hospitalized adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 23: 685–694, 1984. Pearson, G.T. Long-term treatment needs of hospitalized adolescents. Adolescent Psychiatry 14: 342–357, 1987. Pearson, G.T. Social issues in adolescent psychotherapy. In Slomowitz, M. (ed.), Adolescent Psychotherapy. Washington, DC: American Psychiatric Association Press, 1991, pp. 57–79. Pearson, G.T. Psychiatric classification and diagnosis in adolescence. In Noshpitz, J., Flaherty, L., Sarles, R. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. Adolescence: Development and Syndromes. New York: John Wiley, 1997a, pp. 253–267. Pearson, G.T. Personality disorder. In Noshpitz, J., Flaherty, L., Sarles, R. (eds), Handbook of Child and Adolescent Psychiatry, Volume 3. Adolescence: Development and Syndromes. New York: John Wiley, 1997b, pp. 269–284. Rappaport, J., Ismond, D. DSM-III-R Training Guide for Diagnosis of Childhood Disorders. New York: Brunner/Mazel, 1990. Rinsley, D.B. Treatment of the Severely Disturbed Adolescent. New York: Jason Aronson, 1980. Rinsley, D.B. Borderline and Other Self Disorders. New York: Jason Aronson, 1982.

Rinsley, D.B. Developmental Pathogenesis and Treatment of Borderline and Narcissistic Personalities. Northvale, NJ: Jason Aronson, 1989. Rose, M. The context for psychological change in a therapeutic community for adolescents. Residential Treatment for Children and Youth 5: 29–47, 1987. Rutter, M., Tuma, A. Diagnosis and classification: some outstanding issues. In Rutter, M., Tuma, A., Lann, I. (eds), Assessment and diagnosis in child psychopathology, New York: Guilford Press, 1988, pp. 115–134. Samuels, J.F., Nestadt, G., Romanski, A.J., Folstein, M.F., McHugh, P.R. DSM III personality disorders in the community. American Journal of Psychiatry 151: 1055–1062, 1994. Shapiro, E.R. Family and couples therapy. In Gunderson, J. (Chairman), American Psychiatric Association Task Force on Treatments of Psychiatric Disorders: Treatments of Psychiatric Disorders. Washington, DC: American Psychiatric Association, 1989, pp. 2660–2666. Stein, B., Golombek, H., Marton, P., Korenblum, M. Personality functioning and change in clinical presentation from early to middle adolescence. Adolescent Psychiatry 14: 378–393, 1987. Westman, J., Ownby, R., Smith, S. An analysis of 180 children referred to a university hospital learning disabilities service. Child Psychiatry and Human Development 17: 275–282, 1987

5.7 Disruptive behavior disorders DAVID MULLEN AND ROBERT L. HENDREN

INTRODUCTION Disruptive Behavior Disorders are common among children and adolescents. Referrals for care usually are initiated by adults, typically the parents, a teacher, or legal authorities who request an evaluation of the young person due to strained relationships, poor school performance, or contact with the juvenile justice system. As there is often resistance to this referral from the young person, the clinician doing the evaluation may first encounter a sullen, resistant, or minimally cooperative patient. Thus, the first challenge is the establishment of rapport with the patient. Even if adequate rapport is obtained, the history may not be reliable. The young person may present as an innocent victim unjustly persecuted by inexplicably unreasonable and hostile adults. The family and social support systems, often exasperated by the youngster’s behavior, may be only marginally functional. In addition, several institutions or agencies may be involved with the youth. Finally, comorbidity is common and further complicates clinical decision making. Clearly, the assessment and care of these young people can be a complex and highly challenging undertaking. However, effective treatment for most of these conditions is possible, particularly if potential problems are identified early. The DSM-IV (American Psychiatric Association 1994) identifies the following major disruptive behavior diagnoses: two subtypes of Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), and three subtypes of Attention Deficit Hyperactivity Disorder (ADHD). These disorders will be discussed in this chapter in terms of diagnostic criteria and general description including associated features, epidemiology and comorbidity, etiology, prognosis, and treatment issues.

CONDUCT DISORDER The prevalence of CD is difficult to estimate because of the different definitions that have been used and the variations

that occur in different age groups and between the sexes. DSM-IV estimates the prevalence at approximately 9 per cent for males and 2 per cent for females under eighteen years of age. The childhood onset form of the disorder, defined by the presence of at least one criterion prior to age ten years, is clearly much more common in males. Physical aggression is displayed towards others, peer relationships are disturbed, and the criteria for ODD are often met during early childhood. Individuals with childhood onset of CD are more likely to develop adult Antisocial Personality Disorder than are young people with the onset in adolescence. Males are not as predominant when the onset is in adolescence.

DIAGNOSIS AND COMORBIDITY The essential feature of CD, according to DSM-IV, is a persistent pattern of behavior that violates the basic rights of others and major age-appropriate social norms or rules. Diagnostic criteria are divided into four basic categories: 1 Aggression to people and animals that includes behaviors ranging from ‘bullies, threatens, and intimidates others’ to ‘physical cruelty to people’ and ‘has forced someone into sexual activity.’ 2 Destruction of property that includes fire setting. 3 Deceitfulness or theft that includes more surreptitious or covert antisocial behaviors. 4 Serious violations of social norms that includes truant or socially irresponsible behaviors. Three of the above criteria must have been present within twelve months prior to the assessment, with at least one occurring within six months. DSM-IV recognizes two diagnostic subtypes: childhood onset; and adolescent onset. The value of this subtyping is the prognostic significance of age of onset, with early onset being more ominous.

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Many children and adolescents who meet the criteria for the diagnosis of CD have coexisting psychiatric disorders that may have led to the antisocial behavior and will significantly influence their responsiveness to treatment and their long-term prognosis (Woolston et al. 1989; Keenan and Wakschlag 2002). For instance, depressionlike symptoms are noted in some patients with CD (Kovacs et al. 1988). Puig-Antich (1982) reported that symptoms of CD may start and stop with the onset and recovery from affective illness. CD that is comorbid with depression is also found to run a variable course, which may or may not go away as the depression improves (Kovacs et al. 1988). Kovacs and Pollock (1995) found that youth with bipolar mood disorder have a 69 per cent lifetime prevalence of CD, and the presence of CD is associated with a worse prognosis. Also, coexisting ADHD is found in some children and adolescents with CD. The combination of ADHD and CD is associated with more severe physical aggression and antisocial behaviors than is found in children with a diagnosis of CD alone and represents a more serious form of CD (Walker et al. 1987). In addition, a significant number of children first diagnosed as having CD are found to have ADHD at follow-up (Cantwell and Baker 1989). Furthermore, CD which is comorbid with ADHD may be associated with an earlier onset of CD symptoms (Loeber et al. 1995). Some children and adolescents vulnerable to the later development of schizophrenia may exhibit early antisocial behavior that leads to a diagnosis of CD (Offord and Cross 1969; Watt et al. 1982). Disturbances in conduct also are found in children with Tourette’s syndrome. One study has estimated that 10 to 30 per cent of cases of CD may be due to the presence of a Tourette’s syndrome gene (Comings and Comings 1987).

1964; Schmeck and Poustka 2001). The genetic factors that predispose a child to CD and delinquency also make it more likely at least one parent is antisocial (Lahey et al. 1988b). In addition, children with a difficult temperament may interact with their family and environment in such a way that the initial behavioral disturbance becomes even more problematic (Patterson 1982; Slutske et al. 1997). It is a commonly held belief that hormonal changes have a direct influence on adolescent behavior. However, most scientific studies to date have failed to demonstrate this as a direct effect (Petersen 1985). At least a few studies find hormone levels correlate with emotional depositions and aggressive attributes in boys. Disturbed serotonergic function is implicated in episodic aggression and impulsive aggression (Zubieta and Alessi 1992). Low serotonin levels tend to run in families with antisocial personality disorder (Constantino et al. 1997). In addition, disturbed platelet monoamine oxidase is reported in disruptive behavior disorders (Stoff et al. 1989). Minor neurologic abnormalities are found in some children and adolescents who are delinquent (Lewis et al. 1987). However, many of these neurologic abnormalities are associated with a variety of psychiatric disorders and may not relate exclusively to CD (Satterfield et al. 1987). Young people with CD may also possess a degree of autonomic hypoactivity which results in the individual being slow to respond with anxiety to stressful stimuli (Mednick 1981). These individuals tend to recover slowly once aroused. Such a pattern may result in impairment in the person’s ability to learn to escape harm or punishment through passive avoidance.

Psychological factors COGNITIVE FACTORS

Etiology The eventual outcome of CD in marked aggressivity, delinquency, another psychiatric disorder, or healthy behavior depends on the interaction of biopsychosocial factors with the individual’s development (Lewis et al. 1987). Delineation of a number of the known biopsychosocial factors follows, but it should be kept in mind that it is the interaction of these variables that leads to a complete understanding of the etiology of the disorder (Simonoff 2001). For instance, it has been shown that birth complications combined with early maternal rejection at age one year is associated with violent crime at age eighteen years. This effect was specific to violence and was not associated with either risk factor alone (Raine et al. 1994, 1997).

Biological factors Children possessing a difficult temperament are more likely to show or develop behavioral problems (Rutter et al.

Delinquent and aggressive children are found to have distinctive cognitive and psychological profiles compared to children with other psychiatric disorders and normal control subjects (Vitacco and Rogers 2001). When compared with low-aggressive boys, high-aggressive boys are found to: (i) define social problems based on the perception that others are hostilely motivated adversaries; (ii) find fewer and less effective solutions to problems; and (iii) generate fewer consequences for exhibition aggression (Guerra and Slaby 1989). In a large longitudinal study exploring Cloninger’s suggestion that boys who were high in impulsivity, low in anxiety, and low in reward dependence would be a greater risk for delinquency, Tremblay et al. (1994) demonstrated that kindergarten males with this combination of traits were more likely to develop a stable pattern of antisocial behavior.

FAMILY FACTORS Parental psychopathology and disturbed family functioning frequently are found in children who are diagnosed

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as conduct disordered (Stouthamer-Loeber et al. 2001). Antisocial personality disorder, criminal behavior, and alcoholism – particularly in the father – are the stronger and more consistently reported family factors that increase the child’s risk for CD (Robins 1966; Rutter and Giller 1984). In addition, antisocial personality, somatization, or alcohol abuse are often found in the mothers of children with a diagnosis of CD (Lahey et al. 1988b). Families of conduct-disordered children and adolescents have:

• • • • •

high rates of conflictual and negative parental behaviors (Reiss et al. 1995); unsupportive interactions and lack the ability to cope with transitions and stress (Tolan 1988); less emphasis on personal growth dimensions, such as achievement, and cultural and ethical interests (LeFlore 1988); higher rates of parental divorce (Rutter 1971) linked to parental Antisocial Personality Disorder (Lahey et al. 1988a) and the extent of the parental discord (Hetherington et al. 1979); and poor family communication, poor maternal coping skills, and external parent locus of control (August et al. 1995).

SOCIAL FACTORS Early antisocial behavior and peer group rejection are important factors found to precede delinquent behavior (Snyder et al. 1986). However, the predictive ability of deviant peer affiliation for delinquent outcome is related to the amount of parental supervision. Low socioeconomic status is associated with a higher level of CD and delinquency (Rutter and Giller 1984; Loeber et al. 1995). However, when factors associated with social class, such as family size, overcrowding, and supervision are controlled, social class shows very little relation to antisocial behavior (Wadsworth 1979). Cultural variables also are associated with antisocial behavior (Bird et al. 2001). Culturally derived beliefs, such as acceptance of aggression, respect for authority, role of the parent, and the value of independence, are noted to be significant factors in the expression of aggression and antisocial behaviors (Ekblad 1988).

RATING SCALES A number of rating scales are available to help identify disturbed behavior. The Child Behavior Checklist (Achenbach and Edelbrock 1983) is designed for teachers and parents to complete and yields a scale score on such symptom clusters as delinquency, aggression, hyperactivity, depression, and others. Self-report measures have proved effective in identifying antisocial behavior, especially in adolescents (Lewinsohn et al. 2000). Specific scales for rating aggression include the Iowa Conners

Aggression Factor (Loney and Milich 1985), derived from the Conners Teacher Questionnaire (Conners 1969), as well as the Modified Overt Aggression Scale (Kay et al. 1988). Peer ratings of behavior and likeability as well as those of teachers in elementary school reveal significant predictive factors for delinquent behavior in adolescence (Tremblay et al. 1988).

Current treatments The more successful approaches will be briefly described. Since most treatment reports do not differentiate the associated psychopathology, any specific approach believed successful can not be generalized to all children and adolescents with a diagnosis of CD. Further descriptions of treatment modalities are found elsewhere in this text.

PROBLEM-SOLVING SKILLS TRAINING Cognitive behavioral approaches with conduct-disordered youth focus on modifying cognitive deficiencies (e.g., communication skills, problem-solving skills, impulse control, and anger management), believed to underlie antisocial behavior (Faulstich et al. 1988; Barkley et al. 2001). Generally, these are step-by-step approaches to interpersonal situations that utilize modeling, rehearsal, role playing, and development of an internal dialogue for self-evaluation.

FAMILY-FOCUSED TREATMENTS Many of the studies of the efficacy of family therapy in alleviating antisocial behavior in children rely on weak or questionable methodologies. However, in a review of the rather extensive literature, Tolan et al. (1986) found consistently positive results from family therapy. In many cases, family therapy was more effective than other therapeutic modalities. Behavioral, structural, strategic, and communication techniques appeared most effective. Parent management training attempts to alter coercive parent–child interactions that foster antisocial behavior in the child (Patterson 1982). The major intervention is the direct training of parents to interact differently with their child, so that prosocial behavior is rewarded. Outcome studies of this technique demonstrate consistently positive results (Kazdin 1987; Kazdin et al. 1987). Preliminary evidence suggests that aggressive conduct-disordered children do better with this technique than do nonaggressive conduct-disordered youth (Patterson 1982).

PEER RELATIONSHIP AND SCHOOL-BASED INTERVENTIONS Peer rejection has been clearly correlated with aggression and school failure has been correlated with the development of behavior problems. Social skills training programs

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have aimed to improve the peer relationships of highrisk children (Bierman and Furman 1984), and specific academic skills programs have sought to reduce rates of school failure (Kellam et al. 1991).

PHARMACOTHERAPY If a comorbid psychiatric disorder can be identified in addition to CD, aggressive pharmacotherapy of the other disorder may be warranted and may significantly diminish behavioral problems. Psychotropic drugs have not yet shown specific effectiveness in the treatment of CD. However, several drugs are used to treat symptoms associated with CD, especially aggression. For instance, both haloperidol and lithium carbonate have been found to be effective in decreasing behavioral symptoms in treatmentresistant, hospitalized, conduct-disordered children (Campbell et al. 1984). Lithium was also effective in reducing aggressive and explosive behavior in a subgroup of behavior-disordered children who had symptoms of an affective disorder (DeLong and Aldershof 1987). Propranolol has also proven to be effective in the treatment of aggressive behavior in children and adolescents with chronic brain dysfunction and in a few conduct disordered youth refractory to other pharmacologic approaches (Kuperman and Stewart 1987). Carbamazepine has also been demonstrated to be useful in the treatment of aggressive behavior in blinded trials (Rosenberg et al. 1994). Psychostimulants have also been used for the treatment of CD, but the results do not provide definite conclusions about effectiveness because of equivocal findings or methodological problems. One study suggested benefits from a combination of methylphenidate and behavior modification when ADHD and disruptive behavior are combined (Kolko et al. 1999). On the basis of their review, Rifkin et al. (1986) suggested a stimulant trial for conduct-disordered patients when other treatments have not been successful, especially when the patient has symptoms characteristic of ADHD. Recently, several small trials of the atypical neuroleptic risperidone suggest efficacy in youth with conduct disorder (Buitelaar et al. 2001; Findling et al. 2000). The number of studies examining the efficacy of antidepressants in the treatment of CD is surprisingly small, considering the degree of comorbidity with depression. Puig-Antich (1982) found that CD symptoms abated after imipramine treatment in a group of boys with comorbid major depressive disorder and CD. Treatment with bupropion of boys with chronic CD and ADHD resulted in improvements in behavior, affect, and anxiety (Simeon et al. 1986). Theoretically, selective serotonin reuptake inhibitors (SSRIs) may be of benefit in CD given the evidence of serotonergic dysfunction in disorders of impulse control and the effects of SSRIs on negative affective and social behavior (Knutson et al. 1998). Barrickman et al. (1991),

in an open-label study, suggested that fluoxetine might be beneficial in ADHD, particularly with symptoms related to disruptive behavior. Currently, it is worth considering a trial of antidepressant medication in youth with CD who have not responded to nonpharmacologic interventions. Other medications which have shown promise for the treatment of aggression in nonblind studies include clonidine (Kemph et al. 1993), trazadone (Ghaziuddin and Alessi 1992), and buspirone (Stanislav et al. 1994). Clearly, additional studies are needed to delineate clearly those psychotropic medications that are effective for seriously behavior-disordered youth.

Prognosis The clinical course of children with CD is variable, with mild forms showing improvement over time while the more severe forms tend to be chronic (American Psychiatric Association 1987). Generally, the presence of externalizing symptoms is more predictive of future conduct problems in boys than in girls (McGee et al. 1992); however, a history of violence in childhood is not necessarily predictive of adult violent crime. Lewis et al. (1989) found the interaction of such intrinsic vulnerabilities as cognitive, psychiatric, and neurologic impairment and a history of abuse or family violence was a better predictor of adult violent crime than was a history of violence. Longerterm outcome studies (Robins and Ratcliff 1979) found that 23–41 per cent of highly antisocial children became antisocial adults, and 17–28 per cent did not. The most consistent factors to predict poor prognosis for antisocial behavior in children are early age of onset; high rates of antisocial behavior; antisocial acts across multiple settings, such as the home, school, and community; and a diversity of antisocial behaviors (Rutter and Giller 1984). Further research is needed to identify prognostic factors associated with disorders comorbid with CD, such as ADHD, psychosis, and depression.

OPPOSITIONAL DEFIANT DISORDER According to DSM-IV, ‘The essential feature of Oppositional Defiant Disorder (ODD) is a recurrent pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures that persists for at least six months.’ Negativism and defiance is typically manifest through stubbornness, refusal to follow directives, resistance to compromise, or refusal to negotiate in conflictual situations involving adults or peers; and, the tendency to resist is particularly marked with adult authority figures whom the child knows well. Argumentativeness, unwillingness to accept blame for mistakes, and persistent limit testing also are observed frequently. Hostility is typically manifest through deliberately annoying behavior

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and verbal or minor physical aggression (but not the more serious aggressive behaviors typically observed in CD). ODD usually becomes evident by age eight years, and almost always by early adolescence (Lavigne et al. 2001). Associated features of the disorder include a difficult temperament with a high level of negative affective reactivity and difficulty being soothed, mood lability, low frustration tolerance, poor self esteem, and poor and highly conflictual relationships with adults and peers. The majority of data suggest that oppositional defiant behaviors emerge early in clinic-referred children with a peak at around age eight years, while more serious and covert behavior problems typical of CD, such as breaking and entering, truancy, and running away, tend to appear later and often accelerate (Loeber et al. 1991; LeBlanc and Frechette 1989). However, some data suggest (at least in boys) that some oppositional behaviors, such as negativism and demanding attention, may actually decline in latency then increase again in adolescence, another developmental stage in which oppositionality is relatively normative (Kashani et al. 1989).

difficulty managing the autonomy strivings of the child, a power struggle may ensue which transforms the child’s normal attempts to establish autonomy into a defense against parental intrusion or into overdependence on the parent. Alternatively, oppositionality may represent an expression of ambivalence towards independence. While the resistance to the demands of authority may support a sense of autonomy in the child, the parent’s renewed efforts at obtaining compliance keeps the parent closely involved. Or, when conceptualized behaviorally, oppositional defiant behavior patterns may be viewed as the result of negative reinforcement. The child’s angry refusal to follow directives may result in subsequent withdrawal of the parent’s request, thus reinforcing further noncompliance.

Treatment

The prevalence of ODD is between 2 and 16 per cent, with males outnumbering females prior to puberty but close to equal after puberty. This change in gender ratio may be due to males more frequently being given the diagnosis of CD (Rey 1993). ODD may be more common in groups with lower socioeconomic status (SES) (Bird et al. 1988). Risk factors for ODD include high levels of family conflict and adversity, and coercive family interactions (Loeber and Stouthamer-Loeber 1986). Comorbidity with ODD is significant, particularly for ADHD, with 20 to 50 per cent of children with ODD also meeting criteria for ADHD (Rey 1993). A study utilizing the revised version of the Diagnostic Interview Schedule for Children (DISC-R) found that children with ODD often had concurrent diagnoses of separation anxiety, generalized anxiety, and major depression (Shaffer et al. 1988). There also appears to be a relationship between ODD and communication disorders (Rey 1993). As noted above, ODD may not be diagnosed if the behaviors occur exclusively during the course of a mood or psychotic disorder owing to the high rate of oppositional behavior which may be observed during the course of these disorders.

Treatment of ODD involves a combination of individual psychotherapy for the child, family therapy, and parent training. Individual psychotherapy may focus on autonomy issues as they arise in the relationship with the therapist. Family therapy may address issues of communication within the family and seek to ameliorate coercive interactional styles. Parent training addresses issues of reward and discipline and seeks to eliminate the pattern of negative reinforcement of oppositional behavior. Stein and Smith (1990) reported the effectiveness of a behavioral program entitled the Real Economy System for Teens (REST). In this program, teenagers were provided with food and shelter but had to earn allowance money to pay for everything else. Receiving an allowance was made contingent upon compliance with rules for five target behaviors: room care; personal hygiene; completion of chores; abusiveness; and safety violations. This program appeared to be more effective than ‘traditional talk therapy.’ Although there is no specific pharmacotherapy for ODD, comorbid conditions such as ADHD may be effectively treated with medication, and associated oppositional symptoms may improve. Similarly, mood disorders and psychotic disorders often are accompanied by oppositional behavior and effective treatment of these underlying disturbances may ameliorate oppositionality.

Etiology

Prognosis

A difficult temperament with high levels of negative affective reactivity and a resistance to being soothed may predispose a child to oppositional behavior. Oppositional behavior reflecting a capacity to resist the will of others may play a significant role in the normal development of autonomy and a sense of identity. If the parent has

The most significant prognostic issue related to ODD is whether or not the individual goes on to develop a CD. Physical fighting, low parental SES, and parental substance abuse appear to increase the risk of developing a CD, and comorbidity with ADHD may increase risk for an earlier onset of CD (Loeber et al. 1995).

Epidemiology and comorbidity

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ATTENTION DEFICIT HYPERACTIVITY DISORDER Attention Deficit Hyperactivity Disorder (ADHD) is commonly diagnosed in the United States. In fact, the high rate of diagnosis has prompted queries from mental health professionals from other parts of the world who are not identifying as many cases in their countries. They inquire as to the possibility of overlooking the condition in their patients or whether clinicians in the United States are overdiagnosing ADHD. Public perception in the United States is mixed, with some expressing concerns that an excessive number of young people are being given a psychiatric diagnosis and then receiving treatment with stimulants. Critics suggest that North Americans are simply intolerant of high levels of childhood physical activity or disobedience and resort to medication to control their youth. Others contend the high rate of ADHD diagnoses is justified, and then point to a loss of community and high rates of dysfunction in families and other social institutions that previously helped contain children’s impulsive and inattentive behavior as causative, which results in United States children who have more pervasive problems with violence, depression, and impulse control disorders.

Diagnosis The DSM-IV identifies three subtypes of ADHD: 1 A predominantly inattentive type that is more common in girls and older children and is accompanied by more academic problems. 2 A predominantly hyperactive and impulsive type that is typically first seen in pre-school children and has more global symptoms. 3 A combined type (Lahey et al. 1994). Symptoms must be present in two or more settings, must begin prior to age seven years, and must result in clinically significant impairment to make the diagnosis. Approximately one-third of children with ADHD out-grow symptoms that require treatment by adolescence (Wilens et al. 2002). Academic under-achievement, low self-esteem, and impaired social competence are commonly found among adolescents with ADHD (Waddel 1984). Also, there is a lack of self-reflection that often leads to poor peer relationships and problem behaviors. Comorbidity with impulse control disorders such as CD and substance abuse disorders may develop. Some 3–5 per cent of school-aged children are reported to have ADHD in the United States (American Psychiatric Association 1994). The disorder is more prevalent in boys (9–10%) than in girls (3%), although it may be underdiagnosed in girls. Girls are more likely to be older at diagnosis as they show less impulsivity, hyperactivity, and

aggression (Faraone et al. 1991). Girls have more fear, mood swings, social withdrawal, and fear of rejection. In addition, more cognitive and language problems are found in girls.

Etiology Many theories regarding the etiology of ADHD have been put forth, but none has been proved definitely, and at this point the cause is unknown. Some of the most common factors cited as etiologic include perinatal difficulties, maternal substance abuse, genetics (Faraone and Doyle 2001), and dietary factors (Barkley 1990). Brain function is clearly altered in patients with ADHD (Bradley and Golden 2001). It has been proposed that ADHD is caused by dysfunction of the brainstem sensory neurons in the reticular formation regulating the discharge of noradrenergic locus coeruleus neurons (Mefford and Potter 1989). However, no single neurotransmitter system is specifically implicated. Medications affecting noradrenergic, serotonergic, and dopaminergic systems are all differentially effective in the treatment of ADHD. Anatomic imaging studies of people with ADHD consistently point to involvement of the frontal lobes, basal ganglia, corpus callosum and cerebellum (Giedd et al. 2001). A defect in prefrontal cortical functioning is consistently reported (Zametkin et al. 1990). Low striatal activity in the right frontal region is reportedly related to inattentiveness, poor impulse control and disinhibition (O’Tuama and Treves 1993). Abnormalities have been found in the corpus callosum (Giedd et al. 1994; Hynd et al. 1991; Semrud-Clikeman 1994) and the caudate – an area of the brain related to executive function and attention (Castellanos et al. 1994). Neuropsychological testing also reveals brain abnormalities. Children with ADHD are unable to control and direct attention to effectively make use of organization, attention, executive functions, and memory abilities (Barkley et al. 1992). Soft neurological signs, indications of immaturity or minor dysfunction in the nervous system, are increased on the left side in the ADHD and conduct-disordered group, thereby supporting a right hemispheric dysfunction (Aronowitz et al. 1994). Dietary components have also been proposed as etiologic factors for ADHD (e.g., sugar, fatty acids, vitamin deficiency), though there is little empirical support for the role of diet in the disorder (Cantwell 1996). Psychological factors are clearly associated with ADHD, as children with the condition have poor social relatedness, poor communication skills, and poor selfconfidence. They often have poor frustration tolerance and are affectively labile. Repeated failures in a variety of interpersonal situations may make them increasingly vulnerable to a sense of demoralization which may further complicate the basic condition. Peers perceive ADHD

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children as immature, irritating, intrusive, socially inappropriate, and bossy, and so often avoid or neglect them. ADHD children may engage in relationship styles that are controlling and dominating of others, but ineffective.

Rating scales Rating scales helpful in confirming the diagnosis include the Conners Rating Scales available to parents, teachers, and adolescents (Conners 1969); the Achenbach Child Behavior Checklist (Achenbach 1991); and the ACTeRS (Ullmann 1985). For older adolescents, the Wender Utah Rating Scale for retrospective diagnosis (Ward et al. 1993) and the Copeland Symptoms Checklist (Copeland 1991; Copeland and Love 1992) are useful. The Continuous Performance Task (CPT), a computer-administered and scored test, can be useful in confirming the diagnosis and measuring treatment response (Corkum and Siegel 1993). The medical history and physical examination should pay special attention to rule out hyperthyroidism, seizure disorder (petit mal), migraine, traumatic brain injury, and hepatic disease. Medications known to cause symptoms of ADHD include antihistamines, phenobarbital, steroids, and lead. Substance abuse also needs to be ruled out as a potential cause of symptoms resembling ADHD.

Comorbidity It is important to consider and rule out alternative diagnoses that have symptoms similar to those of ADHD. In children, attention problems can be early symptoms of schizophrenia that are present before delusions or hallucinations appear. The attention deficit in schizophrenia is continual, while the attention problem in ADHD tends to be worse with distractions or when sustained attention is required. These attention problems may improve slightly when stimulant medication is used to treat these early schizophrenia spectrum disorders in childhood, but stimulant medication tends to make positive signs of schizophrenia worse in adolescence. Post-traumatic Stress Disorder (PTSD) can present with attention and impulsive symptoms but the time of their occurrence can be traced to a traumatic event in the patient’s history. Bipolar Disorder in childhood can present with symptoms of impulsivity and short attention span, but these symptoms are accompanied by irritability and have a cyclical nature (Wozniak et al. 1995). Information about genetic history and symptoms of psychosis or depression may be helpful in making the diagnosis of Bipolar Disorder. ADHD may be comorbid with Bipolar Disorder and when they are, the Bipolar Disorder is more likely to be of a mixed type (West et al. 1995). Many disorders are comorbid with ADHD or are misdiagnosed as ADHD. Poor impulse control and stress intolerance occur in both ADHD and Depressive

Disorders. With ADHD, there are brief rapid mood shifts, vegetative symptoms of depression are not present, and a developmental history of ADHD is not found. However, the two disorders may coexist (Carlson 1998). Tics may coexist with ADHD and may be precipitated by stimulant treatment. ADHD and Tourette’s Disorder have a 21–54 per cent comorbidity in boys (Leckman et al. 1994). Some 10 per cent of patients with ADHD have tics (Comings and Comings 1987), whereas 50 per cent of patients with tics have ADHD. CD is frequently comorbid with ADHD, and the underlying ADHD may be overlooked as a result of the disturbing behavior. When the two disorders occur together, aggression may respond best to methylphenidate, while other behavioral disturbances may respond better to antidepressants (Pliszka 1987). Other disorders comorbid with ADHD include substance use disorders, learning disorders (language, reading, hearing), anxiety disorders, borderline personality disorder, and obsessive–compulsive disorder. ADHD and substance abuse are probably not causally linked (Lynskey and Hall 2001). Autism, Fragile-X syndrome, and mental retardation may all be comorbid with ADHD and show a similar rate of response to treatment, although stimulant treatment may result in more side effects such as motor tics and social withdrawal (Handen et al. 1991; Aman et al. 1993). ADHD comorbid with anxiety disorder responds less well to stimulant medication (DuPaul et al. 1994). ADHD also has been reported to occur with an atypical neuroleptic-refractory psychosis, both of which seem to be responsive to stimulants (Pine et al. 1993).

Treatment General principles to be considered in planning the treatment of ADHD are the risk–benefit ratio of the proposed treatment, the likely course of the disorder without treatment, and that any treatment chosen should be used in conjunction with other interventions. While medication alone is superior to any other single treatment (Jensen 2000), pharmacotherapy combined with other treatment approaches is often beneficial. Psychostimulants are the most commonly used and best-documented agents for the treatment of ADHD (Greenhill et al. 2002). Some 65–85 per cent of ADHD children will show a favorable response to a stimulant medication (Klein 1993), and this is also true for adolescents. Some people with ADHD will respond unfavorably to one stimulant but favorably to another, and this may vary over time. Tricyclic antidepressants (TCAs) are also effective for ADHD symptoms. They are more effective with anxious and affective symptoms and are less likely to disturb sleep than the stimulants (Biederman et al. 1989). Usage of antidepressants in the treatment of ADHD is considered

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when there is a failure to respond to stimulants or to avoid stimulant side effects such as depression, rebound symptoms, tics, or to avoid a potential for substance abuse (Rapport et al. 1993). The report of four sudden deaths in children age eight to nine years who were taking desipramine has resulted in great caution in the use of TCAs (Riddle et al. 1993). Some advise against the use of TCAs in young people, while others believe that this is an over-reaction. As these deaths were thought to be related to cardiovascular problems, a baseline electrocardiogram should be obtained and monitored during treatment. A few studies of the efficacy of the newer antidepressants in the treatment of ADHD in young people are available. Fluoxetine, an SSRI, has been found to be moderately effective (Barrickman et al. 1991). Some patients have been found to do well with a combination of fluoxetine and methylphenidate. Bupropion, a weakly dopaminergic drug with some noradrenergic activity, showed a 60–80 per cent improvement in symptoms and was equivalent to methylphenidate (Barrickman et al. 1995). Bupropion is thought to be especially helpful when comorbid CD is present, but it is less effective for attention than for impulsivity (Simeon et al. 1986). Stimulant nonresponders may respond well to bupropion. Sympatholytic agents used in the treatment of ADHD include clonidine and guanfacine, ␣2-receptor agonists and propranolol, a ␤-receptor antagonist. Clonidine is helpful in the treatment of anxiety, sleep disturbances, PTSD, hyperactivity, and impulsivity (Wilens et al. 1994), and is also useful for treating children who have stimulant side effects such as tics or sleep disturbances. Recently, however, a small number of deaths in children treated with a combination of stimulant and clonidine has raised some concern regarding its safety. Guanfacine, another ␣2-receptor agonist, but with a longer half-life, offers more selective binding and decreased sedation than clonidine (Hunt et al. 1995). Compared to methylphenidate, guanfacine may be more effective on activity and frustration tolerance and anxiety. Propranolol is a nonselective ␤-adrenergic receptor antagonist that has shown to be beneficial in the treatment of aggressive behavior, treatment-resistant ADHD, intermittent explosive disorder, and aggression secondary to organic brain syndrome, and anxiety, especially when related to PTSD (Connor 1993). Other pharmacologic considerations include the use of combined agents.

Psychotherapy/environmental management Initial or additional treatment approaches to ADHD include special school programs, behavioral therapy, social skills training, cognitive behavioral therapy, family counseling, and individual therapy. Special school programs include small self-contained classrooms and an

individualized educational plan. Special education programs are not always required. Behavior therapy increases academic achievement and reduces conduct problems. Social skills training includes problem-solving, modeling, coping strategies and practice, and often takes place in a group setting. Cognitive behavioral treatment focuses on control of impulses and may make use of special techniques such as tokens for positive reinforcement, role playing, and reframing (Cousins and Weiss 1993). Family therapy for family dysfunction and appropriate, consistent limit setting is an essential part of therapy and parents can, at times, be trained to function as case managers for their children. Parent support groups are valuable in helping parents deal with the stresses of raising children with ADHD (Barkley et al. 1992). Individual psychotherapy is useful in addressing poor self-esteem and developing strategies for improving peer status. Dietary treatment is a controversial approach to treatment based on food allergies, sensitivities (particularly food additives), and megavitamins. Although few scientific studies support the efficacy of these approaches, there is a subgroup of patients who may benefit from elimination diets and avoiding possible food allergies (Boris and Mandel 1994).

Prognosis Most studies demonstrate symptomatic improvement in the short run, but questionable long-term benefits from treatment. The outcome studies to date have a number of limitations in that most of the studies are older, the dosage of medication was not consistent, noncompliance was not assessed, and comorbidity was not taken into account. Few studies compare treatment with no treatment. Three categories of outcome are reported. One group functions fairly normally in adulthood and is comprised of 15–20 per cent of ADHD children. A second group has significant concentration, social, emotional, and impulse control problems. They have difficulties at work, with relationships, and have poor self-esteem. Over 50 per cent of young adults with ADHD are in this group. The last group, which comprises one-quarter of the children with ADHD, have significant psychiatric or antisocial pathology. Comorbid ADHD and CD are related to antisocial outcome, but not ADHD alone. In addition, genetic history, adversity, and other comorbidities are related to outcome. The risk of substance abuse in people with ADHD is two to four times normal, and is not related to stimulant treatment (Lynskey and Fergusson 1995). Comorbidity is associated with more frequent and severe substance abuse problems. Lack of treatment leads to increased risk of substance abuse problems and antisocial personality disorder. Improved attention leads to better peer status, but treatment does not normalize peer relationships.

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Research issues and conclusion Neuroimaging and neurobiological advances have significantly furthered our understanding of these common and frequently debilitating syndromes. Treatment and prevention efforts are benefiting from this new knowledge. However, much remains to be learned regarding the specific deficits and vulnerabilities which underlie these neurodevelopmental conditions. It is likely that no single specific defect underlies all cases of ADHD and other disruptive behavior disorders, and the nature of the deficits may be affected by comorbidity, resilience, and environmental fit (Hendren and Butler 1998). Continued attention to identifying and understanding of these strengths and deficits will prove valuable to the clinician and family in designing effective prevention and treatment programs.

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5.8 Adolescent substance abuse MARSHA E. BATES AND ROBERT L. HENDREN

INTRODUCTION Psychoactive substance use among adolescents can be an early indicator of problem behavior, or it can be a developmental phase that young people grow past. This chapter reviews biopsychosocial factors in the etiology of psychoactive substance abuse to help guide the determination of present and future risk, and for use in developmental assessment and treatment planning with adolescents. The more extensive literature on adult substance abusers is often useful in assessing risk and developing treatment interventions for youthful substance abusers. However, it is clear that the relevant issues in adolescent substance abuse frequently vary from those in adult substance abuse and thus a different clinical approach is necessary (Brown et al. 1989; Deas et al. 2000). One important, yet infrequently considered difference between adolescent and adult substance abusers is the relative cognitive immaturity of the adolescent. This immaturity may present difficulty in understanding some of the frequently utilized concepts within the field of addiction, such as ‘denial,’ responsibility and ‘triggers,’ which are often beyond the reach of the adolescent’s cognitive capacity. Thus, what the frustrated clinician may be experiencing as ‘resistance’ may in fact only represent a failure to understand the goals and means of the treatment modality. Second, the adolescent’s struggle with issues related to dependence and independence can lead to self-preoccupation and to avoidance and devaluation of adults that further complicate efforts to establish a stable treatment alliance. Additional differences between adolescent and adult substance abuse include the increased importance of the peer group for the adolescent, differences in physiology, and the patterns of substance abuse.

EPIDEMIOLOGY AND PATTERNS OF ADOLESCENT SUBSTANCE ABUSE The Monitoring the Future Study has measured the extent of drug use among high school seniors since 1975 (Johnston et al. 2001). Among the graduating class of 2000, some 54 per cent of students had used an illicit drug by the time they finished high school. The extent of use was probably higher for students who were truant or did not complete school and who are thus not included in this survey. The use of illegal drugs by adolescents increased significantly between 1992 and 1995, continuing an upward trend that is related to a downward trend in the students’ attitudes and perceptions about the danger and harm of drug use. The survey reflected an overall increase in the use of drugs (marijuana, cocaine, stimulants and LSD). Inhalant use increased among eighthgraders, making it their most widely abused substance after alcohol and cigarettes. The prevalence of alcohol use ranges from 11.1 to 27 per cent among males aged seven to eleven years (Huzingga et al. 1993). Of even greater concern are the percentages of 10th and 12th graders who report drinking to the point of inebriation: 24 and 32 per cent, respectively, reported being drunk in the past thirty days, with 26 and 30 per cent reporting consuming five or more drinks on at least one occasion in the past two weeks (Johnston et al. 2001). Ethnic patterns of substance use suggest higher rates of substance use among Native Americans, followed by Whites and Hispanics, with Blacks and Asian Americans having the lowest rates (Kaminer 1995). Socioeconomic status (SES) is associated with substance use among teenagers, but the nature of the relationship is not consistent across SES indicators or across race/ethnicity groups (Goodman and Huang 2002).

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Alcohol and drug use peaks in the late teens and early twenties, and for most adolescents is followed by a gradual maturing out (Labouvie 1996; Miller-Tutzauer et al. 1991). Experimentation with licit and illicit drugs during adolescence appears to be normative, and the majority of youth do not appear to sustain any serious negative consequences from light, experimental, or time-limited use, although heavier use is associated with a wide range of negative health, psychological, and interpersonal effects (Newcomb and Bentler 1988). It is thus important to distinguish between adolescent-limited versus lifecourse-persistent developmental pathways of involvement with substance use and other problem behaviors (Compas et al. 1995; Moffitt 1993). The pattern emerging from many studies suggests that, with few exceptions, adolescents first use legal drugs (alcohol or cigarettes) before they try marijuana and/or other illegal drugs (Andrews et al. 1991; Kandel et al. 1992; Kandel and Yamaguchi 1993). Further, age of drinking onset has been shown to be a reliable predictor of later alcohol problems, such as use severity and dependence (Grant et al. 2001a,b). However, the age when an adolescent begins to experiment with legal drugs (cigarettes and alcohol) is not clearly related to the severity and persistence of subsequent illicit drug use. Age of first legal drug use shows little relationship to alcohol or drug use at age twenty years, while age of first illegal use appears to be a fairly strong predictor of drug use at twenty (Golub and Johnson 1994; Kaplan et al. 1986; Labouvie et al. 1997). Neither age of first licit or illicit use predicted alcohol or drug use intensity or problems at age thirty in one longitudinal study (Labouvie et al. 1997).

ETIOLOGY AND PATHOGENESIS The etiology of substance abuse is best characterized as biopsychosocial with variable contributions of biological, psychological, and social factors depending on the individual and the developmental stage. Cloninger describes two distinct forms of problem alcohol use (Cloninger 1987). Type 1 alcoholism is clinically characterized by adult onset (age 20 years or older), less severe dependence, little or no psychopathology or criminality, and a drinking pattern primarily characterized by difficulties with terminating an episode of drinking once begun. The etiology of this type has been conceived as primarily environmental in origin. Type 2 alcoholism is associated with youthful onset and recurrent psychiatric and legal problems occurring almost exclusively in males. These males may have marked depressive symptoms and are at significant risk for suicide attempts and often have histories of incarceration for violence (Buydens-Branchey et al. 1989a; Brady et al. 1998). This form of alcoholism has been associated with a low serotonin turnover (Buydens-Branchey et al.

1989b; Heinz et al. 1998) and alterations in benzodiazepine receptors (Abi-Dargham et al. 1998). Type 2 alcoholics are described as having significant alcohol craving. Type 1 and Type 2 are independently heritable (Sigvardsson et al. 1996), but Type 2 appears less influenced by the environment and genetic vulnerability is a stronger predictor. Babor et al. (1992) defined a similar classification scheme defining two groups of alcoholic patients, Type A and Type B, who are also differentiated by age of onset (late versus early) and by associated features of impulsivity and antisocial behavior in the Type B patient (Babor et al. 1992). Type A/Type B clusters of high-risk adolescents have also been identified using the severity of similar behavior problems, suggesting that this classification system may show some prognostic validity for youth (Blitz et al. 1996).

BIOLOGIC FACTORS Genetic factors Sons and daughters of alcoholics are approximately four times as likely to develop alcohol-related problems as the general population (Goodwin 1983). The rate increases another two-fold in identical twins of alcoholics (see Schuckit 1986, 1999). With regard to specific genetic markers, alcoholism has been associated with the A1 allele for the dopamine D2 receptor gene (Blum et al. 1990); however, this marker may not be specific for alcoholism and may relate to a neural mechanism for reward and for impulsive, restless, somewhat compulsive behavior (Comings et al. 1991). Other indicators of genetic vulnerability may include temperament, level of reaction to alcohol, tolerance, and low serotonin levels, to name a few. A central serotonin defect is commonly detected in early-onset alcoholism (Fils-Aime et al. 1996). However, the reward system of the brain involves dopamine systems in the dorsolateral prefrontal cortex, the nucleus accumbens, and the ventral tegmental nucleus. Thus, the desire to drink is influenced not by a single neurotransmitter system but by several systems, including the opioid, ␥-aminobutyric acid (GABA), serotonin, dopamine, and glutamate systems (see Drummond et al. 2000). Several hormonal systems are also influential (Allen et al. 2001; Litten et al. 1996).

NEUROPSYCHOLOGY Because much alcohol- and drug-associated brain damage is the cumulative result of hepatic, nutritional, and metabolic abnormalities accruing over years of abuse, adolescents may be spared much of the neurocognitive impairment caused by chronic alcohol and other drug

330 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood

abuse. However, alcohol and other drugs known to produce chronic central nervous system (CNS) impairment do have the potential to interrupt the cognitive developmental tasks of adolescence. Physiological maturation of the frontal lobe (Thatcher 1991) and related neurocognitive performances (Levin et al. 1991) exhibit staged development throughout childhood and adolescence, with different executive functions reaching adult-level performance at different ages (Welsh et al. 1991). Differentiation of cortical neuronal networks (Goldman-Rakic 1987; Renis and Goldman 1980) and the organization of cognitive networks into higher-order systems also likely continue into early adulthood. While continued cognitive development is still possible later in the life span, youth who do not complete the cognitive developmental tasks of adolescence have a different and possibly riskier trajectory of development. There is some evidence of significant brain changes in psychoactive substance use-disordered (PSUD) adolescents (Moss et al. 1994; Tapert et al. 2001), and especially with respect to chronic inhalant abuse (Korman et al. 1981). Tapert and colleagues (2001) studied alcohol-dependent young women between the ages of eighteen and twenty-five years by using functional magnetic resonance imaging (fMRI). Participants demonstrated significantly less blood oxygen level-dependent response in the right superior and inferior parietal, right middle frontal, right postcentral, and left superior frontal cortex during spatial working memory tasks. In a younger-aged sample (15–16 years), protracted alcohol use (over 100 lifetime alcohol episodes) was associated with poorer verbal and nonverbal retention in the context of intact learning and recognition. Recent alcohol withdrawal was found to be associated with poor visuospatial functioning, whereas lifetime alcohol withdrawal was associated with poorer retrieval of verbal and nonverbal information (Brown et al. 2000). Lower verbal and full-scale IQs also have been found relative to controls, as well as lower achievement test scores, suggesting the potential for acquired knowledge deficits and the failure to use cognitive skills to acquire education-based knowledge (Block et al. 1992; Block and Ghoneim 1993; Moss et al. 1994) in heavy adolescent users. Co-occurring conditions may increase the probability of neurocognitive impairment in PSUD adolescents. Risk factors include low educational attainment, hyperactivity, impulsivity, learning disabilities, aggressiveness, attention deficit disorder, and other psychopathology (Bates and Convit 1999). Attention problems are associated with substance involvement (Tapert et al. 2002) and, in association with aggressive behavior and deficits in information processing, have been observed in substance-abusing delinquent males (Herning et al. 1990). Overactivity and aggressive behavior in children as young as six years of age is predictive of heavy substance abuse in adolescence (Kellam et al. 1989).

PERSONALITY/ENVIRONMENTAL FACTORS A number of personality characteristics or behavioral dispositions consistently predict individual differences in age of initiation, substance use intensity, and the experience of negative use consequences in adolescence. Risk factors include problems of emotional regulation, sensation seeking, impulsivity, aggression, low needs for achievement and achievement-related behaviors, low harm avoidance, and the inability to delay gratification (Bates 1993). Although environmental risk has been less studied, parental warmth, parental control, and peer deviance often predict initiation and intensity of alcohol and other drug use, or the experience of use-related problems (Barnow et al. 2002; Foxcroft and Lowe 1991; Jessor et al. 1991). During adolescence, person–environment constellations comprising high impulsivity, disinhibition, and deviant peer group associations, and to a lesser extent low parental control, strongly influence high-risk developmental trajectories of use intensity and problems. Personality and environmental risk factors appear to act as mutual catalysts of use behaviors and consequences; that is, their co-occurrence increases the likelihood of sustained movement along problematic developmental trajectories (Bates and Labouvie 1995). However, adolescent levels of these risk factors do not continue to be strong predictors of use or consequence in early adulthood when adolescent levels of use are controlled (Bates and Labouvie 1997). Given that vulnerability to the negative consequences of substance use is determined only in part by consumption level (Bates and Labouvie 1994; Stacy et al. 1991; White and Bates 1993), it may also be useful to distinguish between risk factors that directly affect adolescents’ vulnerability to alcohol problems from those that affect such vulnerability primarily through their influence on high-risk consumption patterns. Cognitive motivations for use, sensation seeking, and peer influence, low selfefficacy, and parental alcoholism (Bates and Labouvie 1994, 1995; Stacy et al. 1991) have been directly related to certain adverse consequences of drinking, independently of consumption levels. Protective personality factors may operate by moderating risks, or potentiating the effects of other protective factors (Brook et al. 1990; Hawkins et al. 1992). High achievement needs and behaviors may attenuate the effects of personality risk factors (Brook et al. 1986a; Labouvie and McGee 1986), as well as peer risk factors (Brook et al. 1986b), on initiation and intensity of substance use.

EXPECTANCY Affective regulation is a primary function of alcohol and other drug use (Marlatt 1987), and alcohol’s influence on

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affective reactions seem to be largely mediated by learned outcome expectancies – the beliefs that one holds regarding the anticipated consequences of alcohol consumption. The enhancement of already positive affective states and the relief of negative affective states – that is, expectancies of positive and negative reinforcement – appear to be two powerful motivations for drinking behaviors (White et al. 1991). In adolescence, positive alcohol outcome expectancies (e.g., enhanced social and physical pleasures, tension reduction) are consistent predictors of individual differences in alcohol use (Christiansen et al. 1989; Stacy et al. 1991). Controlling for adolescent drug use levels, Stacy and colleagues (1991) also showed that adolescent expectancies predicted drug use nine years later. Adolescents’ expectancies for social facilitation from alcohol use and their drinking levels seem to influence one another in a reciprocal feedback fashion, with greater expectancy leading to higher drinking levels, and these higher drinking levels leading in turn to expectancies for more social facilitation (Smith et al. 1995). A final important contextual or social element in substance use is the impact of culture. Variations in attitude toward substance abuse may be observed between Mexican-American and White adolescents (Cockerham and Alster 1983), and Native American young people who are at high risk for substance abuse (May 1982). Substance use and abuse have also been related to the cultural identifications of minority youth with the extent of use being related to the specific attitudes of the culture with whom the young person is identifying (Oetting and Beauvais 1990–91).

ISSUES OF COMORBIDITY The comorbidity of psychiatric disorder and substance abuse among adolescents is high (Simkin 2002), with estimates of a dual diagnosis being at least 50 per cent in adolescent patients (Bukstein et al. 1989). While the relationship between substance abuse and mental disorder is complex, substance use and psychopathology each appear to predict the development of the other. In one study, earlier psychopathology predicted the development of substance abuse seventeen months later, and earlier substance use predicted later psychopathology (Friedman and Glickman 1987a). Interestingly, the presence of psychiatric symptoms in substance-abusing delinquent males has been associated with greater response to treatment (Friedman and Glickman 1987b). This may be due to an increased motivation for treatment and benefit from this treatment due to reduction in distress. Substantial amounts of Axis I psychopathology in male and female adolescent inpatients with alcohol and other substance use diagnoses are reported (Pogge et al. 1992).

Major depressive disorder (MDD) and substance abuse often are associated in older adolescence, but the onset of MDD typically precedes the onset of substance abuse (Deykin et al. 1987). In a study of adolescents in an inpatient substance abuse program, 53 per cent were depressed initially, and in 35 per cent of cases the depression persisted for two weeks (DeMilo 1989). Other disorders of impulse control are associated with substance abuse. Tenth-graders with bulimia nervosa reported higher rates of drunkenness, marijuana use, cigarette use and greater depressive symptomatology than the general population (Killen et al. 1987). Both Conduct Disorder (CD) and attention deficit hyperactivity disorder (ADHD) are commonly associated with PSUD, and when both CD and ADHD are found together, the risk of substance abuse is very great (Wilens and Biederman 1993). A recent prospective study suggests that the early unsanctioned use of alcohol predicts higher levels of, and more rapid growth of, conduct behavior problems (CBP) from childhood to adolescence (Johnston et al. 2001). Alcohol use may reciprocally contribute to the expression of CBPs, or both substance use and CBPs may arise from some more general temperamental predisposition such as sensation seeking or a core antisocial trait. Early-onset delinquency is associated with earlier onset of substance use and more rapid acceleration of problems with drugs (Taylor et al. 2002). Substance abuse has a well-recognized association with suicide gestures and attempts. Interpersonal separations, excess accumulation of stress (discipline or legal) and weakened parental support are associated with suicide among adolescent substance abusers (Marttunen et al. 1994). Schizophrenia, especially in young male patients, is often complicated by substance abuse. Personality disorders, especially cluster B, are also associated with PSUD. Lastly, anxiety disorders are frequently comorbid with PSUD but they appear to be more common in the general psychiatric population than among youth with PSUD (Burke et al. 1994).

ASSESSMENT AND TREATMENT ISSUES Effective substance abuse treatment for adolescents consists of interventions that are different from those utilized in adult treatment. For instance, while the inclusion of the family in the treatment process is important at all ages, it is essential with young people and is a key predictor of outcome. Dual diagnosis is prominent among adolescents and the majority of adolescents with either a substance abuse disorder or a mental disorder have, or will have, a dual diagnosis (Hovens et al. 1994). Polydrug use is also more prevalent among teenagers than adults, and adolescents progress more rapidly into multiple substance abuse. Finally, denial in chemically dependent

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adolescents and their families yields a more complex system of reality distortion and dictates age-specific intervention measures (Morrison 1990). Diagnostic criteria for substance use disorders may not capture the types and patterns of associated problems in adolescence as well as they do in adulthood. Although alcohol dependence symptoms reported by adolescents appear to be generally consistent with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) diagnostic criteria, substantial heterogeneity has been found in the symptomatology of youth with alcohol abuse diagnoses (Martin et al. 1995). Adolescents reporting recurrent black-outs, risky sexual behaviors, and craving (problem domains not represented in DSM-IV criteria) are highly associated with DSM-IV alcohol-use disorders. Tolerance and withdrawal symptoms present differently in adolescent versus adult populations. Tolerance seems to occur as a normal developmental phenomenon in adolescent drinkers, while withdrawal occurs infrequently and usually only as an end-stage symptom (Martin et al. 1996b). In addition, polydrug use is prevalent in both nontreatment samples of adolescents (Chavez and Swaim 1992) and youthful problem drinkers (Martin et al. 1995, 1996a). The establishment of a treatment alliance with an adolescent patient usually requires a sensitive interview approach that asks questions simply, directly, and gently. Information should be gathered in a nonjudgmental fashion, and with genuine interest in the individual experience of the young person. Confidentiality should be addressed directly, and the limits clearly defined. It is important also to be aware of one’s own attitudes and reactions to the adolescent in order to avoid harmful unconscious acting out of negative feelings. During the interview, the following risk factors for substance involvement should be assessed:

• • • •

parental attitudes toward substance abuse, such as permissiveness; genetic vulnerability to substance abuse; participation in a peer subculture which uses drugs; and individual characteristics such as low self-esteem, aversion to conformity, lack of religious and school involvement, and sensation seeking.

The presence of any two of these risk factors signifies a high level of risk. Deterioration in family relationships, a drop in school performance, involvement in the legal system, negative personality changes, and involvement with a negative peer group are all indirect evidence of substance abuse. Once substance use is identified, the extent and intensity of use should be characterized in terms of: (i) the variety of substances used; (ii) the frequency and quantity of use; and (iii) the age of initiation of use of each substance. The family system should also be assessed,

including the parents’ attitudes toward the young person, attitudes toward substance abuse including involvement in PSUDs themselves, willingness to be involved in the treatment process, sibling issues, and family dynamics that may contribute to the maintenance of substance abuse. In addition to the clinical interview, a variety of rating scales are available to assist the clinician in assessing the patient. The Problem Oriented Screening Instrument for Teenagers (POSIT), a part of the AARS (Adolescent Assessment Referral system), is a non field-tested instrument based on expert clinical judgment. The POSIT is an eight-page questionnaire consisting of 139 yes/no items covering ten functional areas including substance abuse/ use, physical and mental health, family and peer relationships and delinquency (Rahdert 1991). The Personal Experience Questionnaire (PESQ) assesses a broad range of substance abuse issues, and is intended to meet the need for a quick, psychometrically adequate screening tool (Winters 1992). For alcohol problems, the Rutgers Alcohol Problem Index (RAPI) (White and Labouvie 1989) is based on the frequency of experiencing eighteen negative consequences while drinking, or because of one’s drinking. It is much used in clinical practice and research; it has good internal consistency, and discriminant and construct validity (White and Labouvie 2000). Laboratory evaluation may include studies to screen for underlying medical conditions as well as toxicology examinations. Indications for a toxicology examination include:

• • • • • • •

psychiatric symptoms; additional risk factors; changes in mental status or performance; acute behavior changes; recurrent respiratory ailments; recurrent accidents or somatic complaints; and abstinence monitoring.

Except for blood alcohol, urine drug screens are more sensitive than serum tests. During the assessment phase, the clinician should begin the process of treatment planning. The nature and extent of intervention are based upon a number of findings, including:

• • • • • •

the family’s denial or acceptance of the problem; the presence of a psychiatric comorbidity; the presence of medical disorders; the number and severity of risk factors present; the young person’s attitude toward treatment; and the young person’s reasons for use and ability to control substance use.

Perhaps the most frequently overlooked element in treatment planning is an adequate understanding of the adolescent’s current motivation to engage in treatment. The presence of psychiatric comorbidity is also often overlooked and, if not adequately addressed, can lead to treatment failure.

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Depending upon patient and family/environmental characteristics, treatment in an outpatient, acute inpatient, residential, or partial hospital/day program setting may be most appropriate. The indications for outpatient treatment include:

• • • •

acceptance of problem and need for help; willingness to abstain from all substances of abuse; cooperation with random urine drug screens to insure compliance; and the ability to commit to regular attendance at therapy and support groups.

Outpatient treatment is not recommended when:

• • • • •

acute medical or psychiatric problems require an intense level of supervision (endocarditis, acute schizophrenia, mania, etc.); chronic medical problems preclude outpatient treatment (brittle, poorly controlled diabetes); continued association with substance-abusing peers persists; lack of motivation exists; or previous outpatient treatment has failed.

An effective outpatient treatment has in-program support groups and enlists external support for the patient from the family or living situation. Family support and therapy to address problematic family dynamics must be available along with individual counseling/therapy. Educational programs regarding substance abuse are important elements in treatment and relapse prevention. Finally, random urine drug screens are needed to ensure ongoing compliance with the treatment program, and should be agreed upon early in treatment contracting. Indications for inpatient treatment include:

• • • •

the absence of patient characteristics necessary for outpatient treatment; significant resistance to authority; major family dysfunction; and inability to function without strong outside support.

Effective inpatient programs have the ability to ensure abstinence from substance abuse, the presence of a skilled interdisciplinary staff, the provision of intensive family therapy and family support groups, frequent group therapy, adequate educational programs and aftercare programming. Residential and day treatment programs are indicated for patients with psychiatric, social, or family problems that have not benefited or are unlikely to benefit adequately from other approaches. These youth may not require the intensity of an acute care setting but may need more extensive intervention services than are available in an outpatient setting and a greater duration of service than can be typically provided from an inpatient setting. An effective program is highly structured and drug free, with frequent groups, individual counseling, substance abuse

education, and remedial and formal education programs. Generally, there will be a strong emphasis on the importance of individual responsibility (Friedman and Glickman 1987c). Usually, several treatment modalities are applied within any treatment setting. Studies reviewing the efficacy of a wide range of treatment modalities suggest that some treatment is better than no treatment, but few comparisons indicate that one treatment approach is clearly superior to another (Williams and Chang 2000). Biological treatments of substance abuse include medical detoxification, which is rarely needed in adolescents, as well as emergency intervention for accidental or deliberate overdose – both of which situations are unfortunately much more common. Most pharmacotherapy in the context of substance abuse is targeted towards comorbid conditions such as ADHD, depression, anxiety disorders, or symptoms related to impulsive aggression. Several agents have been used in these conditions, including antidepressants, both tricyclics and selective serotonin reuptake inhibitors (SSRIs), psychostimulants, and neuroleptics. The overall role of pharmacotherapy in the direct treatment of substance abuse is limited in adult patients, and research in adolescents in this area is even more limited (Deas and Thomas 2001; Kaminer 1995). SSRIs may reduce both cocaine craving as well as alcohol use, though the data are inconsistent (Litten et al. 1996). The use of SSRIs is particularly interesting given the association of impulse control problems and serotonergic abnormalities in Type 2 alcoholics whose early onset of drinking may have particular relevance for adolescent substance abuse. Bupropion has shown benefit in the treatment of ADHD in adolescents with comorbid substance use disorders and conduct disorder (Riggs et al. 1998). There are a few case reports of the successful use of desipramine in cocaine-abusing adolescents; however, again the majority of the data are from adult studies (Jonas and Gold 1992). Generally, psychosocial modalities constitute the primary modes of intervention in PSUDs. Family therapy is usually of central importance in the treatment of adolescent patients. Specific family therapeutic techniques attempt to shift the equilibrium of family dynamics away from patterns that support ongoing substance abuse (Boyd-Franklin and Bry 2000; Bry 1988). The therapist attempts to ‘join’ with the family interactions, and uses restructuring and reframing techniques that focus on concrete behaviors and allows family members to see behaviors in a new light. Shifting the balance of power toward the parents is frequently important as parents often feel helpless and unable to influence the behavior of the young person. Group therapy often plays a key role for adolescents owing to the importance of the peer group to this population. Teenagers will frequently accept and incorporate the confrontations of peers with a substance abuse history much more readily than from adults, and the positive,

334 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood

drug-free culture of the therapy group can offer a degree of protection from negative peer influences. In addition to more traditional psychotherapy groups, assertiveness training groups have been utilized to increase adaptive skills (Wodarski 1990). Patients with PSUD may demonstrate deficits in interpersonal problem-solving skills and may not distinguish between appropriate self-assertion and aggressive behavior. Self-help groups and 12-step programs are also utilized with adolescents. Mutual support from recovering peers is a key element in 12-step programs. Kelly et al. (2002) found that adolescents with more severe substance use problems were more motivated for abstinence and more likely to attend and affiliate with 12-step groups than were those with less severe problems. Their results suggested that greater 12-step affiliation may be the mechanism through which attendance at meetings maintained and enhanced motivation for abstinence. Despite their conceptual and practical emphasis on spiritual conversion processes, 12-step approaches to treatment were found to promote abstinence and decreases in substance use in both adolescents and adults through facilitating a number of cognitive change processes, such as increased self-efficacy, motivation, and active coping responses, that are common to many cognitive behavioral and other treatments (Kelly et al. 2000; Morgenstern et al. 1997). Individual therapy for the adolescent substance abuser is typically focused in the present, examines the current role of substance use in the person’s life, and is supportive in nature. The therapist usually is quite active and seeks to examine those elements in the patient’s behavior and environment that obstruct the attainment of abstinence. The therapist may seek to establish a treatment contract with the patient and family that states the goals of treatment and clearly delineates the responsibilities of each party in attempting to achieve treatment goals, including requirements for therapy attendance, relapse prevention groups, AA/NA, and other aspects of treatment (Kaufman 1989). Cognitive Behavioral Therapy (CBT) techniques are well suited to the needs of the substance-abusing young person (Deas and Thomas 2001; Nay and Ross 1993; Wagner et al. 2001). These therapies focus on underlying errors of cognition that lead to unreasonable interpretations of events in the individual’s life, dysfunctional expectations of others, and distorted expectations for the future. Issues of reinforcement related to drug-taking behavior and environmental cues that may be associated with drug craving and relapse are also examined. Educational interventions are another important component of most effective treatment programs. Drugspecific education should address the risks and problems associated with a range of abused substances, as well as motivations for use, peer pressure, family relationships, and emotional issues. Parent training and social skills training also are valuable educational components. Patients who have dropped out of school can benefit

from special school programs that can help prepare them to acquire a Graduate Equivalency Diploma. Vocational counseling is also a useful element, especially for the older adolescent. There is evidence that some patient subpopulations may respond better to certain interventions than others (Irwin et al. 1990). For example, patients with Type A (Babor et al. 1992) or Type 1 (Cloninger 1987) alcoholism appear to respond better to interactional styles of therapy such as support groups than to coping skills training as the primary treatment modality. Similarly, in an adult sample, cognitively impaired persons who received an alcoholism treatment that involved complex coping skills training and homework had worse outcomes than did impaired persons receiving supportive, interactional therapy (Jaffe et al. 1996; Kadden et al. 1989; Cooney et al. 1991). Conversely, patients with Type B or Type 2 alcoholism seem to respond better to coping skills training and cognitive behavioral therapy than to interactional approaches (Litt et al. 1992). Treatment matching may thus become an important area for outcome research.

OUTCOME Design difficulties are present in many studies evaluating treatment outcome (Hoffman et al. 1987). Between-study differences in referral sources, patient characteristics, characteristics of treatment programs, and definitions of substance abuse and treatment response make comparisons problematic across treatment programs. A review of treatment outcome studies suggests the following: 1 Positive outcome is related to peer influences, family and religious support (Barrett et al. 1988). 2 Family involvement reduces treatment drop-out (Coatsworth et al. 2001). 3 Court pressure can significantly enhance retention in therapeutic communities, particularly during the initial stage of treatment (Pompi and Resnick 1987), although voluntary participation appears to correlate with positive outcome. 4 Relapse rates range from 35 to 85 per cent overall (Catalano et al. 1990–91). Pre-treatment factors related to outcome include such characteristics as patient age, sex, race, drug use, criminality, psychiatric symptomatology, education, peer acceptance of treatment, and IQ (Catalano et al. 1990–91). Treatment factors include staff characteristics, special services, and family involvement. Post-treatment factors that are related to positive maintenance of abstinence include the absence of continued craving for drugs, involvement in productive activities, satisfactory leisure activities, and adequate social support. Youthful substance abusers

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who are prone to relapse generally demonstrate fewer problem-solving capacities, greater social pressure to abuse, and less social support (Myers et al. 1993).

PREVENTION The high prevalence of substance abuse problems, the extensive associated morbidity, and difficulties associated with treatment, including substantial relapse rates, suggest the need for effective prevention programs. Since the early 1980s, social influence models have dominated drug abuse prevention efforts (Gorman 1996). There are two primary social influence programs. One type emphasizes ‘resistance training’ with components such as information about the prevalence of adolescent drug use. The more broadly focused social skills training is based on social learning theory and targets a wide range of psychosocial risk factors (Gerstein and Green 1993). It provides general personal and social skills training for coping in various life situations (e.g., assertiveness training, problem solving), as well as training in drug-specific resistance skills. DARE (Drug Abuse Resistance Education) is one example of a multi-component social influence program delivered by law enforcement officers, but appears to have little short- and long-term effectiveness (Brown 2001; D’Amico and Fromme 2002; Ennett et al. 1994; Thombs 2000). Resistance skills (Just Say No) do not appear to decrease subsequent substance abuse, and social influence-based programs appear to be somewhat more effective (Botvin and Botvin 1992). Evidence supporting the utility of school-based social skills training for alcohol use prevention among adolescents is sparse, stressing the need for continued development and testing of prevention programs, with special emphasis on identifying the most effective methods for the prevention of different drug use (e.g., alcohol versus cigarettes), targeted environmental, interpersonal and intrapersonal risk factors, and targeted risk groups. Ideally, prevention programs should address the etiologic vulnerabilities, childhood development phases, and early exposure to preventive measures for high-risk groups such as children with disruptive behavior disorders. For example, improvement of early reading skills through intervention was found to decrease the continuity and severity of depression, and decrease subsequent aggression (Rowe 1996), which is a potent predictor of adolescent drug use. Treatment of childhood-onset psychiatric disorders that are precursors of PSUD may stop the developmental progression of PSUD. Parent training should be available to aid parents in developing specific childrearing skills to improve family functioning. Peer-focused strategies should be utilized to improve positive socialization and alternatives to drug use that reduce the social tolerance of drug abuse behavior. Problem-solving and

decision-making skills should also be incorporated (Barkin et al. 2002). Intervention should be both community and school-based, with attention to promoting academic skills (Wallerstein and Sanchez-Merki 1994). The fact that television is a primary source of information regarding drugs and alcohol among middle adolescents should be recognized and utilized to support responsible consumption. Delaying the onset of marijuana use may be particularly important in trying to decrease the risk for heavier alcohol and drug use during late adolescence when normative use levels reach a peak (Golub and Johnson 1994; Labouvie et al. 1997). Additional interventions need to be targeted at older adolescents who already use drugs and alcohol, in order to reduce peak levels of licit and illicit use and the likelihood of long-term harm. More research is required to understand fully the etiologic, clinical and treatment issues involved in adolescent substance abuse. However, it is clear that effective prevention and treatment requires developmentally appropriate programs that differ in approach from those typically used with adult patients. Effective prevention and treatment programs for young people carry the promise not only of reduction in morbidity and mortality, but also ultimately of an improvement in the quality of life for the adults that these youngsters will become, as well as for future generations.

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Adolescent substance abuse 337 Cloninger, C.R. Neurogenetic adaptive mechanisms in alcoholism. Science 236: 410–416, 1987. Coatsworth, J.D., Santisteban, D.A., McBride, C.K., Szapocznik, J. Brief Strategic Family Therapy versus community control: engagement, retention, and an exploration of the moderating role of adolescent symptom severity. Family Process 40(3): 313–332, 2001. Cockerham, W.C., Alster, J.M. A comparison of marijuana use amount Mexican-Americans and Anglo youth utilizing a matched-set analysis. International Journal of Addiction 18: 759–767, 1983. Comings, D.E., Comings, B.G., Muhleman, D., et al. The dopamine D2 receptor locus as a modifying gene in neuropsychiatric disorders. Journal of the American Medical Association 266: 1793–1800, 1991. Cooney, N.L., Kadden, R.M., Litt, M.D., Getter, H. Matching alcoholics to coping skills or interactional therapies: two-year follow-up results. Journal of Consulting and Clinical Psychology 59: 589–601, 1991. Compas, B.E., Hinden, B.R., Gerhardt, C. Adolescent development: pathways and processes of risk and resilience. Annual Review of Psychology 46: 265–293, 1995. D’Amico, E.J., Fromme, K. Brief prevention for adolescent risk-taking behavior. Addiction 97: 563–574, 2002. Deas, D., Thomas, S.E. An overview of controlled studies of adolescent substance abuse treatment. American Journal on Addictions 10: 178–189, 2001. Deas, D., Riggs, P., Langenbucher, J., Goldman, M., Brown, S. Adolescents are not adults: developmental considerations in alcohol users. Alcoholism: Clinical and Experimental Research 24: 232–237, 2000. DeMilo, L. Psychiatric syndromes in adolescent substance abusers. American Journal of Psychiatry 146: 1212–1214, 1989. Deykin, E.Y., Levy, J.C., Wells, V. Adolescent depression, alcohol, and drug abuse. American Journal of Public Health 77: 178–182, 1987. Drummond, D.C., Litten, R.Z., Lowman, C., Hunt, W.A. Craving research: future directions. Addiction 95: S247–S255, 2000. Ennett, S., Tobler, N.S., Ringwalt, C.L., Flewelling, R.L. How effective is drug abuse resistance education? A meta-analysis of Project DARE outcome evaluations. American Journal of Public Health 84(9): 1394–1401, 1994. Fils-Aime, M.L., Eckardt, M.J., George, D.T., Brown, G.L., Mefford, I., Linneola, M. Early onset alcoholics have lower cerebrospinal fluid 5-hydroxindoleacetic acid levels than late onset alcoholics. Archives of General Psychiatry 53: 211–216, 1996. Friedman, A.S., Glickman, N.W.: Effects of psychiatric symptomatology on treatment outcome for male drug abusers. Journal of Nervous and Mental Diseases 175: 425–430, 1987a.

Friedman, A.S., Glickman, N.W. Residential program characteristics for completion of treatment by adolescent drug abusers. Journal of Nervous and Mental Diseases 175: 419–424, 1987b. Foxcroft, D.R., Lowe, G. Adolescent drinking behavior and family socialization factors: a meta-analysis. Journal of Adolescence 14: 255–273, 1991. Gerstein, D.R., Green, L.W. Preventing drug abuse: What do we know? Washington, DC: National Academy Press, 1993. Goldman-Rakic, P.S. Development of cortical circuitry and cognitive function. Child Development 58: 601–622, 1987. Golub, A., Johnson, B.D. The shifting importance of alcohol and marijuana as gateway substances among serious drug abusers. Journal of Studies on Alcohol 55: 607–614, 1994. Goodman, E., Huang, B. Socioeconomic status, depressive symptoms, and adolescent substance use. Archives of Pediatric and Adolescent Medicine 156: 448–453, 2002. Goodwin, D.W. The genetics of alcoholism. Hospital and Community Psychiatry 34: 1031–1034, 1983. Gorman, D.M. Do school-based social skills training programs prevent alcohol use among young people? Addiction Research 4: 191–210, 1996. Grant, B.F., Stinson, F.S., Harford, T.C. The 5-year course of alcohol abuse among young adults. Journal of Substance Abuse 13: 229–238, 2001a. Grant, B.F., Stinson, F.S., Harford, T.C. Age at onset of alcohol use and DSM-IV alcohol abuse and dependence: a 12-year follow-up. Journal of Substance Abuse 13: 493–504, 2001b. Hovens, J.G., Cantwell, D.P., Kiriakos, R. Psychiatric comorbidity in hospitalized adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry 33: 476–483, 1994. Hawkins, J.D., Catalano, R.F., Miller, J.Y. Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance abuse prevention. Psychological Bulletin 112: 64–105, 1992. Heinz, A., Ragan, P., Jones, D.W., et al. Reduced central serotonin transporters in alcoholism. American Journal of Psychiatry 155: 1544–1549, 1998. Herning, R.I., Glover, B.J., Koeppl, B., et al. Cognitive deficits in abstaining cocaine abusers. National Institute of Drug Abuse Research Monograph 101: 167–178, 1990. Hoffman, N.G., Sonis, W.A., Halikas, J.A. Issues in the evaluation of chemical dependency treatment programs for adolescents. Pediatric Clinics of North America 34: 449–459, 1987. Huzingga, D., Loeber, R., Thornberry, T.P. Delinquency, drug use, sexual activity, and pregnancy among urban youth. Public Health Reports August, 1993.

338 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood Irwin, M., Schuckit, M., Smith, T. Clinical importance of age of onset in type 1 and type 2 primary alcoholics. Archives of General Psychiatry 47: 320–324, 1990. Jaffe, A.J., Rounsaville, B.J., Chang, G., Schottenfeld, R.S., Meyer, R.E., O’Malley, S.S. Naltrexone, relapse prevention, and supportive therapy with alcoholics: an analysis of patient-treatment matching. Journal of Consulting and Clinical Psychology 64: 1044–1053, 1996. Jessor, R., Donovan, J.E., Costa, F.M. Beyond Adolescence. Problem behavior and young adult development. Cambridge: Cambridge University Press, 1991. Johnston, L.D., O’Malley, P.M., Bachman, J.G. Monitoring the Future national survey results on drug use, 1975–2000. Volume 1: Secondary school students (NIH Publication No. 01-4924). Bethesda, MD: National Institute on Drug Abuse, 2001. Jonas, J.M., Gold, M.S. The pharmacologic treatment of alcohol and cocaine abusers: integration of recent findings into clinical practice. Psychiatric Clinics of North America 15: 179–190, 1992. Kadden, R.M., Cooney, N.L., Getter, H., Litt, M.D. Matching alcoholics to coping skills or interactional therapies: posttreatment results. Journal of Consulting and Clinical Psychology 57: 698–704, 1989. Kaminer, Y. Issues in the pharmacologic treatment of adolescent substance abuse. Journal of Child and Adolescent Psychopharmacology 5: 93–106, 1995. Kandel, D., Yamaguchi, K. From beer to crack: developmental patterns of drug involvement. American Journal of Public Health 83: 851–855, 1993. Kandel, D., Yamaguchi, K., Chen, K. Stages of progression in drug involvement from adolescence to adulthood: further evidence for the gateway theory. Journal of Studies on Alcohol 53: 447–457, 1992. Kaplan, H.B., Martin, S.S., Johnson, R.J., Robbins, C.A. Escalation of marijuana use: application of a general theory of deviant behavior. Journal of Health and Social Behavior 27: 44–61, 1986. Kaufman, E. The psychotherapy of dually diagnosed patients. Journal of Substance Abuse Treatment 6: 9–18, 1989. Kellam, S., Ialongo, N., Brown, H., Brown, H., Laudolff, J., Mirsky, A., Anthony, B., Ahearn, M., Anthony, J., Edelsohn, G., Dolan, L. Attention problems in first grade and shy and aggressive behaviors as antecedents to later heavy or inhibited substance abuse. National Institute of Drug Research Monograph 95: 368–369, 1989. Kelly, J.F., Myers, M.G., Brown, S.A. A multivariate process model of adolescent 12-step attendance and substance use outcome following inpatient treatment. Psychology of Addictive Behaviors 14: 376–389, 2000. Kelly, J.F., Myers, M.G., Brown, S.A. Do adolescents affiliate with 12 step groups? A multivariate process

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Adolescent substance abuse 339 May, P.A. Substance abuse and American Indians: prevalence and susceptibility. International Journal of Addiction 17: 1185–1209, 1982. Miller-Tutzauer, C., Leonard, K.E., Windle, M. Marriage and alcohol use: a longitudinal study of “maturing out”. Journal of Studies on Alcohol 52: 434–440, 1991. Moffitt, T.E. Adolescence-limited and life-course-persistent antisocial behavior: a developmental taxonomy. Psychological Review 100: 674–701, 1993. Morgenstern, J., Labouvie, E., McCrady, B.S., Kahler, C.W., Frey, R.M. Affiliation with Alcoholics Anonymous following treatment: a study of its therapeutic effects and mechanisms of action. Journal of Consulting and Clinical Psychology 65: 768–777, 1997. Morrison, M.A. Addiction in adolescents. In Addiction Medicine (Special Issue). Western Journal of Medicine 152: 543–546, 1990. Moss, H.B., Kirisci, L. Gordon, H.W., Tarter, R.E. A neuropsychologic profile of adolescent alcoholics. Alcoholism: Clinical and Experimental Research 18: 159–163, 1994. Myers, M.G., Brown, S.A., Mott, M.A. Coping as a predictor of adolescent substance abuse treatment outcome. Journal of Substance Abuse 5: 15–29, 1993. Oetting, E.R., Beauvais, F. Orthogonal cultural identification theory; the cultural identification of minority adolescents. International Journal of Addictions 25(5A and 6A): 655–685, 1990–1991. Nay, W.R., Ross, G.R. Cognitive-behavioral intervention for adolescent drug abuse. In Finch, A.J., Jr., Nelson, W.M. III (eds), Cognitive-behavioral procedures with children and adolescents: A practical guide. Needham Heights, MA: Allyn and Bacon, Inc., 1993, pp. 315–343. Newcomb, M.D., Bentler, P.M. Consequences of adolescent drug use. Newbury Park, CA: Sage Publications, 1988. Pogge, D.L., Stokes, J., Harvey, P.D. Psychometric vs. attentional correlates of early onset alcohol and substance abuse. Journal of Abnormal Child Psychology 20: 151–162, 1992. Pompi, K.F., Resnick, J. Retention of court-referred adolescents and young adults in the therapeutic community. American Journal of Drug and Alcohol Abuse 31: 309–325, 1987. Rahdert, E.R. (ed.) The adolescent assessment referral system manual. Rockville, MD: U.S. Department of Health and Human Services, 1991. Renis, S., Goldman, J.M. The Development of the Brain. Springfield, IL: Charles C. Thomas, 1980. Riggs, P.D., Leon, S.L., Mikulich, S.K., Pottle, L.C. An open trial of bupropion for ADHD in adolescents with substance use disorders and conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry 37: 1271–1278, 1998. Rowe, P.M. Progress in the prevention of mental disorders. American Psychological Society Observer 9: 5–27, 1996.

Schuckit, M.A. Genetic and clinical implications of alcoholism and affective disorders. American Journal of Psychiatry 143: 140–147, 1986. Schuckit, M.A. New findings in the genetics of alcoholism. Journal of the American Medical Association 281: 1875–1876, 1999. Sigvardsson, S., Bohman, M., Cloniger, R.C. Replication of the Stockholm Adoption Study of Alcoholism: Confirmatory Cross-Fostering Analysis. Archives of General Psychiatry 53: 681–688, 1996. Simkin, D.R. Adolescent substance use disorders and comorbidity. Pediatric Clinics of North America 49: 463–477, 2002. Smith, G.T., Goldman, M.S., Greenbaum, P.E., Christiansen, B.A. Expectancy for social facilitation from drinking: the divergent paths of high-expectancy and low-expectancy adolescents. Journal of Abnormal Psychology 104: 32–40, 1995. Stacy, A.W., Newcomb, M.D., Bentler, P.M. Personality, problem drinking and drunk driving: mediating, moderating, and direct-effect models. Journal of Personality and Social Psychology 60: 795–811, 1991. Tapert, S.F., Brown, G.G., Kindermann, S.S., Cheung, E.H., Frank, L.R., Brown, S.A. fMRI measurement of brain dysfunction in alcohol-dependent young women. Alcoholism: Clinical and Experimental Research 25: 236–245, 2001. Tapert, S.F., Baratta, M.V., Abrantes, A.M., Brown, S.A. Attention dysfunction predicts substance involvement in community youths. Journal of the American Academy of Child and Adolescent Psychiatry 41: 680–686, 2002. Taylor, J., Malone, S., Iacono, W.G., McGue, M. Development of substance dependence in two delinquency subgroups and nondelinquents from a male twin sample. Journal of the American Academy of Child and Adolescent Psychiatry 41: 386–393, 2002. Thatcher, R.W. Maturation of the human frontal lobes: physiological evidence for staging. Special issues: developmental consequences of early frontal lobe damage. Developmental Neuropsychology 7: 397–419, 1991. Thombs, D.L. A retrospective study of DARE: substantive effects not detected in undergraduates. Journal of Alcohol and Drug Education 46: 27–40, 2000. Wagner, E.F., Waldron, H.B., Feder, A.B. Alcohol and drug abuse. In Orvaschel, H., Faust, J. (eds), Handbook of Conceptualization and Treatment of Child Psychopathology. Amsterdam: Pergamon/Elsevier Science, Inc., 2001, pp. 329–352. Wallerstein, N., Sanchez-Merki, V. Freirian praxis in health education: research results from an adolescent prevention program. Health Education Research Theory and Practice 9: 105–118, 1994. Welsh, M.C., Pennington, B.F., Groisser, D.B. A normativedevelopmental study of executive function: a window

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5.9 Psychotic disorders LOIS T. FLAHERTY

INTRODUCTION Psychoses are severe mental disorders which involve constellations of signs and symptoms as well as significant impairment in day-to-day functioning. Psychotic symptoms can involve distorted perceptions (hallucinations and delusions), aberrant thinking (ideas of reference, grandiosity, delusions), and illogical speech patterns. In many cases there is a long prodromal period between the onset of first symptoms and the recognition of the disorder. Early symptoms frequently go unrecognized, causing delays in treatment that may have grave consequences for prognosis. Positive psychotic symptoms include delusions and hallucinations, thought disorder and grossly disorganized behavior. Delusions involve fixed false beliefs. Grandiose delusions, for example, may include a belief that one is God or sent by God, persecutory delusions that there is a plot against oneself, or hypochondriacal delusions convictions about the body rotting or illness. In adolescents, beliefs that others are talking about the patient behind his or her back are common and often difficult to distinguish from the normal adolescent’s self-consciousness. It is the extreme and fixed nature of the beliefs and the unlikeliness that they are grounded in reality that makes them delusional. Hallucinations involve hearing voices (auditory) or seeing things that are not there (visual). In the early stages of psychotic illness these are likely to be fleeting; for example, a fifteen-year-old boy described seeing a ‘gray form’ outside his window at night in his peripheral vision. Although the term ‘thought disorder’ is used in various contexts, it usually refers to difficulty with associations and logical thinking and expression. This may be mild, marked mainly by unusual uses of words or connections, to moderate, so that it is difficult to follow the patient’s train of thought, to so severe that the patient is incomprehensible. Disorders associated with psychotic symptoms include schizophrenia, bipolar disorder, brief psychotic disorder,

schizophreniform disorder, and psychoses associated with substance abuse. All of these conditions can occur during adolescence. The traditional distinction between ‘functional’ and ‘organic’ psychoses has been superseded by the conceptualization of all of these disorders as ‘brain disorders,’ based on research findings of abnormalities in brain structure and function in these conditions. While the diagnostic criteria are essentially the same for adolescents as for adults, signs and symptoms may be less obvious and the differential diagnosis more difficult. At the same time, accurate diagnosis and prompt treatment are crucial to the outcome. Schizophrenia is a severe disorder that affects many mental functions and is often long term in nature. In addition to positive psychotic symptoms as described above, it also often includes negative symptoms. Negative symptoms include anhedonia, lack of motivation, poverty of thinking, and flattening of affect. DSM-IV criteria specify that symptoms must be present for at least six months. Schizophreniform disorder designates a similar syndrome, but with symptoms present for less than less than six months. Psychotic symptoms in bipolar disorder are relatively rare when community samples are studied (Lewinsohn et al. 1995), but they are frequent in adolescent inpatients with bipolar disorder (Ghadirian and Roux 1995). Bipolar disorder, or manic–depressive illness, once thought to be rare in adolescence and frequently misdiagnosed as schizophrenia, is now diagnosed much more commonly. Psychotic features can be part of this disorder in either the depressed or the manic phases. A first episode of depression with psychotic symptoms presenting during adolescence is likely to be the initial episode of manic– depressive illness (American Academy of Child and Adolescent Psychiatry 1997). Psychotic symptoms are common in full-blown mania. The symptoms associated with depression are likely to involve delusions of guilt and

342 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood

worthlessness and hallucinations telling the patient to kill himself; those associated with mania involve grandiose beliefs, such as that one is all-powerful. The hallmark of bipolar psychotic illness is the prominence of the mood symptoms and the occurrence of the psychotic symptoms only during periods of disturbed mood. Whether the hallucinations or delusions are mood congruent or not is helpful but by itself not a differentiating factor. Psychotic disorders comprise a relatively small percentage of conditions diagnosed in adolescence, even in inpatient settings, where their prevalence has usually been under 10 per cent. The prevalence of schizophrenia in adolescents has been estimated at 0.5 per cent, and that of bipolar disorder less than 1 per cent. Prevalence rates for psychotic disorders in adults are about 1 per cent for schizophrenia as well as for bipolar disorder. These disorders occur equally in males and females. Schizophrenia has long been recognized as an illness that has its peak onset during the late adolescent and early adult years, although it can occur at any age. Although some cases seen during adolescence represent childhood onset or ‘very early onset’ schizophrenia, adolescent onset is more common. The peak age of onset of schizophrenia for males is age eighteen to twenty-five years; for females it is twenty-three to thirty-five years. Onset is prior to age nineteen years for 49 per cent of males and for 28 per cent of females (Loranger 1984). For bipolar disorder, the peak age of onset is in the mid to late twenties, but approximately 20 per cent have their first episode during adolescence (American Academy of Child and Adolescent Psychiatry 1997). Currently, epidemiological data on other psychotic disorders in childhood and adolescence are limited (Volkmar 1996).

Genetic influences Early twin studies established a familial pattern for psychotic disorders, with a strong correlation in twins, greater in monozygotic than dizygotic twins. Although these studies were limited by nonblind evaluation methods and lack of uniform criteria, their results have been replicated in more rigorous studies. These studies have supported a continuity between spectrum disorders and full-blown forms for both schizophrenia and affective psychotic disorders.

Neurodevelopmental abnormalities Much of the new knowledge about schizophrenia has come from studies of cognition and brain imaging in so-called ‘first-episode’ patients. Abnormalities found in these patients are less likely to be secondary to medication effects or chronic illness. Aberrant attention and information processing have been consistent findings (Buchanan et al. 1997).

Brain imaging research has yielded intriguing findings. While many of the results have been inconsistent and even contradictory, ventricular enlargement has emerged as a consistent finding in schizophrenia (Rapoport et al. 1997). This finding has been shown to have a particular correlation with negative symptoms. Negative symptoms are also associated with obstetrical complications, poor pre-morbid functioning, and poor outcome, suggesting that there is a negative subtype of the illness that is related to neurodevelopmental abnormalities. Research has suggested that similar neurodevelopmental abnormalities and poor premorbid functioning, as well as psychotic symptoms, are linked in poor-outcome affective disorders (Cannon et al. 1997).

Environment The role of some environmental factors is supported by the fact that co-twins in identical twin pairs do not both develop psychotic disorders, and that obstetrical complications have been found consistently to be a risk factor. The role of psychosocial stresses has not been established, except in the case of brief reactive psychosis. Taken together, these findings support the concept that at least some psychotic disorders are related to neurodevelopmental abnormalities. Synaptic pruning, which is known to peak during adolescence, has been postulated as a factor in pathogenesis of psychotic disorders with onset during this period of life. The loss of neuronal redundancy could expose pre-existing abnormalities and render the individual vulnerable to psychosis. During the 1950s and 1960s, much thinking focused on the role of family interactions, and the notion of ‘double bind’ and ‘schizophrenogenic’ communication was emphasized by some researchers. These ideas were based on observations of families with a schizophrenic member, in which the interactions were inevitably influenced by the ill family member. More recent work has identified ‘expressed emotion’ (EE) in families as a factor influencing outcome, and one study found that a high level of ‘communication deviance’ and ‘affective style’ in families with adolescents who had behavior disorders was correlated with the later development of schizophrenia and schizophrenia spectrum disorders (Goldstein 1987). Although these investigations remain controversial in terms of their implications for etiology, these findings suggest that family interactions should be an important focus of treatment with the goal of increasing support and reducing stressful interactions (Hogarty et al. 1991).

SPECTRUM DISORDERS AND EARLY SIGNS Spectrum disorders exist for the two main categories of long-term illness associated with psychotic symptoms,

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schizophrenia and mood disorders. Milder forms of mood disorder are unlikely to be associated with psychotic symptoms, but schizophrenia spectrum disorders are not infrequently accompanied by mild psychotic symptoms, such as perceptual distortions, or exaggerated suspiciousness. One cannot be sure when one sees an adolescent with less than a full-blown disorder whether the clinical picture is that of a spectrum disorder which is likely to remain stable, or is a waypoint along the progression of the illness toward a more typical form. The use of the DSM-IV diagnosis ‘psychosis not otherwise specified (NOS)’ is often necessary in such cases. Early symptoms can mimic almost any other disorder. Depression, anxiety, attentional problems and various behavior problems are common presenting signs and symptoms. The presence of severe obsessive–compulsive symptoms may result in a particularly confusing picture, as these symptoms not infrequently co-exist with schizophrenia. The presence of insight, commonly cited as a distinguishing feature in obsessive–compulsive disorder (OCD), may be difficult to identify, and the sense of being controlled by outside forces that accompanies compulsions can be confused with command hallucinations. Schizophrenia presenting during the adolescent period is likely to be associated with prominent mood symptoms, particularly when the onset is acute. Extreme anxiety, panic attacks and phobic symptoms can be seen. Depression and suicide attempts are not rare. The distinction between mood-congruent and mood-incongruent delusions and hallucinations is often difficult and not necessarily a helpful differentiating feature. The persistence of psychotic symptoms independent of mood changes is suggestive of schizophrenia.

that they are a sign that something is seriously wrong, as illustrated by the following examples.

•

•

A sixteen-year-old girl was in therapy for depression for several months, when she asked her therapist if it was normal to see objects flying across the room, and revealed that she had been hearing voices for about a year. The therapist had previously inquired about psychotic symptoms and the patient had denied them. A fourteen-year-old boy was transferred to a state hospital adolescent unit after two weeks on an acute inpatient unit at a teaching hospital. He had been given a diagnosis of conduct disorder because of his delinquent behavior, which had consisted of a spree of burglaries. Oddities of speech and behavior were noticeable in his interactions with other adolescents and staff in the milieu. Eventually he admitted to having auditory and visual hallucinations, saying that he had not told anyone previously and had preferred to be considered delinquent than crazy. It appeared that his lawbreaking represented a desperate attempt to flee into delinquency from insanity.

Resistance on part of clinicians to acknowledge psychotic disorders There is a reluctance of clinicians to attribute long-term mental illness to adolescent patients. Anna Freud’s definition of adolescent turmoil actually included psychotic symptoms as a possible manifestation, blurring the distinction between mild and severe disturbances. While clinicians should be cautious in making these diagnoses, they should also not fail to recognize unmistakable signs that have significant implications for treatment.

Frequency of associated substance abuse Rates of substance abuse are high among adolescents with psychotic disorders. Substance abuse in these youngsters is often an attempt at self-medication. The presence of substance abuse complicates the diagnostic process, as many street drugs can exacerbate or produce psychotic symptoms. The most notable of these are hallucinogens, amphetamines, and cocaine; indeed, amphetamine-induced psychoses closely resemble paranoid schizophrenia. Marijuana and alcohol can also exacerbate psychotic symptoms. Conversely, some youngsters will report having tried street drugs once and then abstained. On inquiry, it is possible to establish that the teenager experienced frightening symptoms, and this is sometimes a clue to the presence of a psychotic disorder.

Guardedness of patients Adolescents with psychotic symptoms are often guarded about revealing their symptoms to therapists, knowing

DIAGNOSTIC ASSESSMENT History A history of pre-morbid functioning is likely to reveal some problems, such as a pattern of childhood unsociability or behavior problems beginning during the school years. Family history is crucial. It should be remembered that even psychotic disorders in adult relatives may not have been recognized, but may have been viewed as criminality, or may have resulted in premature violent death, especially in minority populations.

Mental status examination The youngster may appear anxious and restless, or withdrawn, guarded and suspicious. Attention deficits are common. Denial of psychotic symptoms is not infrequent, as the adolescent is aware that they mean he or she is

344 Clinical conditions: psychiatric disorders in childhood, adolescence and young adulthood

‘crazy.’ There may be religious or philosophical preoccupations that go beyond the normal questioning of adolescence and are difficult for the interviewer to understand. Thought disorder is of course an important sign, and this can be seen in mania as well as in schizophrenia.

Laboratory studies There are no diagnostic laboratory studies. In addition to a physical examination, which of course should include screening neurological tests, drug screening should be performed routinely on adolescent patients who present with a recent-onset psychosis. Other laboratory tests are not indicated as part of the diagnostic evaluation unless there is reason to suspect an endocrine or other metabolic disorder. Similarly, electroencephalograms are not generally helpful in the presence of a normal physical examination unless seizure disorder is suspected, and neuroimaging studies should not be carried out unless there is concern about a space-occupying lesion (Adams et al. 1996). Psychological testing can be helpful in identifying disordered and idiosyncratic thinking, grandiosity or excessive suspiciousness, or perceptual distortions. Neuropsychological testing has shown impairments in motor, sensory, and perceptual functioning, verbal and nonverbal memory, and indexes of frontal lobe functioning. However, these findings are not specific enough to be used as diagnostic criteria. Various instruments have been developed to measure thought disorder, but these are used mainly in research settings (Docherty et al. 1996).

TREATMENT Medication Mood stabilizers and antipsychotic medications are the mainstays of drug therapy, and their uses are described in Chapter 5.4. The so-called novel antipsychotics, especially risperidone and olanzapine, have rapidly moved to the forefront of the therapeutic armamentarium. There is a strong case to be made for using these newer drugs as first-line treatments in adolescents (Sanger et al. 1999). Their decreased incidence of extrapyramidal side effects is an important consideration, as adolescents are more sensitive to these side effects, and the discomfort and distress that they cause can lead to lack of acceptance of the medication and reduced compliance. The possibly lower risk of tardive dyskinesia, as well as the potentially greater impact of these drugs on negative symptoms, is an important factor to consider. Similar arguments can be made in favor of clozapine, although its potential risks and side effects are greater, relegating it to second-line status. Experience with adolescents is very limited for

quetiapine and ziprasidone, more recently introduced drugs in the same family as olanzapine. Weight gain has emerged as a significant side effect of the newer antipsychotic drugs. This side effect is a particular concern for adolescents, not only because of the health risks associated with obesity, but also because of its effect on individuals whose self-esteem is already compromised. Another side effect that is particularly distressing to adolescents is hyperprolactinemia. Research on novel antipsychotics is progressing rapidly, however, and it is likely that the number of choices available in this category will expand greatly during the next few years.

Psychosocial treatment Psychosocial approaches to psychotic illnesses have, at least in the past two decades, been relegated to adjunctive status relative to psychopharmacological approaches, though this view is changing. In addition to patient and family education about the illness, social skills training and occupational habilitation or rehabilitation, psychotherapy for patients themselves is being rediscovered as an important modality (Hogarty et al. 1997). A comprehensive treatment approach for adolescents must include appropriate education and habilitation to maximize functioning.

PROGNOSIS As yet, few long-term follow-up studies have been reported of adolescent-onset psychotic disorders. The typical course in schizophrenia is for waxing and waning of symptoms, with recurrences being common. Much of the progression in this illness occurs during the first five years. Studies of first episodes have shown that most patients will recover completely from their psychotic symptoms (Lieberman et al. 1993), but many discontinue treatment or do not receive appropriate follow-up. In psychotic affective disorders, recurrences are also common, and many patients experience significant ongoing impairment. What is becoming increasingly clear is that early and appropriate treatment is crucial, and that this treatment must be comprehensive and address psychosocial function as well as symptoms.

REFERENCES Adams, M., Kutcher, S., Antoniw, E., Bird, D. Diagnostic utility of endocrine and neuroimaging screening tests in first-onset adolescent psychosis. Journal of the American Academy of Child and Adolescent Psychiatry 35: 67–73, 1996.

Psychotic disorders 345 American Academy of Child and Adolescent Psychiatry. Practice parameters for the assessment and treatment of children and adolescents with bipolar disorders. Journal of the American Academy of Child and Adolescent Psychiatry 36: 138–157, 1997. Buchanan, R.W., Strauss, M.E., Breier, A., Kirkpatrick, B., Carpenter, W.T., Jr. Attentional impairments in deficit and nondeficit forms of schizophrenia. American Journal of Psychiatry 154: 363–370, 1997. Cannon, M., Jones, P., Gilvarry, C., Rifkin, L., McKenzie, K., Foerster, A., Murray, R.M. Premorbid social functioning in schizophrenia and bipolar disorder: similarities and differences. American Journal of Psychiatry 154: 1544–1550, 1997. Docherty, N.M., DeRosa, M., Andreasen, N.C. Communication disturbances in schizophrenia and mania. Archives of General Psychiatry 53: 358–364, 1996. Ghadirian, A.M., Roux, N. Prevalence and symptoms at onset of bipolar illness among adolescent inpatients. Psychiatric Services 46: 402–404, 1995. Goldstein, M.J. Identifying schizophrenia in adolescents. Schizophrenia Bulletin 13: 505–514, 1987. Hogarty, G.E., Anderson, C.M., Reiss, D.J., Kornblith, S., Greenwald, D.P., Ulrich, R.F., Carter, M. Family psychoeducation, social skills training, and maintenance chemotherapy in the aftercare treatment of schizophrenia, II: Two-year effects of a controlled study on relapse and expressed emotion. Archives of General Psychiatry 43: 633–642, 1991. Hogarty, G.E., Greenwald, D., Ulrich, R., Kornblith, S.J., DiBarry, A.L., Cooley, S., Carter, M., Flesher, S.F. Threeyear trials of personal therapy among schizophrenic patients living with or independent of family. II. Effects on adjustment of patients. American Journal of Psychiatry 154: 1514–1524, 1997. Lewinsohn, P.M., Klein, D., Seeley, J.R. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry 34: 454–463, 1995. Lieberman, J.A., Jody, D., Geisler, S., Alvir, J., Loebel, A., Szymanski, S., Woerner, M., Borenstein, M. Time course and biological predictors of treatment response in first episode schizophrenia. Archives of General Psychiatry 50: 369–376, 1993. Loranger, A.W. Sex difference in age at onset of schizophrenia. Archives of General Psychiatry 41: 157–161, 1984.

Rapoport, J.L., Giedd, J., Kumra, S., Jacobsen, L., Smith, A., Lee, P., Nelson, J., Hamburger, S. Childhood-onset schizophrenia: progressive ventricular change during adolescence. Archives of General Psychiatry 54: 897–903, 1997. Sanger, T.M., Lieberman, J.A., Tohen, M., Grundy, S., Beasley, C., Tollefson, G.D. Olanzapine versus haloperidol treatment in first-episode psychosis. American Journal of Psychiatry 156: 79–87, 1999. Volkmar, F.R. Childhood and adolescent psychosis: a review of the past 10 years. Journal of the American Academy of Child and Adolescent Psychiatry 35: 843–851, 1996.

Suggested reading American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry 40: 4S–23S, 2001. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry 154 (4, suppl.): 1–63, 1997. Bilder, R.M., Goldman, R.S., Volavka, J., Czobor, P., Hoptman, M., Sheitman, B., Lindenmayer, J.P., Citrome, L., McEvoy, J., Kunz, M., Chakos, M., Cooper, T.B., Horowitz, T.L., Lieberman, J.A. Neurocognitive effects of clozapine, olanzapine, risperidone, and haloperidol in patients with chronic schizophrenia or schizoaffective disorder. American Journal of Psychiatry 159: 1018–1028, 2002. Calderoni, D., Wudarsky, M., Bhangoo, R., Dell, M.L., Nicholson, R., Hamburger, S.D., Gochman, P., Lenane, M., Rapoport, J.L., Leibenluft, E. Differentiating childhood-onset schizophrenia from psychotic mood disorders. Journal of the American Academy of Child and Adolescent Psychiatry 40: 1190–1196, 2002. Hafner, H., Hambrecht, M., Loffler, W., Munk-Jorgensen, P., Riecher-Rossler, A. Is schizophrenia a disorder of all ages? A comparison of first episodes and early course across the life-cycle. Psychological Medicine 28: 351–365, 1998. Hollis, C. Adult outcomes of child- and adolescent-onset schizophrenia: diagnostic stability and predictive validity. American Journal of Psychiatry 157: 1652–1659, 2000. Remschmidt, H. Schizophrenia in Children and Adolescents. New York: Cambridge University Press, 2001.

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SECTION

6

Psychiatric treatment EDITED BY MICHAEL G. KALOGERAKIS

Introduction Michael G. Kalogerakis

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6.1 Forming a therapeutic alliance with teenagers Ghislaine D. Godenne

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6.2 Cognitive behavior therapy with adolescents David B. Wexler

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6.3 Psychoanalytically informed psychotherapy for adolescents Shelley R. Doctors

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6.4 Adolescent psychopharmacology Glen R. Elliott

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6.5 Family therapy Richard A. Oberfield

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6.6 Group psychotherapy with adolescents Paul Kymissis

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6.7 Adolescent inpatient and other milieu treatments Alan Ravitz

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6.8 Community-based treatment Harinder S. Ghuman, Lance D. Clawson, and Mark D. Weist

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6.9 Multimodal dynamic psychotherapy and the adolescent’s world Michael G. Kalogerakis

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Introduction MICHAEL G. KALOGERAKIS

The psychiatric treatment of adolescents has in many ways paralleled the evolution of treatment of adults. It did not, however, begin until the early part of the twentieth century when adolescence first became identified as a separate stage of human development requiring special consideration. The child guidance movement set the stage for a focus on children, leading, in the case of adolescents, to an early interest in juvenile delinquency. There followed a series of developments in which programs aimed at helping the court-related youth were established, notably at the Institute for Juvenile Research in Chicago, the Judge Baker Clinic in Boston and at residential treatment centers in Michigan. In Vienna, August Aichhorn set up the first psychoanalytically based treatment for delinquent adolescents, adapting Freud’s unfolding theories to efforts to work with this special population. It soon became apparent that the techniques that were effective with younger children and with adults needed to be modified to meet the distinctive needs of adolescents. Just as normal adolescents wending their way through the teenage years and struggling to cope with the demands of the environment often presented challenges to their parents, emotionally disturbed and mentally ill adolescents demanded innovative and flexible treatment

approaches not commonly used with younger or older patients. In general, this involved a more active engagement of the adolescent in the treatment process, and sensitivity to the constant assortment of forces at play in his or her life. The chapters in this section represent a state-of-theart description of the modalities of psychiatric treatment in current use with adolescents. Each method has its appropriate uses and, taken together, the techniques presented cover the treatment of the bulk of adolescent psychopathology. The common denominators are flexibility and creativity in the application of any of the modalities described, and a dynamic approach to any combination of these methods. Psychiatric treatment is forever evolving, and this is no less true in work with adolescents. Since effective treatment is invariably the result of a creative use of the therapist–patient interaction, astute clinicians will introduce modifications of the standard procedures that are more compatible with their own personalities and preferred style. This is both desirable for the individual patient and leads to continuing improvement in our overall approach to helping troubled youth. The difficulties associated with bringing about change make treatment innovations a perennial necessity.

6.1 Forming a therapeutic alliance with teenagers GHISLAINE D. GODENNE

INTRODUCTION In the Comprehensive Glossary of Psychiatry and Psychology (1991), Kaplan and Sadock define Therapeutic Alliance as a: “Conscious contractual relationship between therapist and patient in which each implicitly agrees that they need to work together to help the patient with his or her problems; involves a therapeutic splitting of the patient’s ego into observing and experiencing parts. A good therapeutic alliance is especially necessary for the continuation of treatment during phases of strong negative transference. ”

This implicit conscious contract relationship is different from the ‘therapeutic contract’, which is explicit and arrived at prior to the beginning of treatment. In such a contract, the therapist agrees to take a patient in treatment provided both therapist and patient (or patient’s parents) agree on the fee, the frequency of sessions, their location, their time, etc. Masterson (1992) considers the therapeutic alliance concept from a different point of view: ‘The therapeutic alliance can be defined as a real object relationship that is conscious and within which both patient and therapist agree to work together to help the patient improve through better understanding and control.’ Paolino (1981) believes that certain conditions have to be met in order to form a therapeutic alliance, among which he mentions: the patient identifying with the real person of the therapist, the therapist and the patient agreeing that the treatment will be carried through verbal and not behavioral interactions, that both patient and therapist share the same concept of mental health and psychic growth and that ‘although the patient and the therapist accept the patient as he is currently, the patient and the therapist do not settle for the patient being the way he is’

(p. 103). Also, Sandor Lorand (1961) writes: ‘Success in establishing a therapeutic relationship with the patient depends to a large extent on the therapist’s personality, ease, self-assurance and patience, and especially on flexibility on using all types of therapy.’ Occasionally however, situations beyond the therapist’s control might help or hinder the establishment of a working alliance. Krupnick et al. (1996) contend that in both psychotherapy and pharmacotherapy the therapeutic alliance plays a significant influence on the outcome, while others (Castonguay et al. 1996) found that in cognitive therapy for depression, the therapeutic alliance and the client’s emotional involvement could predict the client’s improvement. In summary, all studies focused on the therapeutic alliance concur with the fact that a therapeutic alliance is a necessary condition to treat a patient successfully, regardless of one’s theoretical position. It is essential not to confuse a ‘therapeutic alliance,’ which is a conscious alliance, with an essentially unconscious ‘positive transference.’ A positive transference without a working alliance might result in a ‘flight into health’ – a ‘transference cure’ which is a result of strong transferential feelings towards the therapist but not a working through of the problems that brought the patient to seek help. Seeing the therapist as a ‘best friend’ might bring the teenager to keep out of treatment for fear of disapproval of important events, thoughts and/or feelings (Godenne 1995).

PREPARING THE STAGE FOR THE FORMATION OF A THERAPEUTIC ALLIANCE It is the first contact with the adolescent patient which sets the stage for the ensuing therapy. Most adolescents have little or no insight into their problems, and cannot define what is troubling them. What makes things worse

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is that those teenagers who blame others for their problems are sent, despite their objections, to see a therapist chosen by the very same people with whom they have difficulties. Furthermore, teenagers who are striving for independence and are eager to move away from parental influence are expected to confide in an adult who is a complete stranger. It is thus important to convey first and foremost to the teenager that he/she is our patient, the person we will attempt to help, and that we are not ‘agents of the parents’ who will attempt to shape them the way their parents may want. We are psychiatrists interested in helping teenagers, we will assess the situation as well as we can, and if we believe they need help we will try to provide it. To achieve such a goal I, for instance, have the adolescent be the one who informs me of his/her difficulties. I choose to know NOTHING about the adolescent I am about to see. I do not read referral notes or school reports, and I ask the person who calls to make the appointment not to give me details about the adolescent’s behavior. I explain that when I am referred adolescents I prefer not to know in advance why I am seeing them in order to facilitate my first contact with them, but I assure parents that in the course of my evaluation I will set time aside to meet with them. If inadvertently I do learn the reason for the consultation, I will mention it to the teenager at the very beginning of my interview as I do not want to be in a position to ask a question for which I already know the answer.

THE INITIAL APPOINTMENT, INTRODUCING THE NOTION OF THERAPEUTIC ALLIANCE After introducing myself to an adolescent boy, for instance, if he looks unusually scared or angry I will ask if I am correctly reading his facial expression. The most common answer is ‘yes, why do I have to see you, I am not crazy!’ I agree that indeed he is not crazy, although at times he may wonder, as so many teenagers do. Once that misconception is out of the way I inform the teenager that I know nothing about the reason he is brought to see me and I wonder if he could tell me. Occasionally, adolescents do not believe that whoever made the appointment did not tell me all about them. I explain that I do ask parents when they contact me not to tell me anything about their child’s problem(s) as I prefer to hear it from them. In addition, I inform them that I have the same policy in regard to their school or any other agency which would want to send me information about them. However, if I do receive a report from the school for instance I will not read it before seeing them. If the teenager is still reluctant to tell me the reason for the appointment, I drop the issue and start taking a history through questions which I try to have flow naturally from topic to topic. For instance, I usually start by finding out

about the adolescent parents, siblings, pets, friends (of same and different sex) and to ask about school, goals in life, recreation activities, etc. I am careful not to appear more interested in one area than in another, as patients sometimes tell us or withhold what they believe we want to hear.

CASE EXAMPLE As part of his psychiatric training, Bob – a medical student – was invited to interview Suzie, a fourteenyear-old with whom I had been working for a couple of years. While reporting to me the data that he had collected from the interview, Bob proudly told me that Suzie had confided in him that she had many sexual experiences, but that she had kept that information from me. I decided not to confront Suzie with this new piece of information at her next sessions with me. A few weeks later however, as Suzie came to my office, she said she felt so guilty about her interview with the medical student that she wanted to tell me about it to get it off her chest. Indeed, she never had sex, but as the student appeared so eager to hear her sexual history she told him that she was no longer a virgin. This led him to ask her how many times she had sex, with how many partners, etc. To please him she made up an exciting history of sexual orgies in a cabin behind her home in Texas. Patients do sometimes go to great length to entertain their therapist!! Once the history is completed, if I still do not know what precipitated the referral I tell the teenager that I am still in the dark about why I am seeing him. This tends to confirm once more not only that I did not get the information from others but above all that I am making no assumptions about the reasons for the referral and that from what he told me I am not even sure that I would recommend further visits.

CASE EXAMPLE Many years ago, Mark was referred in order that I sign a commitment paper on him. He was most uncooperative early in the appointment until I told him that I was asked to commit him to a psychiatric facility because of recent ‘crazy behavior’ but I had trouble evaluating his situation as he would not talk. He responded ‘I thought you had decided to put me away so why talk?’ I told him that I was surprised that he would assume I would sign commitment papers without knowing the exact reason for me to do so.

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Mark then narrated in detail the events which brought him to my office. After hearing his story, I doubted that he needed hospitalization or even psychotherapy, but refrained from sharing my opinion with him before seeing his parents. I saw his parents and their story coincided with Mark’s, but from a different perspective. They were young and inexperienced and had overreacted to typical adolescent behavior. Mark had an argument with his mother and, fearing his aggression, wanted a place to ‘cool off.’ His mother wanted to settle the argument and joined him in his room where he had taken refuge. He then locked himself in the bathroom (the only door with a lock); his mother, worrying about what he might do, then hammered down the bathroom door. Mark, frightened, had jumped out of the window and was found later walking in his neighborhood, when he was unwilling to discuss the incident with his father (Godenne 1995).

Having slowly entered into a rapport with my patient, before the appointment comes to an end, I will ask for drawings (tree, house, person and person of the opposite sex). While the teenager draws, I read the school report I might have received. If it contains new information I just may mention it, giving the teenager the opportunity to comment on it or ignore it. If I have determined that there is a need for further appointments, I do not ask if he is willing to return but I indicate that I will set up another appointment with his parents to see him the following week. Asking teenagers if they are willing to come back is placing them in an awkward position. If they agree, they are admitting that they need psychiatric help. If they refuse to come back, my question would not have been genuine as, regardless of their answer, I expect them to return. With experience I have learned that it is unwise to allow more than a week to go by before the second appointment as one runs the risk of losing whatever headway has been made in forming a therapeutic alliance. Despite legitimate concern that by seeing the parents one compromises the establishment of a working alliance (as teenagers might feel that we are ‘ganging up’ on them), it is essential not only to hear the parents’ concerns about their adolescent but also to get from them a complete developmental history, family history, etc. To minimize any negative effect an appointment with their parents might have on the therapeutic alliance, I discuss with the patient the importance of my meeting with them. Very rarely do teenagers strongly object to my seeing their parents, but if they are adamantly against it I might postpone doing so until we can work through their objections. I always invite adolescents to remain in the office while I see their parents. This reassures them that I will not, as other adults may have done in the past,

talk behind their back. I do mention, however, that parents often feel more comfortable talking in the absence of their children as children usually prefer talking without the presence of their parents. Most adolescents are only too happy to be spared a confrontation with their parents and thus choose to leave the office. Finally, I have teenagers ‘invite’ their parents to come to my office. To both adolescents and their parents I make clear that although, on the one hand, I will not divulge anything teenagers tell me without their permission, unless I feel they are a danger to themselves or to others, I will on the other hand feel free to use in psychotherapy any information I gather from their parents which might be useful in their child’s treatment. If I happen to hear from the parents a very important aspect of Julie’s behavior, for instance, which she neglected to tell me, I make a point to see her for a few minutes before she leaves the building in order to let her know the additional information I gathered from her parents. I add that I can understand why it would have been hard to tell me about it and that only when she is ready to talk about it can we work at understanding it. If one neglects this last step, teenagers who suspect that their parents have related during their interview with their therapist all aspects of their behavior, might be so fearful of the therapist’s reaction to the newly disclosed information that they will refuse to return. Seeing the therapist unchanged after being informed of the ‘withheld fact’ will alleviate undue anxiety.

CONSOLIDATION STAGE OF THE THERAPEUTIC ALLIANCE Having clearly established the beginning of a therapeutic alliance, one has to work at maintaining it despite situations in which it might be threatened as it is indeed, most of the time, only a fragile alliance! A good first appointment will facilitate the formation of a working alliance but it will not necessarily assure it, so therapists have to go on working at establishing or reinforcing it. As adolescents return to see us they want to know more about us and often feel that it is unfair that we get answers to our questions but that they have no opportunity to learn about us. I agree that indeed it seems unfair, but I promise that on the last day of their therapy I will answer all their questions. In the meantime, however, it would be more important for them to share with me what they imagine my answers would be than for me to give them answers. In thirty-five years I have never been asked to fulfill my promise. Michael, on his last day of analysis, said: ‘I could know the answers to all my questions today but I no longer need to. I know you as my analyst and that is enough!!’ As treatment progresses, adolescents will form a certain degree of dependence on their therapist and experience

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some regression. This brings them to face exactly what they struggle so hard to avoid. Hopefully, with time they will learn to trust their therapist whom they will see as a person who is not taking advantage of their dependency and who is more reliable than people in their environment. An earlier poor therapeutic experience will make a new one ‘both threatening and compelling’ (Wohlberg 1996). A former good therapeutic experience will on the other hand facilitate treatment, as both the therapeutic alliance and the positive transference will be transferred to the new therapist especially if the new therapist is not threatened by extolling the virtues of the former. Therapists should not be talking or looking like an adolescent of the 2000s to avoid having teenagers use ‘the generation gap’ as a resistance to treatment. Instead, they should show their young patients their eagerness to learn more about their world. Although adolescents might be amused by hearing their therapist talk their language, they will find it hard to form a therapeutic alliance with a person who ‘plays a role.’ Sharing interests, however, and sharing one’s knowledge in an area important to our young patients, will help to cement a therapeutic bond. There are dangers however to this technique, as there is a thin line between sharing interests in order to consolidate a relationship and sharing interests to show, as a parent might do, one’s superiority. Finally, one has to avoid being unconsciously seductive with such an approach.

CASE EXAMPLE One day, John told me that he had nothing more to tell me because I was not interested in the things he loved. I suggested he give me a chance to prove myself and with some disgust he responded with ‘you know nothing about cars!’ I said that I probably knew more than he expected, and he challenged me in a game where each one of us would give the make of a car and the last one to come up with a name would win. We played, I won, and John left the appointment saying ‘my mother won’t let me talk about cars … she says she is not interested in them. It’s boy stuff.’ The test, however, was not quite over. The next week John wanted to play the car game again, but under his coat I noticed he had brought a car magazine. We played, he lasted longer than the week before, but I ended up by winning because I knew the makes of many European cars. This cemented our relationship: I was trustworthy, I was able to talk about kid stuff, so maybe he could start sharing with me some of his inner world (Godenne 1995). The appreciation of adolescent popular culture was the subject of a workshop at the American Psychiatric

Association 1998 annual meeting. The panel chaired by Debra Rosenblum and Lawrence Harman (Rosenblum and Harman 1998) suggested that therapists, by appreciating the music and style of this age group, enhance the alliance formation. In the same vein, Ruiz (1998), in discussing the role of culture in psychiatric care, concluded that the therapist’s sensitivity and knowledge of the patient’s particular culture will help among other things in the development of a therapeutic alliance. Sometimes, it is through a pet that one reaches an adolescent. One should always inquire if they have pets and eventually share with them one’s own interest in animals. Before a solid working alliance has been established, talking about a pet’s feelings is at times as close as one can get to the feelings teenagers experience, but so poignantly transfer to their pet. Adolescents want quick results, and it is hard for them to come to terms with the fact that therapy is a slow process, has ups and downs, and that the road to achieve the final goal might at times be difficult and even painful. Indeed, during the course of therapy with adolescents one is likely to run into a period (or periods) of negative transference in which patients declare that they just cannot talk to us, that they do not like us, that our personalities are not a good fit, and thus they want to quit therapy. If as a therapist one views the therapy as progressing satisfactorily, such pronouncements can conceal secret fears: ‘is it me or my parents’ money that you are interested in? Do you need to keep me dependent on you for your own sake and will you ever let me go?’ It can also be seen as a defense against a frightening regression. Although one should avoid a direct interpretation of a youth’s request to stop treatment, one should clarify once more one’s role as therapist by offering a referral to another psychiatrist. Doing so one makes the point that the important thing is for the adolescent to remain in psychotherapy, be it with oneself or with someone else. This usually provides the necessary reassurance to allow the patient to drop the issue. Although keeping the reluctant adolescent in treatment long enough to have the opportunity of establishing a therapeutic alliance is not always an easy task, some teenagers – especially those who are hurting and want help – almost instantly form a working alliance with their therapist and do not require any special maneuver to establish or consolidate it. It is not the age of the patient which brings us to modify our approach but the teenager’s eagerness to ‘get well’, and their capacity to relate to an adult.

CLARIFYING THE ROLE OF THE THERAPIST Losing adolescents in therapy might be avoided if from the very beginning of treatment one clarified one’s role as

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a therapist and also the process of therapy. One should mention for instance that, initially, patients become somewhat dependent on their therapist but by the end of therapy they are often more independent than they were when they started. Adolescents should be told that at times it will be hard for them to tell us what is on their minds, especially before they have learned to trust us, but unfortunately that is the only way we can find out what is at the root of their problems. We should let them know that occasionally they might feel like quitting therapy, but if they stick with it those times will pass and they will soon see the benefits of our joint efforts. While discussing the role of the unconscious and how it can play tricks in our daily lives, it is often reassuring to give them examples from our own experiences. Indeed, if the therapist can admit to occasional headaches when unable to express anger they might not only accept the fact that they too have an unconscious but may also become intrigued enough with their unconscious to work at trying to understand the origin of their difficulties. A therapeutic alliance with a teenager is based on the understanding that the therapist is an advocate and ally, but not an accomplice. In acting-out patients it is often difficult to walk the tightrope. Indeed, we work at having patients share with us their thoughts and feelings while we remain nonjudgmental. But what if they inform us of some delinquent act they are about to commit or their plans to run away from home? Should we then compromise our working alliance by breaking confidentiality – the cornerstone on which it is built? Adolescent psychiatrists are often faced with such a dilemma, and there are no set rules on how to deal with it. At times one should just listen and hope that, through the trust established between us, a major catastrophe can be averted. At other times it behooves the therapist to step in and take measures to curtail dangerous actions. Unlike Aichorn, who was a master at forming working alliances with wayward youth and patiently waiting for the day the acting out would no longer be the youth’s way of life, we do not have the luxury of time or a controlled and secure environment in which to treat them.

THERAPEUTIC ALLIANCE AND PATIENT SYMPTOMATOLOGY Certain specific conditions call for a variety of approaches if one is to keep an adolescent in treatment long enough to build a solid working alliance. With an adolescent whose acting out is a defense against depression, one should not attempt early in treatment to break down the defense in order to reach the depression. Such an approach would probably scare the teenager away or increase the acting out. Furthermore, in the eventuality

that one is successful in breaking the defense before some therapeutic work has been achieved, one might precipitate a major depression which the teenager is ill prepared to deal with. This approach, however, does not hold true in cases of openly aggressive and/or sadomasochistic behavior. To quote Feinstein (1995): ‘The establishment of a therapeutic alliance and overcoming of normal resistances is at times very difficult with the adolescent. It has been found helpful, however, to approach the adolescent as though one were responding to a plea for help. Aggressive and sadomasochistic defenses are used for mastery and become overwhelming. Accepting the manifest behavior as an attempt at adaptation and proceeding directly to the depressive core with an interpretation of the depression frequently will relieve the despair and communicate to the adolescent that you have received his message’ (Feinstein 1995, p. 17). With regard to borderline adolescents, Miller (1995) writes: ‘Their intense feelings of persecution make the development of a therapeutic alliance with borderline young people difficult. … In the initial stages of therapy, the therapist needs to empathize with the adolescent beliefs (Bradley 1979), rather than agreeing with their validity.’ (Miller 1995, p. 249). This is true also when treating the delusional patient for whom one should not give validity to the delusion, but one should validate the feelings engendered by the delusional idea. Speaking to the affect brings the therapist close to the patient, whose feelings are thereby acknowledged, even if the therapist has a different view of reality. Bond et al. (1998) examine the effect of clearly defined therapist interventions on the therapeutic alliance in patients with personality disorders. Although the study was conducted on adult patients, the findings are certainly relevant to the treatment of older adolescents with personality disorders. In summary, these authors write ‘Transference interpretations were followed by a deterioration in the therapeutic alliance when the alliance was weak, but by enhanced work when the alliance was solid.’ Regardless of the state of the alliance, the authors feel that ‘defense interpretations and supportive interventions enhance therapeutic work without increasing defensiveness.’ Suicidal adolescents are another group with whom a solid working alliance can prevent acting on the impulse. Suicidal threats should be taken very seriously and dealt with before a crisis erupts in full bloom. Informing the patient that any suicidal attempt will call for a re-evaluation of our treatment contract might be enough to avoid a suicidal attempt, but only if we have been successful in establishing a solid working alliance. Teenagers eager to engage in power struggles should be told that indeed we, therapists, are not omnipotent and cannot control their action outside the office. By working together, however, we hopefully can ease their pain.

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Provocative adolescents can test our resilience and threaten the therapeutic alliance. A good sense of humor with patients who can share it allows them not to fight us but instead value us as adults who understand them. By humoring them, we often can take the wind out of their sails by joining them in their provocations. With the completely silent teenager, in order not to increase their resistance by pressuring them to talk or ‘staring’ at them, one might try a variety of techniques. For instance one might ‘keep busy’ by leafing through a magazine while commenting aloud on what one reads or sees. One might try playing solitaire and by wondering aloud if one is missing a move it might awaken the silent teenager’s curiosity. With other teenagers one might try to involve them in a chess, checker, card or other board game. These parameters tend not only to lighten a heavy silence but also, by placing no demands on the teenager, invite him/her indirectly to participate in the activity. Dogs in the office can be wonderful co-therapists. Their presence and affection can help the shy, angry, anxious, frightened adolescent to open up. They form a friendly bridge between the patient and the therapist.

TEENAGERS’ PARENTS AND THE THERAPEUTIC ALLIANCE To protect the therapeutic alliance with teenagers, many therapists do not directly involve parents in their child’s therapy. They do not meet with them except for the initial evaluation, at which time if they seem to need support they are referred to an another therapist who preferably is someone with whom the teenager’s psychiatrist works closely and who shares similar views concerning psychotherapy with adolescents. Most parents, if one has taken time to explain how one works best with teenagers, accept, albeit reluctantly, that modus operandi. They are informed that for the time being the therapeutic relationship with their adolescent has to remain on a one-to-one basis so as not to compromise the therapy. However, they are also assured that they should feel free to get in touch with their child’s therapist if something important has occurred or if they are not sure how to handle an unusual circumstance. If they contact us they should make sure to inform their child as we will mention it to our patient in the following session. Occasionally, parents might be invited to attend a session when in the course of therapy the teenager, the therapist (or both) feels a need to straighten out with the parents some misunderstanding or to improve their handling of a particular situation. Such an appointment should only be scheduled however after having thoroughly discussed it with the patient, indicating for instance, what one

plans to share and even inviting the youth to suggest what he/she wants one to say!

CASE EXAMPLE Sometime ago I saw Paul’s mother who had referred Paul to me because he was abusing alcohol. I learned from Paul during therapy that it was his mother who provided him with it. In my session with her, Mrs. X. admitted buying the alcohol because she felt that as Paul was not at an age when he could legally buy it she wanted to avoid his running into trouble with the police if he was caught buying it!! (Godenne 1995). Though the approach to work only with the teenager is the traditional approach, some therapists have found that working jointly with parents and adolescents is feasible, and even desirable in selected cases. Occasionally, a family meeting is also advisable so that the adolescent and his/her parents can, in the presence of a third party, exchange their views about a given situation or event. During such family meetings the therapist often feels as if he or she is stepping on egg shells – wanting on the one hand to remain the patient’s ally, while at the same time providing support to the parents, who after all have the last say about their child remaining in therapy. After a tumultuous family meeting, it is wise to try to schedule an early session with the teenager to straighten out any misunderstanding that could threaten the therapeutic alliance. The only adolescents one should avoid taking in therapy are children of friends and family or friends of one’s patient! Treating children of friends frequently not only leads to losing their parents as friends, as one has to curtail all contacts with them as long as their child is in therapy, but also interferes in their adolescent’s treatment. The teenager might wonder with whom the therapist has established a therapeutic alliance: their parents or them? Occasionally, parents also compete with their offspring for our attention. For instance, I had an adolescent whose mother would share with the teenager some of our past activities or tell her daughter to give me (and referred to me by my nickname) her love!! Treating friends of current patients greatly complicates the issue of confidentiality and may bring to the fore intense sibling rivalries. If you hear from one patient something about the behavior of another, you cannot use in therapy what you have learned. It thus places us in a situation where we have to withhold from our patient something we have learned about him/her. Be that as it may, there are circumstances in which one cannot avoid treating children of friends, friends of friends, siblings of patients – and

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you then have to do the very best you can in a non-ideal situation.

SHIFT IN FOCUS AFTER ESTABLISHING A THERAPEUTIC ALLIANCE In the foregoing discussion, the focus has been on forming and consolidating the therapeutic alliance, and only tangentially on psychotherapy issues. Once an alliance has been well established, the manner in which the therapist conducts therapy might change. Indeed, a therapist might become less active, and allow more silences. In order for the adolescent not to experience these changes as a shift in the therapist’s attitude, it is important to explain the reason for the change and remind the teenager of the earlier discussion of the nature of psychotherapy. The point can be made that treatment has progressed sufficiently so that the patient can take more responsibility for the content of the sessions, reducing the need for a more active involvement on the part of the therapist.

WORKING ALLIANCE AND SUPERVISION When one is at a stage in training during which supervision is still needed, most supervisors like to have the benefit of process notes. While the use of a tape recorder during a therapy session is an invasion of the patient’s privacy, and taking notes detracts from what is going on, the therapist might obtain fairly good process notes by simply jotting down the topics covered. With these few landmarks, the therapist can reconstruct the entire appointment after the session, and the patient is not threatened by a therapist who writes down all he or she says. In addition, the adolescent can be offered the opportunity to read the therapist’s notes at the end of the session to reconstruct for themselves the topics in the order they were discussed. This would offer the therapist the associations linking one topic to another – associations which they might have missed.

TERMINATION The therapeutic alliance is based on the understanding that both the patient and the therapist will work together at trying to resolve the patient’s present problem. Once the problem is taken care of, if the adolescent wants to stop treatment and unless some major difficulty has surfaced, he/she should be allowed to do so – ‘limiting both the goals and the duration of treatment, discourage regressive dependency and enhance the formation of a

positive working alliance’ (Golombek 1996). Although it might be beneficial for the adolescent to stay in therapy a while longer, allowing him/her to terminate despite the fact that more work should be done at some time in the future, conveys to the patient that he/she has not been ‘trapped’ in psychotherapy. This will allow the teenager to return for treatment at a later date. John Meeks (1971) wrote that ‘Psychotherapy contracts with adolescents tend to be unnecessarily prolonged. This may result in a blunting of the developmental thrust towards independence, which partially nullifies the positive impact of the therapy. Individuation, the goal of adolescent development, is best served by assisting the adolescent towards a workable character synthesis and then quickly moving aside so that the adolescent’s strengths propel him towards real and available objects outside of the therapy’ (Meeks 1971, p. 266).

REFERENCES Aichorn, A. Wayward Youth. New York: Viking Press, 1935. Bond, M., Banon, E., Grenier, M. Differential effects of interventions on the therapeutic alliance with patients with personality disorders. Journal of Psychotherapy Practice Research 7: 301–318, 1998. Bradley, W. American Journal of Psychiatry 136: 424–426, 1979. Castonguay, L.G., Goldfried, M.R., Wiser, S., et al. Predicting the effect of cognitive therapy for depression: a study of unique and common factors. Journal of Consulting and Clinical Psychology 64: 497–504, 1996. Feinstein, S.F. Adolescent affective disorders. In Marohn, R.C. (ed.), Adolescent Psychiatry, Volume 20. Hillsdale, NJ: The Analytic Press, Inc., 1995, 7–21. Godenne, G.D. Forming a therapeutic alliance with teenagers. In Marohn, R.C. (ed.), Adolescent Psychiatry, Volume 20. Hillsdale, NJ: The Analytic Press, Inc., 1995, 289–298. Golombek, H., Korenblum, M. Brief psychoanalytic psychotherapy with adolescents. In Marohn, R.C. (ed.), Adolescent Psychiatry, Volume 20. Hillsdale, NJ: The Analytic Press, Inc., 1995, 307–324. Kaplan, H.I., Sadock, B.J. Comprehensive Glossary of Psychiatry and Psychology. Baltimore: Wilkins & Wilkins, 1991. Krupnick, J.L., Sotsky, S.M., Simmons, S., et al. The role of the therapeutic alliance in psychotherapy and pharmacotherapy outcome: findings in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. Journal of Consulting and Clinical Psychology 64: 532–539, 1996.

356 Psychiatric treatment Lorand, S. Treatment of adolescents. In Lorand, S., Schneer, H. (eds), Adolescents – Psychoanalytical Approach to Problems and Therapy. New York: Harper & Row, 1961. Masterson, J.F. Psychotherapy of borderline and narcissistic disorders in the adolescent: establishing a therapeutic alliance, a developmental, self, and object-relations approach. In Schwarzenberg, A.Z. (ed.), International Annals of Adolescent Psychiatry, Volume 2. Chicago: University of Chicago Press, 1992, pp. 179–192. Meeks, J.E. The Fragile Alliance an Orientation to the Outpatient Psychotherapy of the Adolescent. Baltimore: Williams & Wilkins, 1971. Miller, D. Diagnostic assessment and therapeutic approaches to borderline disorders in adolescents.

In Marohn, R.C. (ed.), Adolescent Psychiatry, Volume 20. Hillsdale, NJ: The Analytic Press, Inc., 1995, 237–252. Paolino, T.J. Psychoanalytic Psychotherapy: Theory, Technique, Therapeutic Relationship and Treatability. New York: Brunner/Mazel, 1981. Rosenblum, D.S., Hartman, L. Co-chairperson of workshop on ‘Adolescents and Popular Culture’. American Psychiatric Association, Annual Meeting Toronto, Ontario, Canada, 1998. Ruiz, P. The Role of Culture in Psychiatric Care. American Journal of Psychiatry 155: 1763–1765, 1988. Wohlberg, J.W., Reid, E.A. Helen Bransom: treatment after sexual abuse by a mental health practitioner. Bulletin of the Menninger Clinic 60: 52–61, 1996.

6.2 Cognitive behavior therapy with adolescents DAVID B. WEXLER

HISTORY AND BACKGROUND Cognitive Behavior Therapy (CBT) is actually a hybrid of a wide variety of treatment interventions that have grown out of the behavior therapy movement since the 1960s. During the 1950s and into the 1960s, the treatment of children and adolescents was dominated by both psychoanalytically oriented models of treatment and by operant and classical conditioning paradigms. While behavior therapy traditionally focuses on producing direct changes in overt behavior, the cognitive therapies develop from the assumption that cognitions are primary determinants of both affect and behavior. This central concept leads naturally to the treatment paradigm that altering cognitions will lead to changes in affect and behavior. While this concept may seem basic at this point in our understanding of human behavior and treatment intervention, the effects of this emphasis have been quite profound. The cognitive therapies have helped clinicians focus on an aspect of behavior which is generally accessible, user-friendly, face valid, and quite effective in stimulating affective and behavioral changes. CBT focuses on how people respond to their cognitive interpretation of experiences and how their thoughts, emotions, and behaviors are related. It combines strategies for altering cognitions with behavioral contingency programs and new learning experiences – ‘behavioral ‘experiments’ – designed to help change irrational or distorted cognitive interpretations (Kendall 1991). Many theorists, researchers, and clinicians insist on discriminating between cognitive therapy, behavior therapy and CBT, but in clinical practice these approaches are only rarely distinguishable one from another. The most traditional operant and classical conditioning procedures almost always have some cognitive components; likewise, we can almost always identify the use of behavioral strategies and reinforcement models even in clinical

interventions which claim to aim strictly at cognitive content and restructuring. Several important assumptions underlying CBT approaches have been supported by research since the 1960s (Bandura 1977; Beck 1976; Ellis 1962; Kendall and Hollon 1979; Mahoney 1974; Meichenbaum 1977):

• • • • •

Cognitions mediate behavior. Cognitive interpretations of situations mediate emotional arousal. Specific psychological disorders include identifiable patterns of cognitive misinterpretations. Clinical practice is enhanced by the deliberate attempt to combine cognitive interventions with behavioral strategies. Cognitions and behavior are ‘reciprocally determined’: changing one can change the other.

The work of George Kelly (1955) formed some of the original blueprint for contemporary CBT approaches. Kelly’s personal construct theory identified ways in which individuals interpret life events and on the behavioral patterns that follow. Ellis (1962) expanded on these concepts with his Rational Emotive Therapy. Later, Beck’s (1963, 1976) cognitive theory of emotional disorders – and his subsequent work on depression (Beck et al. 1979) and anxiety disorders (Beck and Emery 1985) – provided a structured, multimodal, comprehensive treatment model that has become one of the most popular and clinically effective approaches in the field of psychotherapy. Cognitive therapies are often distinguished by the type of cognitive problem that is being addressed. The clinical approaches of Ellis and Beck and many other CBT practitioners focus on cognitive distortions. These distortions are identified, examined and corrected by a process of ‘cognitive restructuring.’ Ellis’ Rational Emotive Therapy developed the ABC model of cognitive interpretations, in which A stands for the observable event, B is

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the cognitive interpretation of the event, and C is the consequent emotions and behaviors. Beck emphasized an analysis of distorted thinking patterns, such as catastrophizing, overgeneralization, arbitrary inferences, selective abstraction, etc. Many other CBT interventions attempt to teach cognitive skills to individuals with cognitive deficiencies (Kendall 1993). Youths with cognitive deficiencies act without thinking and are inefficient in their processing of information – in the very situations when thinking would be quite beneficial. The nonthoughtful activity must be interrupted, to be replaced with a new and previously unacquired set of skills in thoughtful problem solving. Interventions which attempt to address these deficiencies include problem-solving training, self-instructional training and self-control techniques. This theoretical distinction between cognitive distortions and cognitive deficiencies (much like other theoretical distinctions in the CBT field) is often difficult to apply. Providing a more functional process of ‘self-talk’ (the cognitive interpretations and beliefs) for a teenager often addresses distortions and deficiencies alike. Bandura (1969) published studies on observational learning which formally identified covert (cognitive) events. This new model introduced the O (organism) into the traditional S (stimulus)–R (response) behavioral paradigm. Bandura emphasized that the maintenance of response patterns is not only based on external reinforcement. Instead, he offered the concept of vicarious reinforcement (learning from observing the consequences of the behavior of others) and self-reinforcement (people rewarding themselves for a task well done). He developed the pivotal theory of self-efficacy (Bandura 1977): how capable the individual feels of acting in a way that will successfully achieve desired goals and rewards. This is an especially crucial concept in the treatment of adolescents, who are desperately struggling with their capacity to make an impact on their world. Meichenbaum (Meichenbaum 1975, 1977; Meichenbaum and Goodman 1971) developed models for Self-Instructional Training, which were designed to help children develop ‘self-talk’ strategies for modifying impulsive behavior. The work of Kanfer (1970, 1975) and d’Zurilla and Goldfried (1971) in developing models of self-regulation (including self-monitoring, self-observation, self-evaluation, and self-reinforcement) provided important background for his work. Spivack and Shure (1974) specifically applied these approaches to children. Meichenbaum was also influenced by the theoretical work of two Soviet developmental psychologists, Luria (1961) and Vygotsky (1962), who proposed a sequential model for the way in which children develop verbal control of behavior. Meichenbaum concluded that inappropriate behavior in children indicates a lack of ‘self-talk’ skills in monitoring behavior. His technique involved teaching five steps to help children gain behavioral control. With younger children and with impulsive adolescents, these

self-instructional programs have become some of the most popular and effective CBT clinical interventions.

STRATEGIES AND TECHNIQUES CBT, in practice, is active and goal-oriented. It is a psychoeducational approach, including agenda-setting, feedback, modeling, role-playing, and homework. The role of the therapist is more that of consultant, educator, or coach than is true in more analytically oriented therapies. Kendall (1993) describes this role as one where the therapist presents some possible new perspectives and recommends behavioral experiments to help the ‘student’ come to new conclusions about the world. They proceed in a collaborative, problem-solving manner. All successful CBT treatment ultimately stimulates new and more productive ‘self-talk’ as well as new behavioral skills. The terms ‘cognitive restructuring,’ ‘reframing,’ ‘developing new self-talk,’ ‘challenging irrational beliefs,’ ‘learned optimism,’ and others are all used relatively interchangeably to describe the same fundamental shift in perspective which sets the stage for affective and behavioral change. Adolescents are most likely to respond to interventions which are action-oriented – aiming at a specific problem which requires change. The CBT approach helps to identify these problems and offers adolescents specific, practical new strategies. The emphasis on the collaborative relationship, the active, goal-oriented approach, the teaching of coping skills, and the use of feedback have all contributed to clinical receptivity and success with adolescent populations (Schrodt and Fitzgerald 1987). Bandura’s (1977) contribution of the term ‘self-efficacy’ to the field of CBT helps practitioners frame interventions for teenagers which ultimately enhance this sense of self: through self-awareness, increased coping skills, more effective self-management, and more effective interpersonal skills. The teenager becomes more competent, in the broadest sense of the word.

DARREN Darren was a sixteen-year-old boy who had been out of Juvenile Hall and drug rehab clinics several times already at his age. His mother was alcoholic; Darren had lived with her and two different stepfathers after his natural father left years ago. Darren was bright, very good-looking, and quite popular with his peers, but his teenage life was plagued by a series of aggressive, out-of-control episodes: starting fires, throwing objects at teachers, fights on the street. He was quick to experience insult and injury, and quick to retaliate.

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In his residential treatment facility, Darren was placed in a group especially designed for children with ‘uncontrollable’ behavior. The group focused on the theme of ‘feeling powerful’: a way of reframing the acquisition of cognitive-behavioral coping skills. Here, power was defined as being in charge of oneself, so that ‘teachers and parents and other kids don’t decide how you react – you do!’ The timing of this message was right for Darren. In one exercise about preparing for high-risk triggers for old behaviors, Darren identified what he called the ‘scare yourself ’ image: ‘Yeah, I can picture myself at Juvenile Hall, 103 lbs, strung out on crack, veins bulging out of my arms, ready to die. I never want to go there again! So, when I’m tempted to use again, I can pop that image right back into my head and scare myself out of it!’ This became his trademark coping strategy. Darren also learned the art of ‘self-talk,’ so that he could remind himself about how powerful he wanted to be – in charge of himself. He practiced these relentlessly. He also learned to pay very close attention to his ‘red flag’ situations: cues from the environment or from inside himself that signaled him that he was at risk. Darren was able to label his affect, articulate his cognitions, identify what he needed, and rehearse new options. He took pride in his newfound abilities and, because he was a high status teenager, became a role model for other group members. He described his new skills as his ‘tool box: you never know exactly when you’ll need ’em, but they’re with you just in case.’

Verbal problem-solving skills training Adolescents who are trained to develop more advanced problem-solving skills may employ any of a wide variety of approaches. In this category, interventions all share the approach of helping teenagers interject specific selfstatements at moments of decision-making or stress. Kendall and Braswell (1993), Spivack and Shure (1974), and Camp and Bash (1981) all outline a basic four-step series of questions for children and adolescents to ask themselves, usually like these: 1 2 3 4

What is the problem? What are my choices? What is the best choice? Was it successful?

Teenagers are trained to use these questions to respond more constructively in interpersonal situations, such as with parents and other authority figures. These questions are also used to develop more appropriate responses to peer pressure situations, as well as any other situations which might lead to an impulsive behavioral reaction. Beginning usually with a series of games or puzzles,

teenagers are taught to ask these questions prior to making a move or decision – ultimately developing these same introspective skills for the more complex decisions of their social and behavioral world. Spence (1980) developed a program to help youngsters guide themselves through challenging social situations using a game called ‘The Social Detective.’ This approach involves three steps: Detect, Investigate, and Solve, each of which triggers instructions for evaluating problems and developing coping strategies. Meichenbaum (1975, 1985) developed the procedure of Stress Inoculation Training which helps people prepare for stressful events by rehearsing specific calming selfstatements at four stages: (i) preparing for a stressor; (ii) confronting and handling the stressor; (iii) coping with feelings of being overwhelmed; and (iv) evaluation of coping efforts. Statements such as ‘I’m feeling uptight – that’s natural,’‘I know how to handle this – it’s going to be over soon!,’ ‘Keep it cool – it’s not worth it to lose it over this one!,’ and ‘It wasn’t as bad as I expected’ serve to inoculate the teenager against the stressful situation. This cognitive rehearsal approach has been successfully used with anger (Novaco 1975, 1979), social anxiety, pain, test-taking, performance situations, preparation for medical procedures, discussion with parents, and other anticipated stressful events. Through a collaborative development of the most appropriate self-statements, followed by modeling, role-playing, behavioral rehearsal, imaginal practice, and eventually in-vivo exposure to the stressful events, the adolescent develops the cognitive coping skills to defuse the aversiveness. Using the same principles, Meichenbaum and colleagues (Meichenbaum 1977; Meichenbaum and Goodman 1971) outline a treatment approach for impulsive children in five steps: 1 An adult performs a task while speaking out loud (cognitive modeling) Okay, what is it I have to do? You want me to copy the picture with the different lines. I have to go slowly and carefully. Okay, draw the line down, down, good; then to the right, that’s it; now down some more and to the left. Good, I’m doing fine so far. Remember, go slowly. Now back up again. No, I was supposed to go down. That’s okay. Just erase the line carefully.… Good. Even if I make an error can go on slowly and carefully. I have to go down now. Finished. I did it!

2 The child performs the task, with help from the adult (overt external guidance). 3 The child performs the task while giving instructions to herself out loud (overt self-guidance). 4 The child whispers the instructions to herself while performing the task (faded overt self-guidance). 5 The child performs the task while silently giving herself the instructions (covert self-instruction).

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Cognitive restructuring and re-attributions Many intervention strategies aim directly at altering the cognitive ‘filtering’ of events in teenagers. All of these approaches were originally developed for use with adult patients. For adolescents, these approaches have been modified (Wexler 1991a,b; Friedberg et al. 1992) to make the process and terminology more accessible and lively. The principles, however, remain the same:

• • • • •

Identify the trigger event. Identify the cognition which interprets the event. Recognize the consequent affect and behavior. Challenge the old cognition and replace it with more productive ‘self-talk’. Recognize the new affect and behavior which follows.

For teenagers, this approach is best presented as a pathway to increased power: not power over others, but power over the self. The natural striving for independence and autonomy by teenagers can be effectively utilized here by pointing out that their old ‘self-talk’ has been programmed by parents, peers, and other cultural influences. This is a way for them to take charge of their own reactions. This CBT approach may be conducted systematically by instructing a teenager to write down ‘self-talk’ which coincides with the targeted disturbing experience: aggressive impulses, bulimic urges, social anxiety, etc. The therapist educates about the categories of ‘faulty self-talk,’ and the teenager identifies the categories for his ‘selftalk.’ Each cognition is later evaluated for its accuracy, and collaboratively therapist and teenager substitute counter-cognitions (new ‘self-talk’) which lead to a reduction in negative affect and an increase in behavioral self-management. Linehan’s (Miller et al. 1997) Dialectical Behavior Therapy was originally developed and shown to be effective in treatment with adult chronically suicidal and parasuicidal patients with borderline personality disorder (defined here as parasuicidal behavior, high-risk sexual practices, substance abuse, truancy, instigating fights, or other aggressive or dangerous acts). The therapist focuses on a functional analysis of problem behaviors in which these self-destructive behaviors are viewed as having important self-regulating functions. Adapted for adolescents, this manualized cognitive behavioral therapy includes individual therapy and a multifamily skills training group, followed by weekly group sessions. The treatment models focus on specific skills in core mindfulness, distress tolerance, interpersonal relations, and emotional regulation. Patients complete records of suicidal and self-destructive behaviors, behaviors that interfere with therapy, behaviors that interfere with the quality of life, and use of new behavioral skills. Barkley (1998), in his work with adolescents with attention-deficit hyperactivity disorder (ADHD), identifies the typical pessimistic and negative cognitions for

these teens: ‘This means I am really dumb…. I’ll never be normal … my parents are trying to control my life …,’ etc. Barkley outlines procedures whereby the therapist tactfully collaborates with the patient to:

• • • •

identify the distorted belief; provide a logical challenge; suggest a more reasonable belief; and guide in the conclusion that the reasonable belief is more valid.

By presenting evidence of the teenager’s intelligence, by pointing out other positive role models who have a similar condition, and by demystifying beliefs about medication, the therapist gradually helps to reframe the condition and its treatment. Tactful challenging in this process is a therapeutic art in which the patient’s experience is respected and understood, then respectfully challenged.

ANNIE Annie was a sixteen-year-old girl who was obsessed with her own mistakes. She was excessively selfconscious in all of her social interactions. Her mother dominated her life with controlling and critical comments, all in the guise of ‘trying to be helpful.’ Annie periodically engaged in bulimic episodes when she felt particularly guilty or unworthy. Her treatment included individual CBT sessions and family therapy. Annie’s CBT therapist helped educate her about the nature of different kinds of mistake. She engaged in an extensive reframing process, using the five categories of mistake outlined in McKay and Fanning’s (1987) book on self-esteem. The five types of mistake include the following:

• • • • •

mistakes as teacher; mistakes as warning; allowing a quota of mistakes; mistakes based on best information available; and mistakes based on trying something new and challenging.

Annie kept a record of anything that she considered to be a mistake. She learned to identify one or more category for each of the mistakes – categories that helped her recognize that mistakes were part of being human, not indicators of fundamental character defects. Her therapist talked about some of her own mistakes. Annie developed a specific self-talk response to each of the critical voices in her mind that blasted her for her mistakes, such as ‘I made a good decision based on what I knew at the time,’ or ‘What was this mistake trying to warn me about for the future?,’ or ‘Even the greatest rock stars don’t have a hit record every time out – and they’re still great!’

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Annie also experimented with making mistakes intentionally, like dropping change on the floor in a store, almost going into the men’s room in a restaurant, or wearing mismatched socks to school. She learned, with humor, that most mistakes are not very traumatic and that she could recover from embarrassment. The active nature of both the record-keeping and the behavioral experiments – in conjunction with the positive alliance with her therapist – engaged Annie’s attention and helped reform her self-image. She became much more successful at deflecting her mother’s criticism, and her bulimic episodes reduced dramatically as her self-confidence increased.

Interpersonal problem-solving: skill acquisition The more behavioral component of the CBT approaches is reflected in the acquisition of specific interpersonal skills although, as is true with all CBT, the cognitive component is an essential element in all of these procedures. Feindler and Ecton (1986), Friedberg et al. (1992), Wexler (1991a,b) and Zarb (1992) all outline exercises teaching adolescents fundamental skills in assertiveness, active listening, communicating in ‘I’ messages, resolving peer group pressure, making conversation, handling criticism, and social problem solving. Four components are included in almost all of these programs. The first is affective education: helping the teenager identify, label, and ultimately express inner experiences – without necessarily acting them out. Just as parents of young children offer labels for feelings (‘Oh, you must have felt scared’ or ‘I know that can be so frustrating’), CBT therapists and counselors offer teenagers more sophisticated labels for their previously undifferentiated affective states (‘Sometimes you feel so put down and you just have to show everybody that you are important!’ or ‘When you see him do that at parties, you must feel so rejected and afraid that he’s just going to get rid of you!’). Another component is developing specific skills for expressing needs and feelings. ‘I’ messages teach adolescents how to communicate their own feelings without making an accusation, assigning blame, or putting the other person on the defensive. Most CBT communication programs include a specific sequence of presenting a complaint – in a respectful manner – such as:

• • • •

When you put me down in front of my friends. I feel really stupid and angry. I really wish that you could tell me later when nobody else is around. And if you can do that, I’ll try not to be so defensive. OK?

The third component involves modeling and roleplaying which specifically challenge interpersonal situations: arguments with parents or teachers, peer pressure about drugs or sex, handling criticism or compliments from others, asking someone out for a date, or applying for a job. In these role-plays, the teenagers focus especially on the ‘self-talk’ that they are using in these interpersonal situations. They learn that the ‘self-talk’ is the central determinant of whether or not they are able to use these new skills more effectively. Active listening is the fourth component. Here, teenagers learn how to respond to others with respect and genuine interest. They learn the basic responses that help make the other person feel ‘heard’: mirroring the feelings, asking questions for more clarification and understanding, and offering personal responses that allow the other person to feel more understood. As usual, the appeal to teenagers in learning these techniques is not only that it is a ‘nice’ thing to do, but also that it is in their own self-interest.

Covert techniques Another component of many CBT approaches focuses strictly on covert, nonverbal strategies. These include relaxation skills, visualization techniques, biofeedback, self-hypnosis, positive end-result imagery, covert modeling, and other covert interventions which enhance coping skills. While some of these skills offer unique benefits, most are especially valuable as complement to the other cognitive and behavioral skills that teenagers are developing. For example, almost all programs teaching adolescent anger control (Feindler and Ecton 1986; Friedberg et al. 1992; Wexler 1991a,b; Zarb 1992) teach teenagers specific relaxation skills for managing aggressive arousal. These techniques usually include progressive muscle relaxation (Feindler and Ecton 1986) and ‘stairway’ (Wexler 1991a,b) techniques that teach counting backwards with deep breathing. Adolescents learn to identify arousal states earlier in the process and how to take an active, effective step towards controlling the escalation. As with all of the CBT procedures, the cognitive component is the foundation: “This is a way for me to stay powerful, rather than having situations or people control me. ”

Many imagery techniques enhance other CBT work by intensifying the experience. Adolescents who learn assertiveness skills will often be trained in the use of relaxation techniques, so that they can rehearse their assertive responses in this very focused fashion. Imagery exercises such as the ‘Protective Shell’ (Wexler 1991a,b) employ visualization techniques to enhance the impact of cognitive skills, and to help teenagers rehearse countering self-statements.

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SPECIAL ISSUES IN TREATMENT Although CBT treatment appears to be highly programmed and structured, much of the treatment success still depends (as in most psychotherapies) on the positive relationship between therapist and patient. Some of the essential therapeutic relationship variables that are emphasized in other psychotherapeutic approaches, such as mirroring, establishing rapport and developing a positive transference, are also essential in most effective CBT work.

Establishing empathy Even the most brilliant CBT therapists often fail because they have not effectively empathized with the adolescent’s experience. It is necessary – but not sufficient – to present a behavioral plan or more effective cognitions. Before the teenager is ready to accept these new possibilities, he must first feel understood and respected. It is vital to offer the adolescent profound respect and to let him know that his emotions and reactions make sense, even if some of them have not turned out to be very productive. In most successful CBT treatment, the adolescent identifies the therapist first as a tolerant and compassionate person, then as a resource for providing a real life model of a new and more adaptive way of functioning competently in the world.

Making it user-friendly Unless the therapists or group leaders are particularly creative, many teenagers will easily be turned off by the ways in which CBT sessions remind them of school and CBT experiments remind them of homework. The essential elements of the cognitive perspective can be dramatized and enlivened with role-playing, visual imagery, psychodrama exercises, catchy names, etc. The word ‘cognitions’ or even ‘thoughts’ are much less likely to engage teenagers than the term ‘self-talk.’ Feindler and Ecton’s (1986) use of the ‘fool in the ring’ and ‘trigger’ metaphors and Wexler’s (1991a,b) use of the ‘ally,’ ‘freeze-frame,’ ‘protective shell’ and ‘time machine’ techniques are all examples of creative ways of reaching teens. Friedberg et al. (1992) uses images like ‘milking the angry cow,’ ‘blurry thinking,’ and ‘making lemonade.’ Homework that is packaged as a challenging project, such as the ‘social detective’ (Spence 1980) or the ‘experiment’ (Brigham 1989), helps to reframe and enliven an otherwise dry and rather academic task.

Groups, peers, and families Some of the most effective CBT treatment for adolescents takes place in group settings (Brigham 1989; Feindler and

Ecton 1986; Finch et al. 1993; Wexler 1991a,b). The intense peer-orientation of teenagers (Blos 1979) makes the group format especially valuable. Most group CBT programs for teenagers are psychoeducational, teaching the basic concepts and skills of ‘self-talk,’ assertive communication, physiological self-management, and behavioral experimentation while still allowing room for patients to discuss personal experiences and feelings. The group setting is an ideal place to implement some of the more lively and dramatic approaches to facilitate long-term integration. Parents and other family members are also often trained in CBT approaches. The value of the skills that teenagers are developing is enhanced when other family members are also learning them. Especially with communication and problem-solving skills, other family members need to provide validation and reinforcement for the new skills that teenagers are implementing. The STEP (Systematic Training for Effective Parenting) manuals (Dinkmeyer and McKay 1990) provide an excellent example of training all family members in the interpersonal CBT approaches.

APPLICATIONS AND OUTCOME Assessments of CBT programs and protocols have been conducted on a wide variety of clinical syndromes over the past thirty years with adults, to a lesser degree with children, and to only a very limited degree with adolescents – even though the philosophical underpinnings of the CBT approach emphasize proper assessment of clinical syndromes and therapeutic outcomes. The specific adolescent syndromes that have received the most empirical support for treatment effectiveness have been depression, anxiety, aggression, ADHD and impulsivity, eating disorders, and obsessive–compulsive disorders (Clarke et al. 1990; DiGiuseppe 1988; Emery et al. 1983; Schrodt and Wright 1986; Schrodt and Fitzgerald 1987; Seligman 1995; Snyder and White 1979). Using the ‘Coping With Depression Course for Adolescents’ (Clarke et al. 1990) over sixteen, 2-hour sessions, the authors compared adolescent treatment groups, adolescent treatment groups plus parents’ training, and wait-list controls. Subjects in the two treatment groups improved significantly when compared to waitlist subjects. Treatment gains were maintained at a twoyear follow-up evaluation. In another study comparing individual CBT treatment to systematic behavior family therapy and individual nondirective supportive therapy (Brent et al. 1997), teenagers with major depressive disorder showed a lower rate of depression after the CBT treatment. This study suggests that having a good therapeutic relationship may be necessary but not sufficient to obtain optimal clinical improvement in the treatment of adolescent depression.

Cognitive behavior therapy with adolescents 363

In the treatment of aggression, both short-term and long-term benefits have been demonstrated in residential treatment studies implementing problem-solving training (Spivak and Shure 1974) and anger management programs (Kazdin 1987; Kazdin et al. 1989, 1992). The study by Kazdin and colleagues (Kazdin et al. 1987) using a twenty-session problem-solving skills training program produced significant reductions in both parents’ and teachers’ ratings of aggressive behavior, even after a oneyear follow-up evaluation. Because of the emphasis on cognitive processes, such as problem-solving and anticipation of consequences, CBT has been extensively used in treating ADHD conditions in children. Kendall and Braswell (1982, 1993) have shown that CBT effectively treats impulsivity in children, but not necessarily some of the other components of the ADHD cluster of symptoms.

TIM Tim was a seventeen-year-old Hispanic boy with two younger sisters whose mother brought him into the clinic because of his increasing levels of obsessions and compulsions. Over the previous few years, he had become paralyzed with anxiety about contracting diseases, particularly AIDS. Ever since going on a class field trip at age fourteen years, when he was traumatized because he took money from a clerk who ‘looked gay and looked like he had AIDS,’ Tim had refused to go into stores, exchange money, sit where others had been sitting, pick up objects from the floor, etc. One of the teachers in his school had made a trip to Mexico to volunteer at an AIDS hospice, and since then Tim could not enter any classroom that she had been in. To cope with the anxiety of his obsessions, he engaged in compulsive rituals: writing a series of four-letter words like ACRE or AJAX to magically counteract the effect of the word AIDS, scrubbing his skin compulsively, blowing at people or objects whom he believed were ‘contaminated.’ Like other patients with obsessive–compulsive disorder (OCD), Tim knew that his symptoms were bizarre and irrational, but he still could not control them. He had been treated with marginal success first with anti-anxiety medication, then with anti-depressants, and finally with anti-psychotics. Previous psychotherapy had been primarily supportive and interpretative, focusing on unconscious factors in his symptomatology. The CBT therapist explained to Tim that his condition had become extremely serious and that hospitalization might be necessary. Tim understood, and he agreed to any treatment if it would provide relief. The paradigm for CBT treatment of obsessive–compulsive disorder (Goldstein and Foa, 1980) was explained to

Tim: exposure and response prevention. This meant that he would have to expose himself gradually to anxiety-provoking situations – and refrain completely from engaging in any of his compulsive (anxietyreducing) rituals. His therapist helped form a collaborative relationship from the start by empathizing with the paralyzing anxiety, by reassuring him that he was not psychotic, and by educating him about the nature of his condition. Each session began with ‘Let’s focus on what went right for you since we last met.’ Tim practiced visualization skills to help rehearse coping with anxiety when he entered a stressful situation. He developed a series of specific reframing selfstatements, such as ‘I know this is only anxiety, and it will pass if I wait,’ and ‘My doctor really understands what this is like, and I have confidence in him,’ and ‘I don’t have to be perfect, I just want to do things that are more normal.’ He also rehearsed and enacted gradually increasing assertive behavior with his mother.He planned out specific behavioral challenges, like using a bar of soap several times instead of just once or purposely going into stores and exchanging money with clerks. All of these exposures were reframed as ‘opportunities for change’ rather than merely aversive events. Over a period of two years of intensive outpatient CBT treatment and medication adjustments, Tim became increasingly free from the original symptoms. His range of behaviors expanded significantly. Although he still found himself anxious about AIDS and homosexuals, he was able to withstand most encounters with people, including moderate physical contact. He returned to a successful school and working life. March (March et al. 1994) studied the effectiveness of a CBT treatment protocol (incorporating exposure, response prevention, and cognitive strategies) for OCD. This study employed a specific treatment manual for fifteen children and adolescents ranging in age from eight to eighteen years, and whose primary diagnosis was OCD. Although no control group was used in this study and the interactive effects of medication were not specifically controlled, the results were nonetheless quite encouraging: nine of the patients showed a 50 per cent reduction in symptoms. This improvement persisted after follow-up interviews, averaging seven months post treatment.

REFERENCES Bandura, A. Principles of Behavior Modification. New York: Holt, 1969. Bandura, A. Self-efficacy: toward a unifying theory of behavioral change. Psychological Review 84: 191–215, 1977.

364 Psychiatric treatment Barkley, R. Attention-Deficit Hyperactivity Disorder: A Handbook for Diagnosis and Treatment, 2nd edition. New York: Guilford Press, 1998. Beck, A.T. Thinking and depression: 1. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry 9: 324–33, 1963. Beck, A.T. Cognitive Therapy and Emotional Disorders. New York: International Universities Press, 1976. Beck, A.T., Emery, G. Anxiety Disorders and Phobias. New York: Basic Books, Inc., 1985. Beck, A.T., Rush, A.J., Shaw, B.F., Emery, G. Cognitive Therapy of Depression. New York, Guilford Press, 1979. Blos, P. The Adolescent Passage. New York: International Universities Press, 1979. Brent, D., Holder, D., Kolko, D., Birmaher, B., Baugher, M., Roth, C., Iyengar, S., Johnson, B. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry 54: 877–885, 1997. Brigham, T.A. Self-Management for Adolescents. New York: The Guilford Press, 1989. Camp, B., Bash, M.A.S. Think Aloud: Increasing Social and Cognitive Skills – A Problem-Solving Approach. Champaign, IL: Research Press, 1981. Clarke, G., Lewinsohn, P.M., Hops H. Leader’s Manual for Adolescent Groups: Adolescents Coping With Depression Course. Eugene, OR: Castalia Publishing Co., 1990. D’Zurilla, T.J., Goldfried, M.R. Problem solving and behavior modification. Journal of Abnormal Psychology 78: 107–126, 1971. DiGiuseppe, R. A cognitive-behavioral approach in the treatment of conduct disorder children and adolescents. In Epstein, N., Schlesinger, S., Dryden, W. (eds), Cognitive-Behavioral Therapy With Families. New York: Brunner/Mazel, 1988, pp. 183–294. Dinkmeyer, D., McKay, G.D. Parenting Teenagers: Systematic Training for Effective Parenting of Teens. Circle Pines, MN: American Guidance Service, 1990. Ellis, A. Reason and Emotion in Psychotherapy. New York: Stuart, 1962. Emery, S., Bedrosian, R., Garber, J. Cognitive therapy with depressed children and adolescents. In Cantwell, D., Carlson, G. (eds), Affective Disorders in Childhood and Adolescence: An Update. New York: Spectrum Press, 1983, pp. 445–472. Feindler, E.L., Ecton, R.B. Adolescent Anger Control. New York: Pergamon Press, 1986. Finch, A.J., Nelson, W.M., Moss, J.H. Childhood aggression: Cognitive-behavioral therapy strategies and interventions. In Finch, A.J., Nelson, W.M., Ott, E.S. (eds), Cognitive-Behavioral Procedures with Children and Adolescents. Boston: Allyn and Bacon, 1993, pp. 148–205. Friedberg, R.D., Mason, C., Fidaleo, R.A. Switching Channels. Lutz, FL: Psychological Assessment Resources, 1992. Goldstein, A., Foa, E. Handbook of Behavioral Interventions. New York: John Wiley & Sons, 1980.

Kanfer, F.H. Self regulation: research issues and speculations. In Neuringer, C., Michael, J.L. (eds), Behaviour Modification in Clinical Psychology. New York: Appleton-Century-Crofts, 1970, pp. 178–220. Kanfer, F.H. Self management methods. In Kanfer, F.H., Goldstein, A.P. (eds), Helping People Change. New York: Pergamon Press, 1975, pp. 309–355. Kazdin, A.E. Conduct Disorders in Childhood and Adolescence. Newbury Park, CA: Sage, 1987. Kazdin, A.E., Esveldt-Dawson, K., French, N.H., Unis, A.S. Problem-solving skills training and relationship therapy in the treatment of antisocial child behavior. Journal of Child and Consulting Psychology 55: 76–85, 1987. Kazdin, A.E., Bass, D., Siegal, T.C., Thomas, C. Cognitivebehavioral therapy and relationship therapy in the treatment of children referred for antisocial behavior. Journal of Consulting and Clinical Behavior 57: 522–535, 1989. Kazdin, A.E., Siegal, T.C., Bass, D. Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. Journal of Consulting and Clinical Psychology 60: 733–747, 1992. Kelly, G.A. The Psychology of Personal Constructs. New York: Norton, 1955. Kendall, P.C. Guiding theory for treating children and adolescents. In Kendall, P.C. (ed.), Child and Adolescent Therapy: Cognitive-Behavioral Procedures. New York: Guilford Press, 1991, pp. 3–22. Kendall, P.C. Cognitive-behavioral therapies with youth: guiding theory, current status and emerging developments. Journal of Consulting and Clinical Psychology 61: 235–247, 1993. Kendall, P.C., Braswell, L. Cognitive-behavioral self-control therapy for children: A component analysis. Journal of Consulting and Clinical Psychology 50: 672–690, 1982. Kendall, P.C., Braswell, L. Cognitive-Behavioral Theory for Impulsive Children, 2nd edition. New York: The Guilford Press, 1993. Kendall, P.C., Hollon, S.D. Cognitive-Behavioral Interventions: Theory, Research, and Procedures. New York: Academic Press, 1979. Luria, A.R. The Role of Speech in the Regulation of Normal and Abnormal Behavior. New York: Liveright, 1961. March, J.S., Mulle, K., Herbel, B. Behavioral psychotherapy for children and adolescents with obsessive–compulsive disorder: an open trial of a new protocol-driven treatment package. Journal of the American Academy of Child and Adolescent Psychiatry 33: 333–341, 1994. Mahoney, M. Cognition and Behavior Modification. Cambridge, MA: Balinger, 1974. McKay, M., Fanning, P. Self-Esteem. Oakland, CA: New Harbinger Press, 1987. Meichenbaum, D. Self instruction methods. In Kanfer, F.H., Goldstein, A.P. (eds), Helping People Change. New York: Pergamon Press, 1975, pp. 357–391.

Cognitive behavior therapy with adolescents 365 Meichenbaum, D. Cognitive Behavior Modification: An Integrative Approach. New York: Plenum Press, 1977. Meichenbaum, D. Stress Inoculation Training. New York: Pergamon Press, 1985. Meichenbaum, D., Goodman, J. Training impulsive children to talk to themselves: a means of developing self-control. Journal of Abnormal Psychology 77: 115–126, 1971. Miller, A., Rathus, J., Linehan, M., Wetzler, S., Leigh, E. Dialectical behavior therapy adapted for suicidal adolescents. Journal of Practicing Psychiatry and Behavioral Health 3: 78–86, 1997. Novaco, R. Anger Control: The Development and Evaluation of an Experimental Treatment. Lexington, MA: D.C. Heath, 1975. Novaco, R. The cognitive regulation of anger and stress. In Kendall, P., Hollon, S. (eds), Cognitive-Behavioral Interventions: Theory, Research, and Procedures. New York: Academic Press, 1979, pp. 241–285. Schrodt, G., Fitzgerald, B. Cognitive therapy with adolescents. American Journal of Psychotherapy XLI: 402–408, 1987. Schrodt, G., Wright, J. Inpatient treatment of adolescents. In Freeman, A., Greenwood, V. (eds), Cognitive Therapy:

Applications in Psychiatric and Medical Settings. New York: Human Sciences Press, 1986, pp. 69–82. Seligman, M. The Optimistic Child. Boston: Houghton Mifflin, 1995. Snyder, J., White, M. The use of cognitive self-instruction in the treatment of behaviorally disturbed adolescents. Behavior Therapy 10: 227–235, 1979. Spence, S. Social Skills Training With Children and Adolescents: A Counsellor’s Manual. Windsor: NFER Publishing Co, 1980. Spence, S. Cognitive therapy with children and adolescents: from theory to practice. Journal of Child Psychology and Psychiatry and Allied Disciplines 35: 1191–1228, 1994. Spivack, G., Shure, M.B. Social Adjustment of Young Children: A Cognitive Approach to Solving Real-Life Problems. San Francisco: Jossey-Bass, 1974. Vygotsky, L. Thought and Language. New York: Wiley, 1962. Wexler, D.B. The Adolescent Self: Strategies for Self-Management, Self-Soothing, and Self-Esteem in Adolescents. New York: W.W. Norton, 1991a. Wexler, D.B. The Prism Workbook. New York: W.W. Norton, 1991b. Zarb, J.M. Cognitive-Behavioral Assessment and Therapy with Adolescents. New York: Brunner/Mazel, 1992.

6.3 Psychoanalytically informed psychotherapy for adolescents SHELLEY R. DOCTORS

INTRODUCTION Most clinicians practicing psychotherapy with adolescents today, though not trained psychoanalysts, are practicing in a tradition derived from clinical psychoanalysis. Psychoanalysis refers to psychological treatment based on assumptions about largely unconscious, frequently conflicted, multilayered personal ways of organizing and reacting to experience that allow us to understand and explain thoughts, feelings and actions that would otherwise seem illogical. Despite being unconscious, conflicted or multilayered, such personal patterns and motivations are, in principle, considered to be knowable to the individual through the guided, self-reflective process which is the essence of the psychoanalytic method, and changeable in the context of a relationship dedicated to the patient’s emotional development. Although there is no consensus among clinicians about how to define psychoanalytically informed treatment of adolescents, most would agree that this work seeks to engage, develop and transform internalized meaning structures (established patterns of organizing experience and reacting to the world) via dyadic, affect-laden interaction, both verbal and nonverbal. The clinician attempts to:

• • •

implement his understanding of the relationship between the present and the developmental past in treatment; facilitate the adolescent’s developmental progress; and (sometimes); engage the youngster in the self-reflective process that illuminates the relationship between the present and the past.1

1 Therapeutic engagement that does not include immediate reflective awareness may nonetheless be discovered later in life to have significantly transformed meaning structures (see Marohn 1992b, 1997).

I define psychoanalytically informed psychotherapy by its goal of inner transformation and by the degree to which the resources of the dyad are marshaled to meet that goal, rather than by its conventions and technical precepts of frequency, duration, use of the couch, activity level of the therapist or the development and resolution of a transference neurosis.

THE CENTRALITY OF UNDERSTANDING ADOLESCENT DEVELOPMENT The psychotherapeutic task with adolescents is to effect change in a still-developing, not yet fully formed personality, though one that may already contain residua of faulty development. One must remediate psychological liabilities while simultaneously recognizing the normal developmental tasks of adolescence and fostering further psychological maturation (see also Tyson 1998). Psychoanalytically informed psychotherapy, because it is sensitive to the developmental process, is uniquely qualified to address pathological character formations, and to effect changes in the sense of self. It can alter internalized relationships and defensive styles that would otherwise warp further personality development and restrict healthy growth. While adolescents in the throes of psychological reorganization, transformation and growth may manifest affective and behavioral extremes, the maturational thrust often provides a readiness to form new relationships and take in new experiences that can significantly aid the therapeutic process. To understand developmental indications for psychotherapy, the practitioner needs to acquire an understanding of the adolescent developmental phase. For treatment purposes, differences among the various psychoanalytic theories of adolescent development are less

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important than the goal of absorbing the ‘developmental’ or ‘epigenetic’ point of view. This view holds that development consists of a series of unfolding stages in which the ‘personality’ continually faces new challenges through which higher-order psychological formations may emerge. Past problems are brought forward to the present and may complicate further development, though there are simultaneously renewed opportunities to rework old issues. The developmentalist asks himself, ‘What current problems is the adolescent trying to solve?’, ‘What previous struggles have helped and hindered him?’, and ‘What new experiences can resolve old problems and facilitate further growth?’ The continuous construction model that is revolutionizing the psychoanalytic understanding of development, psychopathology, and treatment (Zeanah et al. 1989) holds that the individual is exquisitely sensitive to the context within which growth takes place. The developmentally attuned pioneers of psychoanalytically informed work with adolescents must have understood this, for the premise provides the rationale for the participatory stance that characterizes successful work with adolescents. The dyad formed by the therapist and patient constitutes an adjunctive developmental opportunity for adolescents.

A BACKGROUND CONTROVERSY The plethora of arguments regarding where to draw the boundary between psychoanalysis and psychoanalytic psychotherapy for adults is reflected in controversies amongst psychoanalysts treating adolescents. Some (Chused 1988) would hold that unless the adolescent’s conflicts, repressed infantile wishes and fantasies, intensify, concentrate and resolve (in the transference) in relation to the analyst, the process is not psychoanalysis. Many others believe that the distinction between psychoanalysis and psychoanalytically informed psychotherapy with adolescents is rapidly disappearing (Marohn 1997). Rather than draw a boundary between these modalities which can suggest a continuum of efficacy or intricacy, I include psychoanalysis for adolescents within the broader category of psychoanalytically informed psychotherapy. Whether or not specific psychoanalytic methodology (e.g., the fostering of a transference neurosis, the analysis of transference, the resolution of a transference neurosis) is linked to developmentally defined psychotherapeutic action is a question to be resolved by research of the sort begun only recently (Fonagy and Target 1994; Target and Fonagy 1994).2

2

With adults, research has not borne out the expected linkage between psychoanalytic methodology and therapeutic action (Wallerstein 1986).

DOING THE WORK Indications for psychoanalysis and psychoanalytic psychotherapy in adolescence In 1905, Freud’s case report of his adolescent patient Dora included evidence of his own frustration with the treatment. It has been widely recognized that there are great difficulties in conducting a classical psychoanalysis with adolescents. Usually, adolescents simply will not cooperate. (For a fresh approach to engaging adolescents in psychoanalysis, see Lament 1997.) In 1958, Anna Freud commented on the regrettably small number of such reports in the literature, and reports of successful, traditional psychoanalyses with adolescents are still few in number. Galatzer-Levy (1985) provided an extensive case report on the psychoanalysis of an adolescent boy, conducted without modification. He believes that Anna Freud’s traditional selection criteria still apply and that psychoanalysis remains the treatment of choice for ‘neurotic’ adolescents; that is, those inhibited and constricted on the basis of psychological conflict who, otherwise, have good psychological endowment. Many well-trained psychoanalysts, however, would not undertake formal psychoanalysis with an adolescent unless it was an extreme case of derailed development. Goldberg (1978), a self-psychologist, was the first to reserve psychoanalysis in adolescence for conditions which required the total reorganization of the self. LevyWarren (1996), a contemporary Freudian, has also prescribed psychoanalysis proper rather than psychoanalytic psychotherapy for cases in which development has come to a complete halt. For her, this ‘heroic’ indication warrants the frequency, intensity, and duration of a full psychoanalysis. Contemporary psychoanalysts treating adolescents more typically speak of ‘psychotherapy,’ and use that term to refer to the way in which they apply psychoanalytic theories of development, pathology and cure to their adolescent patients (Esman 1990; Levy-Warren 1996). Psychoanalytically informed psychotherapy is indicated when there is some interference with the developmental process. Adolescence is a good time to institute psychotherapy, as deficits in development sometimes can be corrected and often the developmental process can be facilitated. Such an indication for psychotherapy is exemplified by Marohn’s work with delinquent adolescents (Marohn 1992a). According to Marohn, ‘Violent adolescents have little awareness of an inner psychological world, cannot name affects or differentiate one from another, and often confuse thought, feeling, and deed. In psychodynamic treatment, adolescents are helped to experience affect as a part of themselves and to develop the capacity to manage affect and use it as a basis

368 Psychiatric treatment

for communication and self-understanding.’ (Marohn 1992a, p. 622). Psychoanalytic psychotherapy has been prescribed for the entire gamut of psychopathological difficulties. Esman (1985) suggests psychoanalytically oriented psychotherapy for virtually all symptoms and behavioral difficulties, whether stemming from internal conflict, deficit, or external circumstances, and excludes only psychotic, frankly addicted, and sociopathic youngsters. Marohn (1992a) does not exclude sociopathic character disorders. Like Aichhorn (1925), Marohn based his judgment on his assessment of the adolescent’s potential capacity to form a transference bond; sociopathic characters are considered treatable if they have a history of having admired something or someone. While some forms of psychopathology have important constitutional roots, even the expression of biological tendencies is affected by psychological context. The concrete pattern of experience which results from the interaction of these factors (Escalona 1965) can be modified or transformed in a new psychological context. That context is psychoanalytically informed psychotherapy.

Structuring the treatment Issues about the structuring of the treatment need to be dealt with especially thoughtfully for each adolescent case. Together, the therapist and patient will form a new psychological system, one that is charged with effecting psychological change within the patient. The therapist must therefore be as mindful as possible as to what each of his communications – in both action and speech – will mean to the patient. Elements that seem routine to the therapist are likely to be experienced by the new patient as communicating something of the therapist’s personality, his attitude towards the patient, and the possibilities inherent in the new process. Later, patient and therapist will examine the meanings made of words, actions, etc. A renewed appreciation that the patient will ascribe meaning to every aspect of the set-up can help the therapist begin to engage his young patient and attempt to avoid behaviors that scuttle the treatment before it is off the ground.

In clinic settings or in private practice, the first practical question the therapist must face is whether to meet the adolescent first or the parent. Levy-Warren (1996) counsels that early adolescents often expect their parents to meet with the therapist first, while late adolescents frequently require that the therapist meet with them and often wish to exclude their parents from treatment altogether. Godenne’s (1995) method (see also Chapter 6.1), which specifically excludes accounts other than the adolescent’s own until after the initial contact has been made, may facilitate the alliance with the adolescent. The point is central to all psychoanalytic theories – all behavior has meaning; adolescents process and react to the meaning they make of all the therapist’s behaviors.

COMMUNICATING WITH PARENTS It must be remembered that some alliance with the parents is virtually always necessary. Sometimes practitioners incorrectly interpret a ‘psychoanalytic’ stance to mean that no contact should occur with anyone other than the adolescent. Parents make the treatment possible through their support. Whether or not they pay for treatment, parents usually help to arrange their adolescent’s life so that treatment can occur, for example, by transporting the teenager or by arranging for lessons and family and school schedules to accommodate the treatment. A failure to respect the parents’ concern for their child may lead to treatments that end suddenly and prematurely, as parents may then sabotage the work. There are treatments that fail when parents either cannot tolerate feelings of competition or cannot understand the need for treatment after symptomatic improvement has occurred. Parents may then pressure adolescents to end treatment in subtle and not-so-subtle ways. Adjunctive, if occasional, parent guidance sessions are useful in helping parents to understand the unfolding of the therapist’s treatment plan. Additionally, an approach that acknowledges parents is usually reassuring to teenagers, though their reservations must be elicited, understood, and sometimes heeded. Whatever the state of their strivings for independence, most adolescents deeply feel some unreadiness for being entirely autonomous.

THE EVALUATION PHASE THE INITIAL CONTACT Often, the first contact is on the telephone with someone other than the adolescent. Adolescents are frequently sent to treatment. If the parent has phoned, the therapist should ask whether the adolescent knows about the contact and whether the adolescent, too, wishes to speak to the prospective therapist. Even if the answer to one or the other question is negative, the therapist has begun to communicate (to the parent, and possibly the adolescent) that in his mind the adolescent is not reducible to what others say about him.

Parents and adolescents should be told that the therapist will require several initial sessions to meet with each (in a sequence determined by one’s best judgment about what might be tolerable) to develop some sense of what is going on and what might be the best way to address the situation. Not only is it clinically prudent to evaluate each youngster, but this communicates the therapist’s interest in understanding the adolescent in depth. While some therapists believe they can assess an adolescent and his family in two single sessions, more time is often desirable. It is wise to suggest that outcomes other

Psychoanalytically informed psychotherapy for adolescents 369

than a plan for individual treatment may be recommended. Aside from the possibility of referring the parents to individual, couple treatment, or family therapy, the clinician’s assessment of parental functioning – and particularly the parents’ capacity to understand the adolescent – will be crucial in determining the form of contact appropriate in each case. Possibilities other than minimal contact may be indicated, from continuing contact to ensure support of the treatment, to the use of the parents to modify the environment, to the possibility of working with the parents in an ongoing manner to identify and ameliorate the effect of difficulties regularly encountered by the adolescent (Rosenbaum 1994). We sometimes forget that Anna Freud (1958, 1968) counseled that working with parents of adolescents is sometimes very useful. The first several visits are a crucial time in which direct emotional contact must be established with the adolescent and, if possible, also with the parents (Blos 1962; Meeks 1971). It is important to be able to speak comfortably and naturally with adolescents. The therapist’s capacity to listen empathically, think developmentally, and speak affectingly must all come to the fore in the first several sessions. Ways must be found to frame the adolescent’s issues which are honest and novel, and which allow for hope about a good resolution to the issues not previously considered by the adolescent. The therapist’s creativity plays an important role. Consider Levy-Warren’s comment (1996): ‘Sometimes the only way an adolescent who feels forced into treatment will be able to engage in it is if the therapist suggests that it might be worth the adolescent’s while to discuss what it is like to live with parents who demand that the adolescent be in treatment.’ (Levy-Warren 1996, pp. 162–163). The process of communicating findings and recommendations to adolescents and parents is an art unto itself. Care must be taken to balance frankness with respect for self-esteem. Real psychological issues must be addressed in jargon-free terms that connect to the adolescent’s experience. The treatment arrangement that follows will be a function of the therapist’s evaluation and the quality of engagement that has developed with the adolescent and family. Similarly, the frequency of sessions will reflect the clinician’s diagnostic judgment, the parent’s financial circumstances, and the adolescent’s other obligations. While many people today need to be educated to the value of two-to-three-times-a-week sessions, the impact of this on the adolescent and the family needs also to be considered. It is useful to remind everyone that initial arrangements are provisional and may require alteration. At this early time, arrangements must be made to protect an on-going treatment – who pays for the sessions, how much, how the bill is transmitted, and under what circumstances there is a charge for missed sessions. All of these arrangements are fraught with

meaning, which the therapist must monitor (see LevyWarren 1996, pp. 157–165).

CONFIDENTIALITY Therapists should, naturally, be alert for opportunities to address issues of confidentiality. Adolescents often allude to beliefs that the parents would be angry or distressed by something the adolescent has just told the therapist, whether thought or deed. The adolescent can then be told that everything which occurs in sessions stays in sessions, that parents would be informed only if the therapist were to become convinced that the adolescent’s safety was in danger. Some adolescents will want to explore examples, and this should be encouraged. Exploration will reveal the distinction in the therapist’s mind between fantasy and action, and between experimentation with risky behavior and commitment to self-destruction. Such clarity in an adult is a source of comfort to virtually all adolescents. Parents, too, must be informed of these clinical boundaries. It is actually more common for issues of confidentiality to be nettlesome with parents than with adolescents, as parents frequently feel threatened by the recognition that a stranger has privileged access to their child from which they are excluded.

DURATION OF TREATMENT How long should treatment last, and how does it end? Treatment in adolescence is often unorthodox. Useful treatment can sometimes be quite brief (Slaff 1995; Golombek and Korenblum 1995). Nonetheless, psychoanalytically informed psychotherapy with adolescents typically implies long-term treatment, perhaps one year or longer. Indeed, careful research on the outcome of psychoanalysis and psychoanalytically oriented psychotherapy has demonstrated that a longer duration of treatment is correlated with more successful outcomes for adolescents (Target and Fonagy 1994). While the therapist holds certain developmental goals, the adolescent frequently links treatment to external circumstances (i.e., ‘Until I graduate.’; see Novick 1976). When therapists are caught off-guard by an adolescent who announces a precipitous end to treatment, it must be remembered that the adolescent’s psychological organization is in a state of flux. A teenager may not be able to articulate why treatment should end. He or she may need to put into action the gains made. Dulit’s presentation, ‘In and out of treatment – An okay thing’ (Dulit 1982), was perennially popular on the adolescent psychotherapy circuit. Episodic treatment is more common with adolescents than with adults. In any case, it is important to remember that the gains of treatment may not become apparent for many years. The impact of treatment and the relationship with the therapist may not be articulated during the course of therapy and sometimes may only be discerned retrospectively (Marohn 1992b, 1997).

370 Psychiatric treatment

Technical aspects of the actual interaction What happens in the room? The work has long been recognized as challenging (Freud 1958), both because adolescents are often difficult to engage and because working with them is thought to arouse and engage the therapist’s own unresolved adolescent issues. While doing psychoanalytic psychotherapy with adolescents is different than working with adults, developing competence with adolescents is excellent preparation for general psychotherapeutic work (especially with more difficult patients). Analyst–patient interaction is less formulaic, more creative, and more active than in adult treatments. While child treatment is sometimes quite physically active, adolescent treatment may be quite emotionally stimulating. To put it mildly, adolescents often use words incisively to express themselves and to explore the psychological world of the therapist. Therapists need to be comfortable being more responsive to their adolescent patients than they may have learned to be with adult patients. More casual conversational style does not lead to countertransference abuses if the therapist understands that this setting, even more than the standard adult setting, requires that the therapist reliably develop access to wide and deep self-knowledge. It is crucial that the therapist come to know his own vulnerabilities and that he be familiar with the affective and behavioral signs which signal that these vulnerabilities are being evoked. When the therapist is sufficiently aware of his vulnerabilities (Doctors 1996), he can decenter from defensive patterns of psychological involvement and resituate himself so as to be useful to the adolescent in the psychological field. The mature analyst may be playful and utilize humor to engage the patient, to change the pace of the dialogue, to promote self-reflection, and to engage the patient’s latent capacities for relatedness (Schimel 1992). Interpretation, the sine qua non of classical psychoanalysis, is also used in adolescent work. Technically, clarifications and confrontations are more often utilized than genetic interpretations, which seek to link current psychic events to their infantile origins. The therapist tends to stay closer to the level of consciously available experience. The adolescent therapist helps the adolescent to become more self-reflective, to recognize patterns of affectivity and to become aware of how he or she organizes experience and reacts to experience. Though genetic reconstruction may occur, therapist interventions are primarily directed at expanding the adolescent’s psychological repertoire, freeing him or her from self-restricting defensive patterns, and helping the adolescent develop a sense of conviction about subjective experience. How the therapist listens, understands, and responds is at least as important as the content of what is interpreted (Kalogerakis 1997). While psychoanalysis originated with the discovery of unconscious impulses and motivations, we have come to

understand that the patterning of experience may also be unconscious (Stolorow and Atwood 1992). Becoming aware of and transforming patterns of attachment and relationship is a crucial mode by which psychotherapy in adolescence can alter the developmental course. Being in relationship to a benevolent therapist who routinely comments on the mental state of both patient and analyst can enhance self-reflective capacities in adolescents (Fonagy et al. 1995). The development of reflective mental processes is increasingly recognized as an element in the individual’s capacity to form secure relationships and to shape and guide a successful life course. The analysis of the transference, a crucial locus of therapeutic illumination in work with adults, tends to take on a different valence in psychoanalytic psychotherapy with adolescents. The definition of transference as organizing activity (Stolorow and Lachmann 1984/85) is useful in adolescent work, as it directs attention to the patient’s typical ways of being, without insisting that the adolescent focus routinely and specifically on feelings about the therapist. Certainly there are times when the clinician senses that feelings about the therapist must be attended to before other matters can proceed. However, understanding that transference will manifest itself in a host of psychological productions allows the therapist of adolescents to avoid the rigid, doctrinaire stance that could easily compromise the therapeutic alliance.

Being with the adolescent: the new relationship The relationship between patient and therapist is probably the crucial component of the therapeutic action of the therapy. The characteristics that underlie the primary attachment relationship, namely emotional availability, dependability, empathic attunement, sensitivity to developmental needs, and provision of comfort and security, are also prerequisites of the therapeutic relationship (Peterfreund 1983, as cited in Zeanah et al. 1989). The combination of the relational perspective (Mitchell 1988) gaining ground in psychoanalysis, and the growing understanding of the implications of infant research for the treatment process (Lachmann and Beebe 1996) is directing our attention to the context in which development, pathology, and cure occur. The real relationship in psychotherapy and psychoanalysis is increasingly recognized as a most powerful element in the transformation of relationship pathology (Zeanah et al. 1989). Some of the papers written by senior psychoanalysts about being with adolescent patients are amongst the most humane, evocative papers in the annals of psychoanalysis (Anthony 1975; Schimel 1992; Marohn 1992b; Kalogerakis 1997). I take this to be a reflection of Marohn’s idea (1992b, 1997) that doing the work contributes to the development of a ‘psychotherapeutic self ’ and, more

Psychoanalytically informed psychotherapy for adolescents 371

broadly, to the maturation of the analyst’s personality. With experience, adolescent therapists come to recognize ‘the powerful impact of one’s personhood on the patient’s experience’ (Marohn 1997, p. 291) and to respect and rely on the process. Describing the way in which patient and therapist may come to share earlier impressions of one another (Anthony 1975), as if sharing photos from a family album, warmly evoked the radically intersubjective nature of the adolescent treatment process. Interestingly, the process of lending oneself wholeheartedly to understanding and enhancing the development of an adolescent often expands and deepens one’s acceptance and understanding of one’s own development. Anthony’s (1975) reminder that psychotherapy is ‘a mutual voyage of discovery and neither therapist nor patient should be too certain how it is all going to turn out’ (Anthony 1975, p. 342) seems a fitting way to epitomize the adolescent psychoanalytic psychotherapy adventure.

REFERENCES Aichhorn, A. Wayward Youth. New York: Viking, 1925. Anthony, E.J. Between yes and no: the potentially neutral area where the adolescent and his therapist can meet. Adolescent Psychiatry 4: 323–344, 1975. Blos, P. On Adolescence: A Psychoanalytic Interpretation. New York: Free Press, 1962. Chused, J.F. The transference neurosis in child analysis. Psychoanalytic Study of the Child 43: 51–81, 1988. Doctors, S. Notes on the contribution of the analyst’s self-awareness to optimal responsiveness. Progress in Self Psychology 12: 55–63, 1996. Dulit, E. In and out of treatment – an okay thing. Child Psychiatry Grand Rounds, Albert Einstein College of Medicine, Montefiore Hospital, Bronx, New York, Fall, 1982. Escalona, S. Some determinants of individual differences. Transactions of the New York Academy of Sciences 27: 802–816, 1965. Esman, A. A developmental approach to the psychotherapy of adolescents. Adolescent Psychiatry 12: 119–133, 1985. Esman, A. Adolescence and Culture. New York: Columbia University Press, 1990. Fonagy, P., Target, M. The efficacy of psychoanalysis for children with disruptive disorders. Journal of the American Academy of Child and Adolescent Psychiatry 33: 45–55, 1994. Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G., Target, M. Attachment, the reflective self and borderline states: the predictive specificity of the adult attachment interview and pathological emotional development. In Goldberg, S., Muir, R., Kerr, J. (eds), Attachment Theory: Social, Developmental and Clinical

Perspectives. Hillsdale, NJ: The Analytic Press, 1995, pp. 233–278. Freud, A. Adolescence. Psychoanalytic Study of the Child 13: 255–278, 1958. Freud, A. Indications and contraindications for child analysis. Psychoanalytic Study of the Child 23: 37–46, 1968. Freud, S. Fragment of analysis of a case of hysteria. The Standard Edition, Volume 7. London: The Hogarth Press, 1905, pp. 3–122. Galatzer-Levy, R. The analysis of an adolescent boy. Adolescent Psychiatry 12: 336–360, 1985. Godenne, G. Forming a therapeutic alliance with teenagers. Adolescent Psychiatry 20: 289–298, 1995. Goldberg, A. A shift of emphasis: adolescent psychotherapy and the psychology of the self. Journal of Youth and Adolescence 7: 119–132, 1978. Golombek, H., Korenblum, M. Brief psychotherapy with adolescents. Adolescent Psychiatry 20: 307–324, 1995. Kalogerakis, M. Adolescent analyzability reconsidered. Adolescent Psychiatry 21: 271–288, 1997. Lachmann, F., Beebe, B. The contribution of self- and mutual regulation to therapeutic action: a case illustration. Progress in Self Psychology 12: 123–140, 1996. Lament, C. Technical issues in adolescent analysis: a Jamesian view. Psychoanalytic Study of the Child 52: 190–213, 1997. Levy-Warren, M. The Adolescent Journey. Northvale, New Jersey: Jason Aranson, 1996. Marohn, R. Management of the assaultive adolescent. Hospital and Community Psychiatry 43: 622–624, 1992a. Marohn, R. On becoming an adolescent psychotherapist: how am I going to work with these kids? Adolescent Psychiatry 8: 369–380, 1992b. Marohn, R. Failures in everyday psychotherapy. Adolescent Psychiatry 21: 289–303, 1997. Meeks, J. The Fragile Alliance. Baltimore: Williams & Wilkins, 1971. Mitchell, S. Relational Concepts in Psychoanalysis. Cambridge, Massachusetts: Harvard University Press, 1988. Novick, J. Termination of treatment in adolescence. Psychoanalytic Study of the Child 31: 389–414, 1976. Rosenbaum, A. The assessment of parental functioning: a critical process in the evaluation of children for psychoanalysis. Psychoanalytic Quarterly 43: 466–490, 1994. Schimel, J. The role of humor as an integrating factor in adolescent development. Adolescent Psychiatry 18: 118–126, 1992. Slaff, B. Thoughts on short-term and single-session therapy. Adolescent Psychiatry 20: 299–306, 1995. Stolorow, R., Atwood, G. Three realms of the unconscious. In Contexts of Being. Hillsdale, NJ: The Analytic Press, 1992, pp. 29–40.

372 Psychiatric treatment Stolorow, R., Lachmann, F. Transference: the organization of experience. The Annual of Psychoanalysis 12/13: 19–37, 1984/85. Target, M., Fonagy, P. The efficacy of psychoanalysis for children: prediction of outcome in a developmental context. Journal of the American Academy of Child and Adolescent Psychiatry 33: 1134–1144, 1994. Tyson, P. Developmental roots of adolescent disturbance. Adolescent Psychiatry 23: 21–39, 1998.

Wallerstein, R. Forty-Two Lives in Treatment. New York: Guilford Press, 1986. Zeanah, C., Anders, T.F., Seifer, R., Stern, D. Implications of research on infant development for psychodynamic theory and practice. Journal of the American Academy of Child and Adolescent Psychiatry 28: 657–668, 1989.

6.4 Adolescent psychopharmacology GLEN R. ELLIOTT

INTRODUCTION Since the late 1970s, several forces have encouraged the increased use of medications to treat mental disorders in children and adolescents. Largely, such use occurred in the absence of data on safety or efficacy, with practitioners relying mainly on extrapolations from research carried out done in adults, as well as on clinical lore and personal experience. Although both the amount and the quality of psychopharmacology research on children and adolescents has expanded notably since the early 1990s, clinicians still often must decide about medication treatments with a dearth of information, especially for the newest drugs. This chapter briefly surveys some of the unique issues entailed in prescribing psychoactive medications for adolescents and reviews available information about their use both in terms of common diagnoses and in terms of potential uses for specific problematic behaviors.

and Shader 1998), and blood serum protein binding increases. All of these can affect a patient’s optimal drug dose and alter the metabolic pattern in ways that may affect efficacy and safety; even more importantly, interactions among such variables are complex, hard to predict, and variable over time. Researchers are starting to delineate the exquisitely delicate sequence of normal brain development and to identify some of the underlying processes that regulate it (Harris 1995). As yet, distressingly little is known about the subtle – and perhaps not so subtle – changes in brain structure and chemistry that occur during adolescence; nonetheless, there is certainly reason to speculate that the appearance of major hormones such as estrogen and testosterone (among others) produces a variety of changes that well may alter mechanisms that mediate the effects of psychoactive drugs. Taken together, the changes in the brain and body that occur during adolescence can be bafflingly complex; clinicians must be prepared to adjust medications as the child traverses this tumultuous period of life.

THE DEVELOPMENTAL PERSPECTIVE Change is an obvious, enduring aspect of childhood, including at least the early part of adolescence, when transformations occur not only in the body’s physiology but also in the nervous system that controls it (Harris 1995). The exact nature of such changes and their significance in the use of psychoactive medications only recently have become an area of substantive research, and much remains to be learned (Carrey and Kutcher 1998; Tosyali and Greenhill 1998). Several examples can serve to illustrate the potential importance of such inquiries. Puberty produces pronounced alterations in a variety of physiological variables of clear relevance to how the body handles drugs: body mass increases, fat/muscle ratios change, liver metabolism decreases (Oesterheld

PRAGMATIC ASPECTS OF PRESCRIBING FOR ADOLESCENTS In many respects, the environment in which adolescents exist may be as intricate and as difficult to characterize as is their internal physiology. Adolescents seldom initiate treatment and often arrive under some level of duress. Young adolescents still are apt to have at least one caregiver who ultimately will help decide whether they receive the medicine as prescribed and for how long, older adolescents becoming increasingly pivotal in determining if they will take a medication, and how reliably. As adolescent psychiatrists soon learn all too well, such decisions usually are the result of an elaborate interplay between two or more parents and stepparents, grandparents,

374 Psychiatric treatment

siblings, teachers, peers, and others. Clinicians should try to identify the key figures for each adolescent and ensure that, to the extent possible, everyone is aware of the treatment plan and is willing to abide by it, at least in principle. Attention to the basic mechanics of ensuring that the patient gets a medication at the prescribed dose, reliably, regularly, and safely may well be the most important task during the early phase of a successful intervention (Sprenger and Josephson 1998). A crucial dictum sometimes worth sharing with adolescents and families alike is that even the best and safest drug is useless unless it gets into the body. Pills are a powerful intervention in and of themselves, regardless of the patient’s age; clinicians should explore the meaning of taking the pill both to the adolescent and to relevant adults (Bastiaens and Bastiaens 1993). Most states in the United States require that, by the age of fourteen years, adolescents actively consent to taking medication, making exploration of these issues especially cogent. With the emphasis many schools have on antidrug campaigns, adolescents may fear that their parents are trying to poison them or get them ‘hooked.’ Also, they often resent such concrete evidence that they have a ‘problem,’ and may resist treatment until that issue is addressed. If a medication must be taken during school, peer influences and decreased adult supervision may be further promote problems with adherence.

Medications often used with adolescents The major classes of psychoactive agent commonly used to treat adolescents with severe mental disorders and behavioral disturbances are summarized in Table 6.4-1. Dramatic changes occurred during the early 1990s with the introduction of a new generation of antidepressants that appear to be much safer than and at least equally effective as those previously available. Then, in the latter part of the 1990s, clinicians gained access to new-generation antipsychotics and anticonvulsants. Although such innovations hold great promise, they produce a dilemma for clinicians and patients alike: should one use a new drug that seems safer but may have as-yet-unsuspected side effects or an older drug that has more severe known risks but about which much more is known?

PSYCHOPHARMACOLOGY OF COMMON ADOLESCENT MENTAL DISORDERS Broadly, psychoactive medications are used with adolescents either for:

• •

disorders that typically arise in childhood or adolescence; or disorders that occur during adolescence but are common also in adults.

The former will receive more focus here, because clinicians are apt to be less familiar with the appropriate use of medications to treat these disorders.

Disorders that typically arise in childhood or adolescence ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD) ADHD and its earlier diagnostic congeners such as Hyperactivity and Minimal Brain Dysfunction (MBD) hold a key position in psychopharmacology, being among first mental disorders of childhood for which medications were deemed to be both appropriate and beneficial. The long-held belief that ADHD was strictly a prepubertal disorder was challenged only in the late 1980s, when longitudinal studies showed that a large proportion of children with well-diagnosed ADHD continue to have notable symptoms through adolescence and into adulthood. Current estimates suggest that as many as one-third of such individuals continue to have severe symptoms, while another third have less severe but marked problems (Mannuzza et al. 1993). In prepubertal children, medications play a prominent and persistent role in the treatment of many patients with ADHD (MTA Cooperative Group 1999a,b; Spencer et al. 1996; Stubbe 2000). Stimulants remain the drug class of first choice: about 60 per cent of patients respond well to the first stimulant tried, and an additional 15–20 per cent of those who fail to respond to one will do well with a second stimulant. A typical treatment plan is:

• • • • • •

Stimulant, e.g., methylphenidate Stimulant, e.g., d-amphetamine Bupropion New-generation mixed-receptor antagonists, e.g., venlafaxine or mirtazapine Tricyclic antidepressant, e.g., imipramine or nortriptyline ␣-Adrenergic agonist, e.g., clonidine or guanfacine.

Such drug protocols are well defined for preadolescents, but much less is known about the optimal medication strategies after puberty. Adolescents may be less motorically driven, or at least are better able to keep their motor activity within socially acceptable bounds, so that impulsivity, inattention, and distractibility are more likely to be the focus of concern. On the other hand, the need for prolonged benefits to accommodate the typical demands an adolescent faces for good functioning at school raises questions about the utility of short-acting interventions such as immediate-release methylphenidate. In addition, the need to take stimulants several times during the day raises concerns both about patient adherence to dosage and possible diversion in abuse. For these and similar reasons, clinicians have been somewhat more prone to

Adolescent psychopharmacology 375 Table 6.4-1 Psychoactive medications commonly used to treat adolescent mental disorders and severe behavioral disturbances Drug class/drug

Daily dose (mg or [mg/kg])

Doses (per day)

Main indications

Common or major side effects

5–30

1–3

ADHD

Insomnia; loss of appetite and weight; exacerbation of tics

Stimulants Amphetamine immediate and SR (Dexedrine, Adderall) Methamphetamine SR (Desoxyn) Methylphenidate immediate and SR (Ritalin, Concerta, Methylin) Pemoline (Cylert)*

5–30 10–60

1 1–3

17.75–112.5

1–2

Antidepressants Selective serotonin reuptake inhibitors (SSRIs) Citalopram (Celexa) Fluoxetine (Prozac) Fluvoxamine (Luvox) Nefazodone (Serzone) Paroxetine (Paxil) Sertraline (Zoloft)

10–20 5–100 25–300 200–600 10–20 25–200

1 1 1 2 1 1

Depression OCD Bulimia Anxiety(?)

Insomnia, restlessness irritability, GI distress anorgasmia

Tricyclics (TCAs) Desipramine (Norpramin) Imipramine (Tofranil) Nortriptyline (Pamolar)

[2–5] [2–5] [1–3]

1–2 1–2 1–2

Depression ADHD Anxiety Enuresis Bulimia

Anticholinergic; weight gain or loss; cardiovascular, heart and blood pressure; lowers seizure threshold

[1–3]

1–2

Above ⫹ OCD

150–450

2–3

15– 45 50–600 37.5–200

1 1–2 1–2

Depression ADHD Depression Depression Depression ADHD

0.25– 8 2.5–20 1–24 0.25–8 25–100 0.25– 6 25–100

1–4 1–4 1–4 1–4 1–4 1–4 1–4

Psychosis, mania Anticholinergic, weight Tourette’s disorder gain, extrapyramidal Aggression, reactions, tardive Severe anxiety, dyskinesia (may be less Perseverative with those that have *) behaviors

[10–20]

1–3

Bipolar disorder

[10–30]

1–3

Bipolar disorder

[15–60]

1–3

Bipolar disorder

300–1800

1–3

Bipolar disorder

Clomipramine Other novel antidepressants Bupropion, immediate and SR (Wellbutrin) Mirtazapine (Remeron) Trazodone (Deseryl) Venlafaxine, immediate and SR (Effexor) Antipsychotics Haloperidol (Haldol) Olanzapine (Zyprexa)* Perphenazine (Trilafon) Pimozide (Orap) Quetiapine (Seroquel)* Risperidone* Thioridazine Mood stabilizers Carbamazepine immediate and SR (Tegretol, Carbatrol) Lithium immediate and SR (Eskalith, Lithobid) Valproic acid SR (Depakote) Gabapentin (Neurontin)

*Liver toxicity!

Insomnia, GI upset, lowers seizure threshold Sedation Sedation, priapism As for SSRIs, plus dizziness, nausea

Bone marrow suppression, nausea, dizziness, rashes Polyuria, tremor, nausea thyroid and renal dysfunction Sedation, nausea, liver toxicity Sedation, nausea, fatigue, dizziness, ataxia Continued

376 Psychiatric treatment Table 6.4-1 Continued Drug class/drug

Daily dose (mg or [mg/kg])

Doses (per day)

Main indications

Other agents Buspirone (BuSpar) Clonidine (Catapres)

10–60 0.1–0.8

2–3 2–4

Guanfacine (Tenex)

0.5–4

2–3

Propranolol (Inderal)

[2–12]

1–4

Anxiety Minimal ADHD Marked sedation, Tourette’s disorder rebound hypertension on withdrawal ADHD Similar to clonidine Tourette’s disorder Aggression Bradycardia and hypotension

consider longer-acting drugs such as one of the antidepressants. Anecdotal evidence and small-sample trials suggest that tricyclic antidepressants, bupropion, and venlafaxine all may be of use. More controversial is the usefulness of selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, or paroxetine. Pemoline use, never all that common, has fallen markedly with the report of rare but potentially fatal liver failure. As with younger patients, adolescents with ADHD have high rates of comorbidity, including communication disorders, learning disabilities, oppositional-defiant disorder and conduct disorder, depression, and anxiety disorder. Such additional problems well may affect medication response, but little systematic research exists to guide clinicians in using this information in drug selection. Broadly, especially when stimulants are ineffective or infeasible for other reasons, it is helpful to try to choose a drug that may treat both ADHD and one or more other disorders; thus the presence of depression or anxiety might suggest the use of antidepressants.

OPPOSITIONAL AND CONDUCT DISORDERS With or without ADHD, defiant, negativistic, socially unacceptable behaviors that lead to diagnoses of oppositional-defiant disorder (ODD) and conduct disorder (CD) are among the most common causes of psychopharmacology consults (Greenhill 1994). ODD is typically diagnosed before puberty but can persist into adolescence; CD is more usually a diagnosis of adolescence. These diagnostic categories still are relatively new to the field, and their biological substrates, if any, are not well understood. Although medications are used as part of treatment in many clinical settings, their efficacy, even in the short term, remains to be established (Connor et al. 1998). Nonetheless, it is important to be aware that comorbid conditions such as ADHD, major depression, anxiety disorders, and post-traumatic stress disorder (PTSD) are common, and medication interventions for these conditions sometimes seems to ease the disruptive behaviors.

Common or major side effects

DEVELOPMENTAL DISORDERS Mental retardation and pervasive developmental disorders such as autism are among the most serious derailments of cognitive development. To date, no available medications appear to alter the course of these disorders, per se; in fact, most children with these diagnoses neither need nor benefit from medication use. Still, the psychopharmacologist not infrequently is asked to consult on such patients, especially during adolescence, if behavioral disturbances become dangerous (Bregman 1995). Approaches to the treatment of such disruptive behaviors are described in the next section of this chapter. In addition, individuals with mental retardation, autistic disorder, or both, are heir to all the major mental disorders, including depression, anxiety, obsessions, problems with attention and impulsivity, and psychosis (Fuller and Sabatino 1998). Diagnosis often is difficult because of the patient’s poor communication skills and confounding environmental influences. Even so, such patients merit and can benefit from a careful diagnostic evaluation and, when appropriate, selected medication treatment. Like geriatric patients, adolescents with severe developmental delays may have a heightened sensitivity to medications, especially side effects. For instance, as many as one-third of adolescents with autistic disorder may experience seizures if exposed to medications that lower seizure threshold. In general, clinicians are well advised to start out with relatively low doses and to increase the dose slowly to minimize complications.

TOURETTE’S DISORDER AND OTHER TIC DISORDERS Tourette’s Disorder typically appears during childhood, usually between ages seven and nine years, but may not come to clinical attention until early adolescence (Cohen et al. 1988; Saunders-Pullman and Braun 1999). It has a waxing–waning course over years, with exacerbations being characterized by multiple, often-shifting motor and phonic tics. Children with Tourette’s Disorder often

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have a prodromal clinical picture consistent with ADHD, and many adolescents display both tics and ADHD symptoms. The need to treat both ADHD and Tourette’s Disorder creates problems for the clinician, because stimulants typically exacerbate tics, yet drugs that are most effective for treating tics often do little to help with attention and distractibility. Tourette’s Disorder and other tic disorders are quite responsive to high-potency antipsychotics such as haloperidol and pimozide; the newer antipsychotic risperidone also is quite efficacious. However, as noted, they do relatively little to treat such comorbid problems such as ADHD or Obsessive–Compulsive Disorder (OCD). The ␣-adrenergic agonists clonidine and guanfacine have been helpful in reducing tics and also may help with ADHD symptoms. Despite clear evidence that medications can greatly reduce tics, studies suggest that most patients do not continue treatment even for as long as a year. Commonly, side effects such as lethargy, tiredness, restlessness, and sedation prove too burdensome, even with good symptom relief. Given the variable course of this disorder and the high prevalence of adverse effects of the medications used, it is especially important for the clinicians to develop an alliance with both the patient and the patient’s family to ensure sensitive, helpful responses to changing needs.

Major mental disorders common to adolescents and adults AFFECTIVE DISORDERS The prevalence of major depression and other affective disorders increases rapidly to adult levels during adolescence. Interestingly, early adolescence results in a notable shift in the male-to-female ratio from about equal to the 1:2 ratio typical of adult populations; change occurs about the time of puberty, but both psychosocial and biological explanations are possible, and no physiological basis has been shown, as yet (Cantwell 1992). The course of depression appears to be somewhat more chronic in adolescents than in adults, with a mixture of major depression and dysthymia being common. Early optimism about the efficacy of antidepressants to treat childhood depression gave way to concern it might be peculiarly resistant to treatment, particularly in adolescents (Lee et al. 1997). It is remarkable that no wellcontrolled study of antidepressant use for depression with clear evidence of efficacy was published until the late 1990s (Emslie et al. 1997, 1999). Explanations for earlier failures to show such benefit ranged from possible physical phenomena mentioned earlier to biases introduced in the recruitment of young patients for research studies. Even the absence of research support, most clinicians are steadfast in their belief that depressed adolescents can benefit markedly from medications. SSRIs have

become the first-line agents because of their high degree of safety and relatively better side-effect profile. Bipolar Disorder is largely a mental illness that first manifests as a clear clinical entity in adults; still, first episodes can occur in mid- or even early adolescence (Cantwell 1992). Adolescents seem especially prone to presenting with mixed states, having prominent depressive and manic symptoms simultaneously, with marked irritability; these symptoms well may be difficult to differentiate from other more common adolescent disorders such as ADHD, conduct disorder, or drug abuse. Further, the risk of inducing mania with antidepressants is increasingly of concern as antidepressants become ubiquitous in treating many of those alternative diagnoses. Once the diagnosis of Bipolar Disorder is made, treatment is not markedly different from that in adults (Ryan et al. 1999; Shelton et al. 1998).

ANXIETY DISORDERS Anxiety disorders are common in children and adolescents, as they are in adults (Leonard 1993). Most are transient and probably do not require specific intervention, and certainly not drug treatment. Those that are more severe – for example, school phobia, panic disorder, or PTSD – need careful assessment and a full treatment plan, including consideration of individual cognitive, behavioral, or insight-oriented therapy and family work. Experience suggests that medications alone are almost never sufficient but may be useful adjuncts to other modalities. Few studies have examined the usefulness of drugs for anxiety disorders in adolescents (Labellarte et al. 1999). Most clinicians assume that adolescents, like adults, can benefit from antidepressants such as tricyclic antidepressants, and this class of drugs remains the treatment of choice. Even less is known about whether SSRIs, especially in low doses, have comparable effects, with fewer side effects. Considerable work is needed in this arena.

OBSESSIVE–COMPULSIVE DISORDER Adolescents can develop OCD, but fortunately this disorder appears to be responsive to the SSRIs, as is true for adults (Leonard et al. 1993). Unfortunately, like adults, adolescents have high relapse rates when these medications are discontinued. Combining medication with targeted behavior therapy may help to reduce subsequent relapse, especially after the drug is discontinued (King and Scahill 1999).

PSYCHOSES Adolescents of all ages can experience psychotic episodes. For many, such episodes are easily diagnosed; however, some have no clear evidence of either delusions or hallucinations yet exhibit poor reality testing that clinicians

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may characterize as ‘pre-psychotic’ or ‘psychotic-like.’ Because psychosis is such a uniquely internal experience, it can be especially difficult to establish, particularly with adolescents who have poor communication skills for other reasons (Caplan 1994). Antipsychotics are widely used in adolescents, both to treat psychosis and for many other indications (Lohr and Birmaher 1995). With respect to psychosis, clinical experience suggests that adolescents may be relatively less responsive than adults. Still, some do quite well, with a marked improvement in functioning. Perhaps more than any other drug class, antipsychotics require care when used in young patients: start low, build slow. At least until the mid-1990s, thioridazine and haloperidol were by far the best-studied and most widely used antipsychotics in children. New-generation antipsychotics such as risperidone and olanzapine combine dopamine receptor blockade with serotonin receptor blockade (Toren et al. 1998). These drugs have fewer antiparkinsonian side effects and potentially lower rates of tardive dyskinesia. Their availability has renewed interest in this class of drugs, but clinicians are finding (as always) that new drugs can have new types of side effects, for example major increases in appetite with marked and rapid weight gain.

PSYCHOPHARMACOLOGY OF KEY BEHAVIORS IN ADOLESCENTS Ideally, medications are used only for specific, identifiable disorders: for example, antidepressants for depression, and antipsychotics for psychosis. Pragmatically, situations often arise in which an adolescent has dangerous behaviors or intolerable symptoms that demand intervention even in the absence of a clear target disorder. In such circumstances, wise use of medications may be a valuable component of an overall treatment plan. Although many pressures urge the psychopharmacologist simply to try a drug that may helpful, nowhere is the need greater for the clinician to keep the total picture clearly in focus. Such nondrug interventions as changing placement, using behavioral programs, or educating parents or other caregivers often are essential. In fact, at times, the most valuable – and difficult – prescription that a psychopharmacologist can make is the reasoned judgment that no drug will be helpful in alleviating a particular behavior or ongoing situation.

General strategies Some common problems that bring adolescents to the attention of a clinician are listed in Table 6.4-2. These behaviors may emerge in a wide range of contexts, so the first task for the clinician must be to define as precisely as possible when problems occur, under what conditions,

Table 6.4-2 Common behavioral disturbances in adolescence for which medications may be used • • • • • •

Aggression against people or property Motoric hyperactivity Obsessional rigidity Oppositionality Psychotic-like thinking Severe or sustained anxiety

and with what effect. Gathering such information often helps to suggest how useful medications are apt to be and what type of intervention is needed:

•

•

•

•

Is there a treatable disorder? Careful assessment may reveal a previously unsuspected disorder. Adolescents with one major mental disorder often are at increased risk for others. For instance, the impulsivity associated with ADHD increases the likelihood that vulnerable individuals may experience life stressors that lead to depression, anxiety, or even PTSD. Or a child with autism also may have Tourette’s Disorder. The identification of a treatable condition can help the patient and family reframe what is happening and suggest a medication or other treatment course. Are there stressors that may respond to medication? Many adolescents with major mental disorders are under such high levels of stress that seemingly minor additional burdens may be intolerable. For example, disrupted sleep may create a chaotic household and dysfunctional parents, or a pattern of rigid obsessionality may limit program options for a child with mental retardation or autism. Offering relief from such stressors can be a great help, even if the underlying disorder is unchanged. Is the problem predictable? In using medications to treat behaviors, clinicians often need to assess several variables. A key issue is the pattern of a behavior over time. A problem may highly predictable, for example a girl who has aggressive outbursts only during the week before her period, or a boy with autism who has overwhelming anxiety only when undergoing dental work or some other intrusive medical procedure. In such cases, intermittent drug use may work well. Episodic medication use is much less likely to work if the problem behaviors occur often and unpredictably, the patient is too agitated to take medicine when the problem arises, the onset of medication action is too slow, or drug action is known to be slow and cumulative. Is it best to avert the problem or suppress the behavior? Some behaviors such as rages, aggression, or incapacitating anxiety may have an identifiable underlying or precipitating cause. Broadly, effective intervention strategies must either decrease the likelihood of the behavior occurring or suppress its intensity and duration once it begins. Thus, for patients with panic

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attacks, the goal may be either to abort attacks as quickly as possible, for example by having a benzodiazepine on hand, or to prevent future attacks with an ongoing course of an antidepressant. When possible, preventing the recurrence of problem behaviors often is preferable, even if it requires ongoing medication use, because it is more reliable, minimizes disruptions, and may produce fewer adverse side effects.

Specific target behaviors or symptoms AGGRESSION Aggression may be the most frightening behavior in which mentally ill patients engage. As adolescents grow larger and heavier, the impact of such behaviors becomes increasingly problematic. Since aggression is far from a unitary concept, it is perhaps not surprising that drug approaches to treating it also are diverse (Stoewe et al. 1995). As is often true when multiple treatments exist for a problem, no one intervention is clearly superior, yet each can be of value at least in some cases. When aggression arises from a definable disorder or other cause, drug interventions should be directed toward easing that problem. Thus, children with ADHD who are prone to impulsive aggressions may do well with stimulants. Similarly, anxiety or obsessionality may enhance aggression in patients with mental retardation; reduction of such precipitating factors can reduce the likelihood of aggressive episodes. Drugs that reportedly suppress aggression run the pharmacological gamut (Connor 1993; Cueva et al. 1994; Stoewe et al. 1995). Traditional first drugs of choice are antipsychotics such as haloperidol or thioridazine. Although widely used, the anti-aggressive properties of these drugs in adolescents with various diagnoses have not been well studied, and concerns about short- and long-term side effects have curtailed their use as alternatives become available. Still, the introduction of newer antipsychotics such as risperidone and olanzapine may require a reconsideration of the role of this class of drugs. So-called mood stabilizers, including lithium, carbamazepine, and valproic acid, sometimes can be helpful (Ryan et al. 1999). However, the administration of all these drugs requires to be monitored, and the feasibility of obtaining blood samples from labile, potentially dangerous patients must be assessed; furthermore, the therapeutic window is relatively narrow, and potential toxicity is high. Gabapentin would appear to be easier to use, though its efficacy is uncertain. Small studies in children and adolescents with a primary diagnosis of ADHD or of autistic disorder, hyperactivity, and impulsivity suggest that clonidine may reduce oppositional behavior and decrease the likelihood of aggressive outbursts in selected cases (Stoewe et al. 1995).

A few case reports suggest that buspirone may reduce aggression, but it also has been reported to aggravate aggressive behaviors (Stoewe et al. 1995). The benzodiazepine anti-anxiety agents typically are not used to treat aggression in young patients, both because of concerns about possible disinhibition and because of possible dependence and abuse or diversion, especially among aggressive adolescents with Conduct Disorder. Antidepressants are seldom drugs of choice for aggression, unless depression is an underlying etiology. However, limited open trials of trazodone suggest that it can reduce aggression in children with diagnoses ranging from developmental delay to psychoses to mood and anxiety disorders. Moreover, the SSRIs (notably fluoxetine) do not appear to be helpful and may even worsen aggressive behaviors (Stoewe et al. 1995). Persistent (albeit sporadic) reports made since the late 1970s have described the efficacy of ␤-blockers such as propranolol for aggression, although no well-controlled studies exist to support this suggestion (Connor 1993). Available evidence suggests that any of the ␤-blockers may be effective, whether or not they cross the blood–brain barrier, adding to the uncertainty about the mechanism of action. Patients must be free of heart problems, asthma, hyperthyroidism, insulin-dependent diabetes, or severe renal disease. The reported effective dose range is large, from 10 to 300 mg per day. In addition, the response often is quite slow, necessitating trials of three months or longer. Most published trials of propranolol were carried out in open-label fashion, with patients who were also taking a wide range of other drugs; even so, it is important to recall that propranolol can dramatically alter the metabolic patterns – and therefore also blood concentrations – of some anticonvulsants, antipsychotics, and antidepressants.

MOTORIC HYPERACTIVITY Especially with patients who have severe cognitive delays that markedly impair judgment, motoric hyperactivity may be a major presenting complaint even in the absence of clear evidence of ADHD. A small subset of these individuals respond well to stimulants; the rest probably do best with low doses of high-potency antipsychotics such as haloperidol, risperidone, or olanzapine (Fuller and Sabatino 1998).

OBSESSIONS AND COMPULSIONS Even in the absence of diagnosable OCD, persistent obsessive and compulsive behavior may be responsive to the same kind of medication approaches described earlier for OCD. Such problems are especially common in individuals with autism or other forms of pervasive developmental disorders. They may not qualify formally for a diagnosis of OCD because they do not regard their behaviors as undesirable. Even so, SSRIs have proved to be highly efficacious and can provide great relief for patient and caregivers alike.

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OPPOSITIONALITY Although oppositionality is less immediately threatening than aggression, few settings in which adolescents find themselves tolerate on-going oppositional behavior. This behavior seems especially responsive to consistent, welldesigned behavioral interventions (Greenhill 1994). Even so, it may arise from disorders such as ADHD or depression that are responsive to medications. Once again, a careful evaluation is an essential first step in treatment. A few open trials of clonidine suggest that it may reduce oppositional behaviors in adolescents with either ADHD or autistic disorder. However, at least in the latter group, tolerance may develop after a few months. Antipsychotics and mood stabilizers are used commonly to reduce oppositional behaviors, partly because such behaviors not infrequently co-occur with aggression. There are no controlled studies of the specific benefits of these latter drugs for oppositionality; it seems likely that the major effect is a general decrease in overall activity level and initiative.

PSYCHOTIC-LIKE THINKING AND SEVERE, UNREMITTING ANXIETY One of the more controversial areas for which no resolution is in sight is the appropriateness of using medications to treat disordered thinking that does not rise to the level of clear psychosis and yet produces significant difficulties for the patient. Formal psychological testing may be interpreted either as psychosis or as severe anxiety. Not infrequently, the patient is in severe distress, as are caregivers. Many clinicians believe that, in the absence of clear research, low doses of an antipsychotic can ‘glue’ such an adolescent together with little or no risk of side effects. Since antipsychotics also are potent antianxiety agents, even clear improvement begs the question of what the medication is treating, yet a patient who responds well to such treatment is at great risk of being labeled ‘psychotic.’ Furthermore, and especially if improvement is partial or equivocal, long-term treatment is often the rule, with no clear guidelines to tell the clinician when to stop using the medicine. Once again, this is an area in which ongoing assessment and a willingness to insist on trials off the medication at appropriate intervals are essential.

PSYCHOTHERAPY AND PSYCHOPHARMACOLOGY An extensive discussion of potential positive and negative interactions between psychotherapy and psychopharmacology in adolescents is beyond the scope of this chapter, but a few general observations are pertinent.

As noted earlier, both the cognitive changes that occur in adolescence and the changing legal status of the adolescent make it imperative for adolescent patients to become aware of the nature of their disorder and, to the extent possible, to accept responsibility for it. At a minimum, physicians who work with mentally ill adolescents need to help their patients understand why they are taking medications and what good and bad effects those medications are apt to produce. Just as not every adolescent should be taking a psychoactive medication, not every adolescent who is taking such a medication needs psychotherapy. However, many may benefit from training that helps them become more active in their own care by monitoring symptoms and drug side effects, reducing precipitating stressors, and keeping track of changes in their internal states. As noted for the treatment of OCD, some studies suggest that effective psychological interventions may change the course of the disease. In addition, adolescents may have strong feelings about the impact of their mental illness on who they are and how they are perceived. Such concerns may offer an unequalled opportunity for the adolescent to engage in therapy, and failure to help the patient to address such concerns may inhibit effective medication treatment. A prime example of potential problems relates to the wide use of SSRIs, which have a high incidence of sexual dysfunction. If older adolescents do not have someone with whom they feel able to discuss such matters, treatment compliance is apt to suffer. The order in which psychotherapy and medication therapy are introduced usually must be tailored to the specific situation. Some adolescents will insist on receiving a pill to ‘fix it’ and will not be open to working with a talk therapist until they have tried the medication route. Others may be so disturbed by the idea of being ‘drugged’ that use of a medication is not feasible until they have had a chance to explore the issues. Optimal care requires flexibility, familiarity with the advantages and limitations of both medications and psychotherapy, and interactive style with patients that enable the physician to elicit and respond to the needs of the patient and his or her family.

CONCLUSION Currently, adolescent psychopharmacology is at an interesting point in its history. At least in the United States, both the general public and large sections of the medical profession have, for now, abandoned what was undoubtedly an overly pessimistic and possibly an excessively cautious attitude about using medications to treat severe mental disorders in adolescents. In its place is what sometimes seems to be a distressingly optimistic belief that the right medication can alleviate almost any ill, even when that ill is only poorly understood.

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To the extent that therapeutic activism leads to a more concerted effort to find ways of helping severely ill youth, this shift if attitude may be a boon. As suggested in this chapter, many exciting leads to more effective treatment have emerged during the past few decades. Working with adolescent patients and their families, psychopharmacologists now sometimes can offer prompt, sustained relief to previously debilitating problems. Still, this is one circumstance for which the all-too-common call for further research seems amply justified. The huge areas of uncertainty about such key issues as brain development, shortversus long-term outcomes, possible subtle, possible rare or delayed-onset side effects, and the interface of drug therapy with other types of interventions all merit serious study. In the meantime, clinicians must make every effort not only to do good, but also to do no harm.

REFERENCES Bastieans, D., Bastiaens, D.K. A manual of psychiatric medications for teenagers. Journal of Child and Adolescent Psychopharmacology 3: M1–M55, 1993. Bregman, J.D. Psychopharmacologic treatment of neuropsychiatric conditions in mental retardation. Psychiatric Clinics of North America 4: 401–433, 1995. Cantwell, D.P. (guest ed.) Mood disorders. Child and Adolescent Psychiatric Clinics of North America 1: 1–296, 1992. Caplan, R. Thought disorder in childhood. Journal of the American Academy of Child and Adolescent Psychiatry 33: 605–615, 1994. Carrey, N., Kutcher, S. Developmental pharmacodynamics: implications for child and adolescent psychopharmacology. Journal of Psychiatry and Neuroscience 23: 274–276, 1998. Cohen, D.J., Bruun, R.D., Leckman, J.F. (eds) Tourette’s Syndrome and Tic Disorders: Clinical Understanding and Treatment. New York: John Wiley & Sons, 1988. Connor, D. Beta-blockers for aggression: a review of the pediatric experience. Journal of Child and Adolescent Psychopharmacology 3: 99–114, 1993. Connor, D.F., Ozbayrak, K.R., Harrison, R.J., et al. Prevalence and patterns of psychotropic and anticonvulsant medication use in children and adolescents referred to residential treatment. Journal of Child and Adolescent Psychopharmacology 8: 27–38, 1998. Cueva, J.E., Overall, J.E., Small, A.M., et al. Carbamazepine in aggressive children with conduct disorder: a double-blind and placebo-controlled study. Journal of the American Academy of Child and Adolescent Psychiatry 35: 480–490, 1994. Emslie, G.J., Rush, A.J., Weinberg, W.A., et al. A double-blind, randomized placebo-controlled trial of fluoxetine in

depressed children and adolescents. Archives of General Psychiatry 54: 1031–1037, 1997. Emslie, G.J., Walkup, J.T., Pliszka, S.R., Ernst, M. Nontricyclic antidepressants: current trends in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 517–528, 1999. Fuller, C.G., Sabatino, D.A. Diagnosis and treatment considerations with comorbid developmentally disabled populations. Journal of Clinical Psychology 54: 1–10, 1998. Greenhill, L.L. (guest ed.) Disruptive disorders. Child and Adolescent Psychiatric Clinics of North America 3: 177–425, 1994. Harris, J.C. Developmental Neuropsychiatry. Volumes I and II. New York: Oxford University Press, 1995. King, R.A., Scahill, L. The assessment and coordination of treatment of children and adolescents with OCD. Child and Adolescent Psychiatric Clinics of North America 8: 577–597, 1999. Labellarte, M.J., Ginsburg, G.S., Walkup, J.T., Riddle, M.A. The treatment of anxiety disorders in children and adolescents. Biological Psychiatry 46: 1567–1578, 1999. Lee, D.O., Spratt, E.G., Jenson, J.J., et al. Pharmacotherapy of depression in children. Essential Psychopharmacology 1: 409–434, 1997. Leonard, H.L. (guest ed.) Anxiety disorders. Child and Adolescent Psychiatric Clinics of North America 2: 563–838, 1993. Leonard, H.L., Lenane, M.C., Swedo, S.E. Obsessive– compulsive disorder. Child and Adolescent Psychiatric Clinics of North America 2: 655–666, 1993. Lohr, D., Birmaher, B. Psychotic disorders. Psychiatric Clinics of North America 4: 237–254, 1995. Mannuzza, S., Klein, R., Bessler, A., et al. Adult outcome of hyperactive boys. Archives of General Psychiatry 50: 565–576, 1993. MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/ hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Archives of General Psychiatry 56: 1073–1086, 1999a. MTA Cooperative Group. Moderators and mediators of treatment response for children with Attention-Deficit/ Hyperactivity disorder: the Multimodal Treatment Study of children with Attention-Deficit/Hyperactivity Disorder. Archives of General Psychiatry 56: 1088–1096, 1999b. Oesterheld, J.R., Shader, R.I. Cytochromes: a primer for child and adolescent psychiatrist. Journal of the American Academy of Child and Adolescent Psychiatry 37: 447–450, 1998. Ryan, N.D., Bhatara, V.S., Perel, J.M. Mood stabilizers in children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 529–536, 1999.

382 Psychiatric treatment Saunders-Pullman, R., Braun, I., Bressman, S. Pediatric movement disorders. Child and Adolescent Psychiatric Clinics of North America 8: 747–746, 1999. Shelton, R.C., Thase, M.E., Kowatch, R., et al. Update on the management of bipolar illness. Journal of Clinical Psychiatry 59: 484–495, 1998. Spencer, T., Biederman, J., Wilens, T., et al. Pharmacotherapy of Attention-Deficit Hyperactivity Disorder across the life cycle. Journal of the American Academy of Child and Adolescent Psychiatry 35: 409–432, 1996. Sprenger, D.L., Josephson, A.M. Integration of pharmacotherapy and family therapy in the treatment of children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 37: 887–889, 1998.

Stoewe, J.K., Kruesi, M.J.P., Lelio, D.F. Psychopharmacology of aggressive states and features of conduct disorder. Child and Adolescent Psychiatric Clinics of North America 4: 359–379, 1995. Stubbe, D.E. (guest ed.) Attention-Deficit/Hyperactivity Disorder. Child and Adolescent Psychiatric Clinics of North America 9: 469–731, 2000. Toren, P., Laor, N., Weizman, A. Use of a typical neuroleptics in child and adolescent psychiatry. Journal of Clinical Psychiatry 59: 644–656, 1998. Tosyali, M.C., Greenhill, L.L. Child and adolescent psychopharmacology. Important developmental issues. Pediatric Clinics of North America 45: 1021–1035, 1998.

6.5 Family therapy RICHARD A. OBERFIELD

INTRODUCTION In recent years in psychiatry, the family has begun to emerge not only as the background for the evolution of psychological problems, but also as a potential treatment unit. Family therapy, in the past, had been viewed by some practitioners as being inappropriate for adolescents, however, owing to the developmental task of separation/individuation. The prevailing view, held most often by psychoanalytically oriented clinicians, was that to involve the adolescent in family treatment would be tantamount to reinvolving him/her in the family system from which distance is being attempted. More recently, most clinicians treating adolescent patients have accepted the principle of actively dealing with the family either within the context of the individual treatment or within a separate treatment context. Psychiatrists, when treating adolescents, have been integrating the family/systems component into the treatment of a wide range of clinical disorders, and training in family systems and therapy has become an established part of programs in child and adolescent psychiatry. Third-party payers also have the frequent expectation that the primary clinician working with the adolescent will intervene at the family/systems level as well if indicated. Various theoreticians have attempted to define family treatment since its clinical inception. Gurman and his colleagues have described this form of treatment as: “Family therapy is any psychotherapeutic endeavor that explicitly focuses on altering the interactions between or among family members and seeks to improve the functioning of the family as a unit, or its subsystems and/or the functioning of individual members of the family. This is the goal regardless of whether or not an individual is identified as ‘the patient’. Family therapy typically involves face to face work with more than one family member . . . although it may involve only a single member. . . .” (Gurman et al. 1986).

Family therapy with adolescents usually involves various family members participating simultaneously; however, there may be times in the course of systems work when the therapist decides to meet individually with the youngster to pursue separate issues in the context of the ongoing family work.

HISTORY OF FAMILY THERAPY The roots of family therapy go back to the Child Guidance Movement of the early 1900s. At this time, the child was viewed as a separate entity from the parents, and they (usually the mother) were interviewed and treated separately. Freud, in his revolutionary work on psychoanalysis, pointed to the significance of pathological interpersonal relationships within the family which predisposed some individuals to psychological symptoms. The Freudian model, however, has not been consistent with engagement of the entire family in the treatment. With the emergence of the ego psychology branch of psychoanalysis during the post-war period, it became apparent to some clinicians that the interpersonal realm was critical in assessment and treatment. An important American theorist, Harry Stack Sullivan, had been psychoanalytically trained, but stressed the role of interpersonal relationships in personality and symptom development. Sullivan argued that in order to understand how people function, it is necessary to study their ‘relatively enduring patterns of recurrent interpersonal situations.’ Sullivan was one of the first psychiatric theoreticians to write about the repetitive patterns of family interaction. (Sullivan 1953). Nathan Ackerman, a child psychiatrist and trained psychoanalyst, has been credited with adapting psychoanalytic formulations to the study of the family from a family systems’ perspective. Ackerman, from his early papers during the late 1930s to his late writings in the

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1970s, emphasized the role of the family as a dynamic psychosocial unit unto itself. He was the first clinician who attempted to integrate the constant interaction between the biologically driven person (according to psychoanalysis) and the social environment (Ackerman 1958). During the 1950s, the team of Bateson, Jackson and Haley elaborated the concept that certain family dynamics lead to severe psychopathology such as schizophrenia (Bateson et al. 1956). These authors described ‘double bind’ communication which, at the time, was believed to play a role in the genesis of a severe psychiatric disorder. Other researchers during the 1950s and 1960s were investigating the issue of communication deviance in families with schizophrenic offspring. Lyman Wynne, with his collaborator Margaret Singer at the NIMH, studied such families and developed the term ‘pseudomutuality’ to describe their interaction (Wynne and Singer 1963). Murray Bowen, a key figure in the development of family therapy, elaborated an ‘extended family systems’ theory which focused on the generational context of emerging individual symptoms. While working at the NIMH in the 1950s, he described the impact of symbiotic relationships in families, and elaborated his ideas regarding differentiation of self, ‘triangulation,’ and the multigenerational transmission process which would eventually yield deviant offspring (Bowen 1966). The structural branch of the family therapy field was elaborated and originally described by Salvador Minuchin and his colleagues at the Philadelphia Child Guidance Clinic in the 1960s (Minuchin 1974). Rather than examining and working with psychodynamic communication in the family, Minuchin described that family interaction is best understood in terms of the overall structure, and the therapist serves a vital role in the transition toward forming a new and more adaptive structure. Minuchin’s group often focused on adolescent members of the family, in particular those suffering from anorexia nervosa (Minuchin and Fishman 1979). The strategic family therapy field, led by major figures such as Jay Haley and Cloe Madanes, became prominent during the 1980s. Haley had been interested in the issues of power and control in the family, and presented a novel type of therapy which utilized these issues within a theory which focused on ‘circular’ as opposed to ‘linear’ interactions. Haley and his colleagues often utilized a paradoxical approach when treating especially resistant families (Haley 1984).

organism to correct deviations and maintain ‘homeostasis’ or steady state. Physical systems may be closed but the family system is an open system with a boundary to the outside environment which is semipermeable (to information, ideas, customs, individuals, etc.). The degree to which family homeostasis is maintained depends on the permeability of the boundary to the environment, the amount of deviation permitted from the ‘rules’ of the family, and the tightness of communication linkages between family members. In a psychodynamic framework, a symptom is viewed as a product of a sequence involving an unconscious wish leading to anxiety, followed by a defensive structure which binds the anxiety. From a systems perspective, a symptom is generated by stress within a system which moves the entire group from homeostasis and inhibits the re-establishment of balance. A symptom develops in the context of the entire group attempting to re-establish equilibrium. As in individual psychotherapy, a symptom may be viewed as ‘ego-dystonic’ or ‘ego-syntonic’ for the family. For example, in a family where the father has a substance abuse problem, it may be ‘syntonic’ for the entire family group to protect and shield him from the outside world during a crisis, and for the adolescent to present with a psychological symptom which distracts from the other interpersonal dynamics about the substance problem.

INDICATIONS AND CONTRAINDICATIONS Indications for family therapy vary widely among different clinicians. The indication may pertain to diagnosis (e.g., adjustment disorders involving the family), family structure (e.g., symbiotic enmeshment), developmental issues (e.g., separation/individuation issues), or family communication patterns. Another common indication occurs when the family is threatening to discontinue the treatment of an adolescent, or when the family needs to be involved in order to keep the adolescent in psychotherapy. Generally speaking, contraindications for family therapy include severe depression, acute psychosis, severe psychopathology or paranoia in a family member, or insufficient structure within a family to maintain regular meetings (Oberfield 1981).

ROLE OF THE FAMILY EVALUATION KEY CONCEPTS IN SYSTEMS THEORY A system is defined as a structure composed of a set of elements and a set of rules which specify the relationship among the elements. Systems maintain their integrity through the use of ‘feedback loops’ which permit the

It is vital for the clinician to conduct a wide-ranging and comprehensive evaluation of the family of the adolescent as well as an evaluation of the individual patient. A detailed assessment of the family structure, including the specific areas of cohesion and adaptability, is crucial (see Chapter 4.2). The issue of who becomes the treating

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clinician after assessment of the adolescent and the family is often complex, and may relate to the specific details of patient flow in a particular mental health setting.

ORIENTATIONS AND SELECTED SCHOOLS OF FAMILY THERAPY The theoreticians and practitioners of family therapy today may be divided into four broad groups:

• • • •

insight-oriented; structural; strategic; and behavioral–social–psychoeducational.

A brief review of the four major groups outlined will be presented, followed by a discussion of how each theory relates to clinical issues involving adolescents. Therapeutic techniques associated with each category will be reviewed, including clinical vignettes illustrating these techniques.

Insight-oriented family therapy The insight-oriented group of family therapists uses terminology and has interests associated with the psychoanalytic tradition. The individual is seen as carrying with him/her a nonrational and unconscious truth that when encountered meaningfully in the therapy will help to liberate him/her psychologically. The goal is to uncover internal part-objects of family members, especially the internalizations and projections of the parents, which are analyzed by looking at the distorted involvements among family members and their transference onto the therapist or therapists (co-therapy is occasionally utilized in this type of treatment). Analytic theorists consider family therapy useful in the assessment of family dynamics in vivo, overcoming resistances that arise in individual therapy, sustaining the family through a crisis, and helping the family with symbiotic features to deal with the impending independence of members. Others have written about the need to analyze projective identification, wherein an individual projects onto another family member conflictual aspects of him/herself and then identifies with the other person as a means of maintaining control. A prominent therapeutic technique utilized by family therapists in the insight group is clarification of communication (verbal and nonverbal) between family members. Positive as well as negative feelings are elicited to aid in achieving mutual reconciliation. Confusing or ‘double bind’ communications are explored and their roots discussed in terms of individual motivation. Transference manifestations among members (including the therapist) are analyzed, although many practitioners prefer to deal only with negative transference which is impeding

the treatment. ‘Ghosts’ of figures such as departed grandparents which enter the individual and/or interpersonal psychologies of family members are often discussed. According to Bowen – the most prominent insightoriented family theoretician – there are two opposing forces present in family relationships: those which bind individuals together (fusion); and those which lead to separation of members (differentiation) (Bowen 1978). Before individuals can effectively separate, unresolved emotional attachments to one’s own nuclear family must be resolved. In Bowen’s theory, which has in recent years been termed ‘extended family systems therapy,’ triangular relationships are considered to be the building blocks and foundation of interpersonal systems. Since two-person (dyadic) relationships are inherently unstable, according to Bowen, individuals may form ‘dysfunctional triangles’ which can lead to a lack of differentiation and symptom formation for one or more members. The classical triangular configuration involves two parents and a symptomatic child or adolescent. Bowen suggested that if such triangulation and fusion continues over multiple generations in a family, the result may be exacerbation of individual symptomatology in successive generations. Carl Whitaker (Whitaker 1967) was the leading practitioner of ‘experiential’ family therapy, which may be viewed as closely related to other insight-oriented approaches, but with greater focus on expression of feelings in the ‘here and now’ experience. Within the experiential model, because of the greater emphasis on nonrational forces of treatment, openness and spontaneity are called for on the part of the therapist in sharing the family’s stresses and problems. Experiential family therapists maintain that an elaborate theoretical framework often seems to detach the therapist from the family. They suggest that a co-therapy arrangement is preferable, if possible, in order to allow each therapist to alternately lose oneself to the family dynamics and, in turn, remain emotionally distant as an impartial objective observer. The co-therapy arrangement also aids countertransference difficulties.

CASE STUDY The following is an example of an ‘insight’ family case. Mary B., a fifteen-year-old adolescent who has functioned fairly well until recently, began to be disruptive at home and somewhat so at school. Mrs. B., aged thirtyeight years and formerly a secretary, lost her father at an early age and had a conflictual and guilt-ridden relationship with her mother. Mr. B., aged forty-four years, was a businessman and felt that his wife was too hard on Mary but assumed the role of disciplinarian despite his long work hours. There were no other children because Mrs. B. was unable to conceive again. The couple considered their marriage to be satisfactory in most respects and

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they were proud of the fact that they rarely argued, except about Mary. In the family sessions that followed a series of individual sessions with Mary, it was discovered that Mrs. B. provoked her daughter to misbehave and her husband to punish the girl. The mother both identified with the punished daughter and attacked her husband for his strictness. The therapist helped her to see the connection between her husband and her own punitive father whom she had never successfully mourned. Eventually, areas of dispute between husband and wife emerged having little to do with Mary, such as sexual matters and Mr. B.’s previously hidden resentment of his wife for not producing a son. The couple was then referred for marital treatment and Mary’s individual treatment ended after several months, during which she discusses her substantial apprehension about eventually leaving home and her parents.

Structural family therapy Structural family therapy, as described by its major theoretician Salvador Minuchin (Minuchin 1974) is “… a body of theory and techniques that approaches the individual in his social context. Therapy based on this framework is directed toward changing the organization of the family. When the structure of the family group is transformed, the relative positions of members in that group are altered accordingly. As a result, each individual’s experiences change.” Minuchin speaks of three axioms surrounding structural family treatment: 1 An individual’s psychic life is not an entirely internal process. He/she influences and is influenced by the environment in constantly recurring sequences of interaction. 2 Changes in a family’s structure contribute to changes in the behavior and the inner psychic processes of members of that family. 3 When a therapist works with a family, their behavior becomes part of the context. Minuchin, a trained psychoanalyst, does not ignore individual dynamics in his theory. He believes that the individual’s present is comprised of his/her past in addition to current circumstances. Part of the past will always survive, modified by current interactions. He maintains, however, that the most effective target of intervention is the social system as opposed to the self system. According to the structuralists, dysfunctional transactional patterns are a product of developmental changes and stresses. These stresses may come from outside the family (e.g., financial, career, school) or from within it. New subsystems arise as a result of developmental changes within a family; for example, the sibling subsystem is

added to the spouse subsystem after children arrive. As new subsystems appear, new lines of differentiation must be drawn. Minuchin postulates a continuum of family functioning or style, with ‘enmeshment’ as one polarity and ‘disengagement’ as the other (Minuchin et al. 1978). The enmeshed family is characterized by little tolerance for individual variation or deviance, tight communication linkages, high frequency of interaction, relatively closed boundaries, and much centralized communication. The disengaged family is characterized by much tolerance for deviance, loose communication linkages, low frequency of interaction, relatively open boundaries and little centralized communication. Severely enmeshed family style, from a structural point of view, is associated with psychosomatic symptoms, overanxious features, mutual clinging and overdependency, and exacerbation of psychotic illness (e.g., schizophrenia). Disengaged family style is associated with conduct disorder, antisocial behavior, and delinquency in offspring. The techniques of the structuralist clinician are designed to fit the theoretical model. The ‘therapeutic alliance’ is here made with the family, via such processes as ‘joining’ and ‘accommodation.’ Joining refers to the process of the therapist reaching out and empathizing with each individual member. It often requires significant interpersonal skill as well as awareness of one’s own feelings toward particular individuals and is analogous to countertransference in individual treatment. Accommodation refers to the therapist’s psychological adjustments of him/herself in order to achieve joining. The use of both techniques must precede the restructuring of the family. Minuchin refers to the importance of accommodating to each person’s interactional style, affect, and language. The cognitive stage of all members, including that of young children and adolescents, must always be taken into account by the therapist. Individual sessions with the adolescent are integrated into the treatment and usually have a specific rationale, such as accentuating the autonomy of a young adult member of the family. Techniques utilized by structural family therapists usually involve much activity. Seats are often rearranged during the sessions in order to alter spatially the family structure. For example, if a husband and wife are arguing, the adolescent may be moved from between them to demonstrate the ‘go-between’ function she/he has served. Interruptions are blocked in order to prohibit others from detouring a conflict pertaining to a pair or dyad. A family member may be taken behind a one-way mirror or screen for the same purpose. Family tasks or ‘homework’ may be assigned to test the flexibility of the system. For instance, a teenage son with academic problems may be instructed to review his assignments with a passive, detached father while the mother socializes with friends. This technique may be helpful if the evaluation of the

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family has demonstrated an overly close bond between mother and son. Eventually, the parents may be instructed to go out together more often without the boy. For anorexia patients Minuchin and colleagues instituted the ‘family lunch,’ during which evaluation and therapy begin in a natural arena for discussion of the symptom, over food.

Strategic family therapy The strategic group of family therapists is heterogeneous to a certain extent. It includes such theoreticians as Haley (1976), Watzlawick (Watzlawick et al. 1974)‚ Madanes (1991), and Selvini-Palozzoli (Selvini-Palozzoli et al. 1980). The common thread underlying their respective positions is that they do not believe that the ‘truth’ of the unconscious will render the family free of its problems. The curative agent, they believe, is not insight or catharsis of affect but the rearrangement of behavioral sequences and shift of power and hierarchy. Strategic writers, like the structuralists, have abandoned a ‘linear’ interpretation of psychopathology; that is, that a specific behavior is caused by either unconscious or conscious intrapsychic conflict or by the behavior of another individual. Instead, a systemic or ‘circular’ etiology is sought and each member of the system is viewed as an active participant, despite the fact that one person may appear to be a ‘victim’ of another. The strategic therapist seeks to uncover the underlying ‘family game’ and its rules and attempt to modify the maladaptive cycle. The strategic therapists and the structuralists agree that action is more important than insight in order to forge change. However, the strategic therapists have developed specific techniques, at times indirect, for countering resistance to therapeutic interventions. The structuralist clinician perseveres against the resistance using straightforward directives, designed to alter the pathological structure of the family group; the strategic therapist may circumvent the resistance via seemingly illogical or paradoxical maneuvers. Directives, or task assignments to be performed as ‘homework’ outside of the therapy session, have a central role in strategic family therapy. The rationale for giving the task assignments includes the following: encouraging people to behave differently so that their subjective interpersonal experience is altered; obtaining information and feedback as to how the respective family members will respond to the suggested tasks and about the varying degree of resistance among the members; and intensifying the therapeutic relationship by having the family think about the therapist and the therapy between sessions. Cloe Madanes (1991), a major figure in the strategic family therapy field, has stated: ‘The directive is to strategic therapy what the interpretation is to psychoanalysis. It is

the basic tool of the approach.’ In most cases, the strategic therapist suggests the directive and expects that the family members will comply and therefore alter their behavior toward one another. For example, a singleparent mother having difficulty managing her teenage son may be asked to set up a system of consequences for misbehavior and to conscientiously and consistently follow through on enforcing the consequences. This might be offered following the revelation that the mother puts out ineffectual threats for misbehavior with rare and erratic follow-through. A further elaboration might involve having the son ‘grade’ his mother on her weekly performance as an authority figure. If there is questionable motivation on the part of the family members to actually change, the therapist will at times experience a failure of the task or directive. For example, the single-parent mother may return and sheepishly report that she forgot to set up the system of consequences or was too tired or overwhelmed and let the boy manipulate her into giving rewards despite his continuing misbehavior. After repeated failures of this type, many strategic therapists will adopt a different type of approach referred to as ‘paradoxical’ or ‘symptom prescription.’ The effectiveness of a specific paradoxical intervention during the treatment is usually related to its ability to confuse the family, which may lead to constructive change. An excerpt from Jay Haley (1963), a major strategic theoretician, about dyadic therapy illustrates this point: ‘As an example of a typical problem, a couple can be continually fighting, and if the therapist directs them to go home and keep the peace, this will doubtfully happen. However, if he directs the couple to go home and have a fight, the fight will be a different kind when it happens. This difference may reside only in the fact that they are now fighting at the direction of someone else. or the therapist may have relabeled their fighting in such a way that it is of a different kind.’ With adolescents in family treatment, a typical paradoxical directive would involve all family members in a ‘counterintuitive’ approach. For example, in the example of the single-parent family given previously, the teenager might be directed to continue his misbehavior with inconsistent consequences, as this keeps his mother from being depressed and distracted about her own life such as problems with work, extended family and socializing. This type of approach is often referred to as a ‘positive connotation’ technique, whereby the therapist gives approval to all observed behavior of the patient and the family, particularly those behaviors which have traditionally been considered pathological. For instance, an intrusive parent may be called extremely caring and interested, or an underachieving adolescent who does not prepare for tests may be told that he is showing the rest of a ‘high-strung’ achievement-oriented family how to be spontaneous (at some cost to himself).

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Developmentally, the adolescent is often rebellious and negativistic and often rebels naturally against a positive interpretation of behavior in the direction of more adaptive behavior. Strategic family therapists often work in teams with the use of live supervision and a one-way mirror. This model capitalizes on the placebo effect of the unseen ‘panel of experts,’ which enhances the power of the interventions. In addition, the expert team may ‘split vote’ which externalizes the conflicts within the adolescent or the family. For example, one observer may predict that the adolescent will continue his/her symptomatic behavior (which may have been relabeled as altruistic), whereas another may predict that he/she will not because of the refusal to sacrifice oneself and the desire to pursue more personally fulfilling endeavors.

Behavioral–social–psychoeducational family therapy The behavioral–social–psychoeducational group of family therapists includes behavioral practitioners who utilize learning theory techniques in the systems context, as well as practitioners of the ‘psychoeducational’ model, who help families to deal with severe chronic psychiatric illness such as schizophrenia. Stuart (1980) was one of the early behavioral clinicians to transfer operant principles to dysfunctional families. A mutual reinforcement paradigm is utilized, wherein family members learn to list behaviors desired from each other and monitor mutual exchange of these behaviors. This type of operant conditioning/systems model relies little on developmental history, unconscious motivation, or extremely complex familial interaction. Overcoming resistance is not a strong focus of this model, in marked contrast to the other models. A strong positive alliance with the therapist is sought; one criticism of this form of treatment is that it fosters exaggerated dependency on the therapist to ‘problem solve’ for the family. Dattilio (1998) has recently described the utilization of a cognitive-behavioral family therapy model in treating families including symptomatic adolescents. This model integrates features of cognitive and behavioral therapy within a family/systems framework. The psychoeducational model, as described by, amongst others, Leff and Vaughn (1985) is based on the premise that if the emotional climate within the family is changed, the course of serious psychopathology such as schizophrenia can be positively altered. This modification of the family emotional climate is associated with detailed education of the family about psychobiology, phenomenology, and treatment of the particular illness. According to the psychoeducational treatment model, a family environment which is intense, with members

overinvolved and critical of the psychotic patient and his/her behavior, increases the likelihood of psychotic relapse. The concept of ‘expressed emotion’ (EE), as described by Anderson et al. (1986) and others, is applied to measure the degree and quality of interpersonal intensity within the family. The psychoeducational treatment approach is designed to decrease the intensity of the family environment through a program which provides families with information, support, structure, and specific coping strategies in dealing with a family member with a psychotic diagnosis. The program usually involves several steps. First, the therapist forms a strong alliance with both the patient and the family, usually during the inpatient component of treatment. Next, the family attends a practical workshop which utilizes a multiple-family group format. The workshop deals with education about the illness, its course, and suggested management by family members. Subsequently, the focus is on discharge to home and consolidation of workshop themes, followed by continued treatment tailored to the clinical situation.

SELECTION OF APPROACH Generally speaking, it is most useful for beginning therapists to work from one particular model with a family in treatment. The choice of model depends on several different factors, including the clinician’s familiarity with the various ‘schools’ of family therapy, the clinical setting and the predominant theoretical orientation of colleagues and supervisors. In addition, the therapist may be more comfortable with a particular approach than others. The type of intervention chosen should also be related to the family’s own view of how best to approach their difficulties. The clinician needs to assess the ‘goodness of fit’ between a particular family and a distinct intervention style. While a dynamic, uncovering approach might be useful for a family accustomed to dealing with abstractions and exploration of affect, a more action-oriented family would most likely profit from a directive structural or strategic/behavioral approach. As one becomes more experienced in family therapy, various forms of family treatment may be effectively integrated into the process. Many clinicians begin with the most direct and straightforward types of intervention, such as behavioral and strategic (nonparadoxical type). The addition of a structural component renders the process somewhat more complex, as there is an additional focus on helping the family to achieve a new interpersonal formation which is more adaptive. Most experienced clinicians believe that the structural and strategic types of intervention are highly compatible, and that it is possible to easily move from one model to another, sequentially, during the treatment (Stanton

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1981). A more psychodynamic approach, utilizing interpretations and analysis of communication patterns, is favored for certain families presenting for treatment. Individuals who have previously been exposed to analytically based individual psychotherapy are often better equipped to deal with the role of unconscious motivation and the less active nature of this approach. Experienced family therapists often consider their theoretical position in relation to the work to be ‘eclectic,’ by which they usually mean that the various therapeutic strategies are utilized as they appear to be necessary and effective at a particular juncture. However, even a highly experienced therapist may be challenged by the transitions between theoretical models during the course of treatment. Generally, it is advisable to change course from the less complex type of treatment (behavioral and strategic) to the more complex structural and psychodynamic models. At a higher level of complexity, the hypothesizing of the paradoxical–strategic therapist is analogous to the offering of dynamic interpretations by the psychodynamic therapist. Regarding the question of combining individual and family systems approaches, most family therapists working with adolescent patients agree that because of the unique aspects of their developmental stage, it is usually critical to have separate individual visits with the young person. Some clinicians will refer the adolescent patient to a different individual therapist to enhance the emerging separation/individuation, as well as to reassure the patient about lines of confidentiality.

REFERENCES Ackerman, N.W. The Psychodynamics of Family Life. New York: Basic Books, 1958. Anderson, C.M., Reiss, D., Hogarty, B. Schizophrenia and the family. New York: Guilford Press, 1986. Bateson, G., Jackson, D.D., Haley, J., et al. Toward a theory of schizophrenia. Behavorial Science 1: 251–264, 1956. Bowen, M. The use of family theory in clinical practice. Comprehensive Psychiatry 7: 345–374, 1966. Bowen, M. Family therapy in clinical practice. New York: Aronson, 1978. Dattilio, F. Cognitive-Behavioral Family Therapy. In Dattilio, F., et al. (eds), Case studies in couple and family therapy: Systemic and cognitive perspectives. The Guilford family therapy series. New York: Guilford Press, 1998, pp. 62–84. Gurman, A.S., Kniskern, D.P., Pinsof, W.M. Research on the process and outcome of marital and family therapy. In Garfield, S.I., Bergin, A.E. (eds), Handbook of Psychotherapy and Behaviour Change: An Empirical Analysis, 3rd edition. New York: John Wiley, 1986, pp. 565–566.

Haley, J. Strategies of psychotherapy. New York: Grune and Stratton, 1963. Haley, J. Problem-solving therapy. San Francisco: Jossey-Bass, 1976. Haley, J. Ordeal Therapy: Unusual ways to change behavior. San Francisco: Jossey-Bass, 1984. Leff, J., Vaughn, C. Expressed emotion in families. New York: Guilford Press, 1985. Madanes, C. Strategic family therapy. In Gurman, A.S., Kniskern, D.P. (eds), Handbook of Family Therapy, Volume 2. New York: Brunner/Mazel, 1991, p. 402. Minuchin, S. Families and family therapy. Cambridge MA: Harvard University Press, 1974. Minuchin, S., Fishman, H.C. The psychosomatic family in child psychiatry. Journal of the American Academy of Child Psychiatry 18: 67–75, 1979. Minuchin, S., Rosman, B.L., Baker, L. Psychosomatic families. Cambridge, MA: Harvard University Press, 1978. Oberfield, R. Family therapy with adolescents: treatment of a teenage girl with globus hystericus and weight loss. Journal of the American Academy of Child Psychiatry 20: 822–833, 1981. Selvini-Palazzoli, M., Boscolo, L., Cecchin, G.F., et al. Hypothesizing-circularity-neutrality: three guidelines for the conductor of the session. Family Process 19: 3–12, 1980. Stanton, M.D. An integrated structural/strategic approach to family therapy. Journal of Marital and Family Therapy 7: 427–439, 1981. Stuart, R.B. Helping couples change: a social learning approach to marital therapy. Champaign, IL: Research Press, 1980. Sullivan, H.S. The interpersonal theory of personality. New York: W.W. Norton, 1953. Watzlawick, P., Weakland, J.H., Fisch, R. Change: Principles of Problem Formation and Problem Resolution. New York: W.W. Norton, 1974. Whitaker, C. The growing edge. In Haley, J., Hoffman, L. (eds), Techniques of Family Therapy. New York: Basic Books, 1967. Wynne, L.C., Singer, M.T. Thought disorder and family relations of schizophrenics, I and II. Archives of General Psychiatry 9: 191–206, 1963.

Suggested reading Geist, R., Heinman, M., Stephens, D., Davis, R., Katzman, D.K. Comparison of family therapy and family group psychoeducation in adolescents with anorexia nervosa. Canadian Journal of Psychiatry 45: 173–178, 2000. Kolko, D.J., Brent, D.A., Baugher, M., Bridge, J., Birmaher, B. Cognitive and family therapies for adolescent depression: treatment specificity, mediation, and moderation. Journal of Consulting and Clinical Psychology 68: 603–614, 2000.

6.6 Group psychotherapy with adolescents PAUL KYMISSIS

INTRODUCTION Within the field of adolescent psychiatry, group therapy is becoming an increasingly important modality of treatment, and recent developments in the healthcare system and current research data are the major driving forces behind this trend. Today, treatment is becoming shortterm, problem focused, and more cost effective, and new research data suggest that adolescent group treatments produce better results than do individual therapies (Tillitski 1990). In this new healthcare era, a major challenge for psychiatry is to learn how to do things less expensively yet more efficiently. For many medical procedures, this may seem a contradiction and an impossible task, but for adolescent group therapy it might be a realistic possibility as groups cost less to create and run, require fewer therapists, and can treat larger numbers of patients. Hence, the group could represent a powerful tool for both support and change.

HISTORICAL NOTES Pioneer workers in the field of adolescent group therapy (Rachman and Raubolt 1984) included:

• • • •

J. Moreno, who used psychodrama with adolescents early in the century; A. Adler, who used groups to prevent delinquency among disadvantaged youth, based on his theoretical framework of individual psychology. Adler’s group approach was called ‘collective therapy’; A. Aichorn, who organized groups in educational settings and schools; and S. Slavson, who was considered by many as the father of adolescent group therapy in the United States, and

who introduced activity therapy groups which were based on psychoanalytic theory. Here, the role of the therapist was to show unconditional acceptance for the adolescents. The period shortly after World War II was critical for group therapy, when the group system was first used to treat the large number of psychiatric casualties of the war. These groups proved to have both economic benefits and therapeutic advantages. Today, groups are being used routinely in larger numbers in various settings (hospitals, clinics, residential centers, schools, detention centers and private offices) to treat adolescents. Managed care companies have also shown special interest in groups as they are both clinically useful and cost effective.

THEORETICAL POINTS One of the important factors which enables the child to move from the stage of symbiosis with the mother towards separation–individuation is that of relationships with peers. This early struggle is reactivated and re-encountered with the onset of puberty, and is the reason why Blos (1962) called adolescence ‘a second chance for individuation.’ According to Erickson’s (1968) description of psychosocial development, the peer group plays a major role in the struggle of the adolescent to establish his/her identity. Although the process to establish and develop identity is a life-long task, it is especially during adolescence that it becomes a central theme. Animals go through a very short (if any) adolescence. Their offspring move almost instantly from dependency on the mother to self-sufficiency and independence. In humans, adolescence is a prolonged period which can extend from six to eight years. In today’s society, adolescence is even more prolonged since dependency on parents

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lasts longer. The struggle to establish identity includes the effort to develop a personal identity (a sense of self as a separate person with goals and purpose), a group identity (which refers to the individual’s sense of belonging to a group) and a philosophical identity (when the person discovers his/her orientation towards some ideological view.) Many of the developmental tasks of childhood and adolescence are directly related to a person’s ability to relate to others, and the peer group plays a major role and is a powerful force in the developmental process (Kymissis 1996). During adolescence, therefore, groups are an important and powerful tool in the hands of the clinician in the effort to enable the adolescent to move towards identity formation and autonomy. However, when groups are used solely for economical reasons, or when they become a classroom type of educational experience – when the group process is ignored – the therapeutic value is compromised and the healing forces of the group, which maximize the therapeutic effects, cannot be utilized. In Slavson and Schiffer’s (1975) activity therapy groups, which are based on ego psychology, drive theory and education principles, the therapist accepts certain behaviors which are within socially acceptable limits, the group becomes a safe environment in which corrective peer interaction is encouraged, and new adaptive models for identification are provided.

PRACTICAL ISSUES Since adolescent groups are unique in so many ways, the special developmental aspects of the members need to be considered when organizing this type of group. The principle of developmental specificity in adolescent groups, in addition to being critical in the selection process, should also apply to the development of goals for group treatment, in the utilization of particular techniques, and in organizing training programs and supervision for the therapists. A major dilemma for the adolescent group therapist is to organize the group in such a way so that there will be a balance between structure and freedom of expression. If the group is extremely structured, it will leave very little opportunity for members to express their thoughts, feelings and concerns. The group will be focused only on the original assumptions of the therapist and will not adequately represent the problems of individuals in the group. It will leave no room for testing out the original diagnostic hypothesis and the group may end up focusing on irrelevant issues. This may be the danger of relying only on manualized treatment procedures where everything is planned in advance, leaving little room for group interaction. The other extreme would be to allow members to express themselves freely without any restriction verbally

and behaviorally. This type of group runs the danger of becoming a chaotic, frightening, dangerous and nontherapeutic experience. In his book Wayward Youth, Aichorn (1935) described how adolescents, after such a group experience, broke windows and furniture causing the room to be filled with broken glass and debris. Adolescents in such groups not only fail to benefit but may also actually deteriorate. Many theoretical schools have vacillated between structure and freedom of expression. Behavioral and cognitive groups tend to use more structure, while the activity therapy, psychodynamic and analytic groups are less structured. The choice of a specific approach to the group may be related to the type of patients being treated, as well as to the personality, training, and experience of the therapist. An example of such an approach is the General Systems Theory (GST) (Bertalanffy 1968). In GST, the world from the atom to the galaxy is composed of systems which are in continuous communication, transaction, and interdependence. The human system and the group system are constantly participating in these reciprocal and continuous processes of transaction and interdependence. In addition, the human system – as a living system – is in a continuous process of opening and closing. During the time it is opening up, it is amenable to transformation and change. These are the transforming moments in a person’s life. The group provides a safe and secure system wherein the individual may be able to open up and accept the challenge to change. The group experience provides the adolescent with many such opportunities for transformation and change. The experience and flexibility of the therapist will provide the necessary structure that will turn the group into an organized system while still allowing freedom of expression. This will set the stage for the ‘transforming moments’ which can lead to change and growth. The role of the group leader, then, is to facilitate the maintenance of openness while keeping the group structure intact. Yalom (1985) stressed the interpersonal aspects of the group experience. He emphasized the importance of interpersonal learning, which was found to be one of the major curative factors in adolescent groups (Corder et al. 1981). Groups which are focused on the here-and-now and the interpersonal learning, enable the adolescent to review maladaptive interpersonal beliefs and behaviors, and to develop healthier adaptive skills first in the group and later on in the outside world. Bion (1959) proposed a group-centered model, where the therapist limits any intervention to the group as a whole. With adolescents, the therapist should be flexible and use the group-as-a-whole approach with alternate focus on the individuals as needed. Other approaches include the cognitive behavioral methods, short-term

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focused groups for special populations (e.g., eating disorders and substance abuse).

GOALS OF THERAPY The goals of group therapy are determined partly by the therapeutic potential inherent in group process, and partly by the needs of the patient. According to Sugar (1975), some of the goals for adolescent groups are to give ego support; provide a mixture of societal and life situations for learning and practicing; stimulate new ways for dealing with life and develop new interpersonal and social skills; review the original concept of self and develop a new one; reduce isolation; and maintain self examination and solve relationship problems. Many of these goals are less easily attained in individual therapy. Riester (1993) divided the goals of adolescent group therapy into three categories: 1 Goals related to peers: when the members interact with each other, accept input, form relationships and communicate their needs and feelings. 2 Goals related to the group: when the patient uses the group for problem solving, is able to control impulses within the group atmosphere, and asks the group for clarifications and uses the group to gain insight. 3 Goals related to adults: the adolescent learns to accept guidance and input from the adult, ask for help and communicate verbally needs and feelings. Some other goals for the group are to improve peer interaction, increase autonomy, and enhance academic performance. Both Levin (1982) and Zabusky and Kymissis (1983) wrote on the use of the group as a transitional object in order to assist the adolescent to achieve the goal of individuation and autonomy. Rachman (1996) described the use of the group to assist the adolescent to successfully resolve the conflict between role identity and identity confusion. Rachman (1996) also noted the contribution to adolescent treatment by S. Ferenczi, who some time earlier had written about the ‘confusion of tongues’ between adolescents and adults. According to Ferenczi (see Rachman 1997), this confusion is related to the trauma that the adolescent experiences when he/she is blamed for all the problems of the adolescent–adult relationship. Family groups offer an appropriate context in which this trauma may be further explored and healed. This is especially beneficial when the adult is willing and has the courage openly to share his/her own contribution to the problem. Such a disclosure will foster an authentic and honest relationship between the adolescent and adult. Other group goals could be related to the particular focus of the group, especially if it is a short-term focused group.

TECHNIQUES The techniques of group therapy should be adjusted in order to meet the developmental needs of the adolescent. Although nonverbal methods such as drawings, play, art and music can be used, the objective is to help the adolescent verbalize his/her thoughts and feelings. The more analytic approaches will allow the members to choose their themes and focus on issues of transference and resistance, with the therapist being more active than in adult analytic groups. Behavioral methods use manualized treatments where the sessions are structured and organized around specific goals, that is, depression or anger management. The focus is to recognize feelings, how they affect the body, and how they relate to cognitive structures. Special techniques for relaxation may also be incorporated in these sessions.

Specialty groups In these groups, the selection of the members is based on one particular medical, social or psychological problem. Many specialty clinics are organized on this principle. Groups could be organized for adolescents with eating disorders, anxiety disorders, Attention-Deficit Disorder, depressive disorders, bereavement groups, groups for suicidal adolescents, or for those who are learning disabled, diabetic, chronically physically ill, victims of trauma, sexual or physical abuse, drug abusing, dually diagnosed, or conduct disordered, etc. Pickar (1988) wrote on the benefits of groups for learning disabled adolescents wherein the members were able to experience positive changes in their ability to relate to others in a short period of time. Satin et al. (1989) studied the effect of group therapy with diabetic adolescents, and found that the patients improved in their diabetic condition and were also able to maintain the benefits for a period of at least six months. Mulcahey and Young (1995) studied a bereavement support group for children and their parents who had lost loved ones as a result of cancer, and found that the group reduced anxiety, improved the family’s communication, and helped the bereavement process. Kennedy (1989) worked with physically ill adolescents in groups, with some of the members having diabetes, asthma, heart disease, blindness, arthritis, and paralysis. He found that adolescents of the same sex quickly form cohesive groups which helped them deal with their physical problems in more effective ways. Kitchur and Bell (1989) reviewed the literature on group therapy with sexually abused adolescents, and found that many displayed fear, anger, hostility, guilt, and low self-esteem. These youngsters may also have sleeping and eating disorders, school problems, and may also act out sexually. The group could help them to build their

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self-esteem, heal the trauma, and begin to trust others. Litvak (1991) described the use of adolescent groups in schools where high-risk adolescents can be identified and early intervention initiated before their behavior and academic problems become worse. Besides the use of smaller groups of four to eight members, larger groups of up to fifteen to twenty adolescents have been used in community meetings in hospitals, treatment centers and drug rehabilitation programs. According to Carlin (1996), these groups can function better than smaller groups for managing day-to-day problems on a hospital unit, but they should be well structured with strict rule enforcement.

INDICATIONS Adolescents who could be referred to open-ended analytic groups would be those who present with maturational problems, difficulties in adjustment in the family and school, or those with the inability to relate to peers and have interpersonal difficulties. For specific specialty groups, the members could be selected on the basis of a particular problem, including anxiety disorder, depression, substance use, and eating disorder. For short-term focused groups, the criteria for selection are based on the goal of the group, usually anger management or stress management.

TRAINING/SUPERVISION OF GROUP LEADERS Training in adolescent group therapy is a component in many child and adolescent psychiatric training programs. In two surveys carried out a few years ago (Kymissis et al. 1991), it was found that although group therapy is widely used with adolescents, very few programs had wellorganized training components for adolescent group therapy. Training should include a didactic course outlining the history of adolescent group therapy, various schools of thought, group dynamics, adolescent development and groups, techniques, and research. Also, trainees should lead their own groups, under supervision, and participation in an experiential group would be helpful. Trainees with special interests could also organize or participate in research relating to group therapy. Adolescent group leaders should make a special effort to resolve their own adolescent issues which could otherwise interfere in a negative way in their work. Countertransference could be a very powerful force, and may be related to the therapist experiencing a sense of helplessness, anxiety, and anger. Supervision is an essential component of training in adolescent group therapy. It is also valuable during the

early phase of the practice of group psychotherapy. Alonso (1985) identified two purposes of supervision: one is to teach and provide information; and the second is to assist the trainee to grow and mature, like the parent helps a child from infancy toward adulthood. The trainee is helped to move from the status of being a student to that of a professional and colleague. Supervision can be done as a dyadic model of supervisor–supervisee, a co-therapist model where the supervisor is a co-therapist in a group with the supervisee, or as a group supervision model where the members play a dual role (supervisor and supervisee), at the same time. Soo (1966) suggested a supervisory format wherein individual and group supervision are provided, and is focused on patient selection, understanding of group formation, group resistances and countertransference reaction of the therapist. The supervisor needs to create a receptive atmosphere of trust that will allow the novice therapist to feel supported and secure.

RESEARCH Research into adolescent group therapy has evolved over the past twenty years as part of the progress in the research of child and adolescent psychotherapy. According to Kazdin (1993), new methods of assessing adolescents and their dysfunctions, and new methods for evaluating treatments have made this progress possible. Research is becoming a priority since patients, parents, government agencies and insurance companies all wish to see the results of different interventions. Many efforts have been made to bridge the gap between researchers and practitioners and to integrate the findings into clinical practice. Weisz et al. (1995) examined 150 outcome studies in child and adolescent psychotherapy in which most of the treatments that showed significant results were behavioral, and focused on a particular target. This does not necessarily mean that nonbehavioral treatments are not effective, but it does suggest that more rigorous studies are needed to assess the effectiveness of nonbehavioral approaches. A good study should include a careful description of the treatment process, and also a study of the patients before, during and after treatment using standardized tests as well as control or contrast groups. Blind raters should be used, and a follow-up included for results later on. In some cases, it has been noticed that the adolescent may not show considerable improvement immediately, but three to six months later could show significant changes (termed ‘sleeper’ or delayed effects). Tramonata (1980) identified six clinical and thirteen experimental studies of adolescent groups for the period of 1967 to 1970. Only five of these studies met acceptable research criteria and showed the efficacy of group treatment. In her most recent publication, Azima (1996)

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noticed that after 1980 there have been more studies of adolescent groups, and that the research methodology has improved. When taken together with the vast clinical experience and literature which has been collected over the past forty years, these new research data suggest that adolescent group treatments provide better results than individual therapies (Tillitski 1990). More recent studies have examined time-limited interventions with special populations, including patients with eating disorders, depression, HIV positivity, sexual abuse, substance abuse and residential treatment groups. Most studies have suggested that highly structured psychoeducational groups using manualized formats and dealing with the here-and-now are very effective. Sugar (1993) reviewed the research in child and adolescent group psychotherapy, and found that most of the studies suggested that adolescents in groups improve their socialization skills, are more accepted by their peers, and become less isolated. Groups are the most frequently used modality of treatment in institutional settings (i.e., hospital units, residential centers, clinics, youth correctional facilities). Adolescents who work on a specific problem in groups tend to show better results in outcome studies than those who do not have a clearly defined target from the beginning. It is interesting to note, that when adolescents are invited to participate in a research study they do so willingly. Gilbert et al. (1994) found that adolescents who dropped out from a group for depressed adolescents were, at a later date, less successful in school and used alcohol and drugs more frequently than those who stayed in the group. Corder et al. (1981) studied the curative factors of adolescent groups who were in group therapy for six months. These authors used self-reports, and found that the most helpful factors were catharsis, cohesion, universality, interpersonal learning and existential factors (‘I must take responsibility for myself.’). In the same paper, Corder et al. suggested that it would be helpful in future adolescent group therapy research to identify techniques that would allow free expression and at the same time maintain tension and anxiety within tolerable levels. Kymissis et al. (1996) suggested that the use of a structured dynamic approach could regulate the level of anxiety, within optimal therapeutic levels; make cohesion possible early in the life of the group; and, at the same time, provide the possibility of free expression. Lindon and Nourse (1994) treated sexually abused adolescent girls in group therapy. The members were assessed prior to treatment, six months later (after sixteen group sessions), and after a further six months. All members showed improvement in self-statements and behavioral measures, with the treatment approach including three components of skills training, group therapy, and education.

Lewinsohn et al. (1996) developed a course using cognitive behavioral methods to treat depressed adolescents in groups. These authors asked the adolescents to monitor their moods, and also taught them how to relax and how to reduce depressotypic cognitions. The preliminary data suggest that members improved. The study used the power of the group only minimally; indeed, this was mainly an education experience and addressed a nonclinical population (depressed adolescents in school). Albano and Barlow (1996) studied the effects of cognitive behavioral group treatment for socially anxious youth. The members were assessed prior to treatment, and six, twelve and twenty-four months thereafter, with the treatment being given in sixteen sessions. The protocol included education, skills building, modeling, role playing, cognitive restructuring and exposure to situations which may provoke anxiety. The findings were encouraging and highlighted the use of this approach in specialty programs, notably in anxiety disorder clinics.

SUMMARY Although adolescent group therapy has been used since the beginning of the twentieth century, it is only during the past twenty-five years that systematic efforts have been made to develop a theoretical framework and organize training and research programs in this area. As new information needs to be integrated into existing clinical experience, it is important that the experienced clinician and research investigator begin to communicate effectively in a constructive dialogue which would help to identify the important therapeutic elements that can be utilized with adolescent groups as well as the type of patient who might benefit from the particular method of treatment. Further clarification is also needed to determine the respective effects of short- and long-term group therapy on adolescents, and on what the basic requirements should be for training in this modality of treatment. In addition, such studies should help to define the future direction that the field should take, not only on the basis of economic realities but also according to the ultimate criterion – what is best for the patient.

REFERENCES Aichorn, A. Wayward Youth. New York: Viking, 1935. Albano, A., Barlow, D.H. Breaking the vicious cycle: cognitive-behavioral group treatment for socially anxious youth. In Hibbs, E., Jensen, P. (eds), Psychosocial Treatments for Child and Adolescent Disorders.

Group psychotherapy with adolescents 395 Washington, DC: American Psychological Association, 1996, pp. 43–62. Alonso, A. The Quiet Profession: Supervisors of Psychotherapy. New York: McMillan, 1985. Azima, F.J.C. Status of adolescent research. In Kymissis, P., Halperin, D. (eds), Group Therapy with Children and Adolescents. Washington, DC: American Psychiatric Press, 1996, pp. 369–386. Bertalanffy, L. General Systems Theory. New York: Braziller, 1968. Bion, W.R. Experiences in Groups. New York: Basic Books, 1959. Blos, P. On Adolescence: A Psychoanalytic Interpretation. New York: McMillan, 1962. Carlin, M. Large group treatment of severely disturbed, conduct-disordered adolescents. International Journal of Group Psychotherapy 46: 379–397, 1996. Corder, B.F., Whiteside, L., Haizlip, T.M. A study of curative factors in group psychotherapy with adolescents. International Journal of Group Psychotherapy 31: 345–354, 1981. Erickson, E.H. Identity: Youth and Crisis. New York: W.W. Norton, 1968. Gilbert, M., Fine, S., Haley, G. Factors associated with drop outs from group psychotherapy with depressed adolescents. Canadian Journal of Psychiatry 39: 358–359, 1994. Kazdin, A.E. Psychotherapy for children and adolescents: current progress and future research directions. American Psychologist 48: 664–657, 1993. Kennedy, J.F. The heterogeneous group for chronically physically ill and physically healthy but emotionally disturbed children and adolescents. International Journal of Group Psychotherapy 39: 105, 1989. Kitchur, M., Bell, R. Group psychotherapy with preadolescent sexual abuse victims: literature review and description of an inner city group. International Journal of Group Psychotherapy 39: 285, 1989. Kymissis, P. Developmental approach to socialization and group formation. In Kymissis, P., Halperin, D. (eds), Group Therapy with Children and Adolescents. Washington, DC: American Psychiatric Press, 1996, pp. 21–33. Kymissis, P., Licamele, W.L., Boots, S., Kessler, E. Training in child and adolescent group therapy: two surveys and a model. Group 15: 163–167, 1991. Kymissis, P., Christenson, E., Swanson, A., et al. Group treatment of adolescent inpatients: a pilot study using a structured therapy approach. Journal of Child and Adolescent Group Therapy 6: 45–52, 1996. Levin, S. The adolescent group as transitional object. International Journal of Group Psychotherapy 32: 217–232, 1982. Lewinsohn, P., Clarke, G., Rohde, D., Heds, H., Seely, J. A course in coping: a cognitive behavioral

approach to the treatment of adolescent depression. In Hibbs, E., Jensen, P. (eds), Psychosocial Treatments for Child and Adolescent Disorders. Washington, DC: American Psychological Association, 1996, pp. 109–135. Lindon, J., Nourse, C.A. A multi-dimensional model of group work for adolescent girls who have been sexually abused. Child Abuse and Neglect 18: 341–348, 1994. Litvak, J.J. School based group psychotherapy with adolescents: establishing an effective group program. Journal of Child and Adolescent Group Therapy 1: 167, 1991. Mulcahey, A.L., Young, M.A. A bereavement support group for children: fostering communication about grief and healing. Cancer Practice 3: 150–156, 1995. Pickar, D.B. Group psychotherapy and the learning disabled adolescent. Adolescence 23: 761, 1988. Rachman, A.W. Analyst self-disclosure in adolescent groups. In Kymissis, P., Halperin, D. (eds), Group Therapy with Children and Adolescents. Washington, DC: American Psychiatric Press, 1996, pp. 155–173. Rachman, A.W. Sandor Ferenczi: The Psychotherapist of Tenderness and Passion. Northvale, NJ: Jason Aronson, 1997. Rachman, A.W., Raubolt, R.R. The pioneers of adolescent group psychotherapy. International Journal of Group Psychotherapy 34: 387–413, 1984. Riester, A. Creating the adolescent group psychotherapy experience. In Alonso, A., Swiller, H. (eds), Group Therapy in Clinical Practice. Washington, DC: American Psychiatric Press, 1993, pp. 219–236. Satin, W., LaGreca, A.M., Zigo, M.A., et al. Diabetes in adolescence: effects of multi-family group intervention and parent simulation of diabetes. Journal of Pediatric Psychology 14: 259, 1989. Slavson, S.R., Schiffer, M. Group Psychotherapies for Children: A Textbook. New York: International Universities Press, 1975. Soo, E. Supervision. In Kymissis, P., Halperin, D. (eds), Group Therapy with Children and Adolescents. Washington, DC: American Psychiatric Press, 1996, pp. 111–132. Sugar, M. The Adolescent in Group and Family Therapy. New York: Brunner Mazel, 1975. Sugar, M. Research in adolescent group psychotherapy. Journal of Child and Adolescent Group Therapy 3: 207–226, 1993. Tillitski, C.J. A meta-analysis of estimated effect sizes for control treatment. International Journal of American Group Psychotherapy 40: 215, 1990. Tramonata, M.G. Critical review of research on psychotherapy outcome with adolescents 1967–1977. Psychological Bulletin pp. 429–450, 1980.

396 Psychiatric treatment Weisz, J.R., Denenberg, G.R., Han, S.S., et al. Child and adolescent psychotherapy outcomes in experiments versus clinics: why the disparity? Journal of Abnormal Child Psychology 23: 83, 1995. Yalom, I.D. The Theory and Practice of Group Psychotherapy. 3rd edition. New York: Basic Books, 1985.

Zabusky, G., Kymissis, P. Identity group therapy: A transitional group for hospitalized adolescents. International Journal of Group Psyochotherapy 33: 99–109, 1983.

6.7 Adolescent inpatient and other milieu treatments ALAN RAVITZ

INTRODUCTION Within the past twenty years, adolescent inpatient care has undergone a series of quite radical changes (Lewis 1991) which have been motivated, in large part, by economic forces. During the late 1970s and early 1980s, the number of inpatient beds in the United States grew exponentially due to the fact that there was increased insurance coverage for mental disorders in children and adolescents. As the number of beds increased, more and more adolescents were hospitalized (Thompson et al. 1986); in fact, between 1980 and 1984 adolescent admissions increased by more than 350 per cent (Gelman 1986), and lengths of stay were generally in the range of several months. Although most of these admissions were clinically appropriate, as competition between hospitals increased, treatment excesses did occasionally occur. During the early to mid-1980s, these ‘abuses of the system’ became the focus of a great deal of national media attention. Inappropriate admissions, excessive lengths of stay, and substandard and/or unethical treatment of hospitalized adolescents became a staple of newspaper and magazine articles as well as television and radio talkshows. At the same time, in response to the growing costs of all forms of medical care, third-party payers began to direct their efforts at reducing healthcare expenditures. Inpatient treatment for a variety of medical conditions became a major focus of these efforts, and adolescent psychiatric inpatient treatment, with its excess of beds, its fierce economic competition, its paucity of well-structured outcome studies, and its overwhelmingly negative public image, became an easy target of these efforts. As a result, within the past ten years, the inpatient treatment of adolescents has changed dramatically. Not only has length

of stay decreased from several months to several days, but reimbursement rates have also declined, and profit margins have diminished. This, not surprisingly, has led to a concomitant decrease in resources available for inpatient treatment in general. These changes have occurred with incredible rapidity (Pottick et al. 2000). Approximately 10 years ago, in the ‘Debate Forum’ of The Journal of the American Academy of Child and Adolescent Psychiatry (Sarles and Alessi 1993), the topic was ‘Resolved: Two-Week Psychiatric Hospitalizations of Children and Adolescents Are Useless.’ Richard Sarles, M.D., director of the Division of Child and Adolescent Psychiatry at the Sheppard and Enoch Pratt Hospital and Clinical Professor of Psychiatry and Pediatrics at the University of Maryland School of Medicine argued, ‘It is extremely hard for me to justify hospitalizations shorter than two weeks. … Almost all will require more than two weeks in the hospital.’ Norman Alessi, M.D., Associate Professor and Director, Child Psychiatric Inpatient Program at the University of Michigan took the opposite position. He stated, ‘We need to redefine and decentralize our conceptualization of patient care from a ‘hospital does it all’ perspective to a ‘defined role for the hospital’ within a continuity of care … . In all honesty, we do not have adequate data to substantiate any length of hospitalization as being categorically useful.’ That debate took place almost ten years ago, yet today a two-week length of stay is – in many, if not the majority, of facilities in the United States – a rare occurrence. Most managed care companies and HMOs want adolescents out of the hospital in three to five days, or at most, a week. As a result of the shortened length of stay (Masters 1997), the nature of inpatient treatment has had to change.

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Under the best circumstances, as Dr Alessi suggested, hospitalization is part of a continuum of care that offers a wide range of residential, intensive outpatient, and home-based services. Unfortunately, in the real world, most of these other types of services either do not exist or are not funded. (This is despite the fact that there is at least one study [Bickman et al. 1996] which indicates that the availability of intermediate levels of care decreases hospital use by severely disturbed adolescents.) Thus, psychiatrists practicing inpatient care in the United States today must make the best of a bad set of circumstances. Nevertheless, despite the economic motive to decrease utilization of this form of care, there is a great deal of agreement between child and adolescent psychiatrists (Strauss et al. 1995) that inpatient treatment is not only clinically appropriate but necessary under a wide variety of clinical conditions, and to lose this treatment option would seriously compromise the therapeutic needs of a significant number of disturbed adolescents.

CRITERIA FOR ADMISSION The most undisputed indication for admission to an inpatient unit is risk of harm to self or others (Strauss et al. 1995; Dicker et al. 1997). Suicidal and/or homicidal behaviors are the most obvious manifestations of this type of risk. (In a managed care environment, however, general suicidal or homicidal threats are not enough to precipitate an admission. Instead, patients must either have made a credible suicide or homicide attempt or have generated a specific plan for carrying out such behavior.) Other indications for hospitalization include moderate to severe psychosis and reckless behavior (Harper 1989). Interestingly, in a relatively recent study that examined variables involved in the decision to hospitalize adolescents, Gutterman (1998) found that in patients with equivalent levels of dangerousness, diagnosis (e.g., mood and psychotic disorders) was the strongest predictor of who would be hospitalized. An additional variable which plays a role in the decision to hospitalize is the presence or absence of an adequate psychosocial support system. If such a support system does exist, then it will be at times possible to provide treatment services in a less restrictive environment. If the support system is either inadequate or in some way harmful to the patient, however, then inpatient or residential care should be more strongly considered. Thus, children who are imminently dangerous and/or psychotic, and who have inadequate support systems are frequently hospitalized; but there is one more question which should be asked before making the decision to admit an adolescent: How resistant to treatment is the patient? When there is a high degree of resistance, inpatient hospitalization is often the only alternative, but treatment

can at times be accomplished in less restrictive settings when adolescents are able to acknowledge their problems and actively seek help for themselves. There are basically three ways that teenagers manifest resistance. The most overt is outright refusal to attend outpatient sessions. Another, more subtle form of resistance is the refusal to actively engage in treatment. These patients may attend sessions every week, but that is all they do. For these children, the fear of being affectively overwhelmed and/or cognitively disorganized is simply too great to allow them to actively confront their problems in anything other than a tightly controlled, structured, yet nurturant environment such as an inpatient milieu. Finally, there is a group of adolescents who cooperate superficially with treatment, but whose problems continue to increase in severity despite their overt cooperation. It is interesting to note that although most inpatient admissions are precipitated by an acute incident, the majority of patients have had longstanding behavioral and/or psychological problems. Over the course of many years they have learned to cope with these problems through the use of adaptive rationalizations (Schrodt et al. 1996). They make excuses for their behaviors; they externalize blame; and they frequently deny their feelings. Ultimately, their unquestionably maladaptive functioning becomes ego-syntonic. The great majority of these adolescents minimize the severity of their problems and are opposed to the idea of being hospitalized, just as they were previously opposed to other forms of mental health treatment. It is just this denial that makes hospitalization necessary, for if these patients could acknowledge their problems, then they might be able to benefit from less restrictive treatment alternatives.

GOALS OF HOSPITALIZATION Given the fact that the functional objective of any inpatient hospitalization is to transition the patient as rapidly as possible to a less restrictive level of care, what can be accomplished during a brief inpatient stay? The first goal should be to stabilize whatever crisis precipitated the admission while at the same time protecting the patient from his or her self-destructive or destructive tendencies. The second goal should be to adequately diagnose the patient and initiate appropriate pharmacological treatment. The third goal should be to assess the family situation so as to determine how parents and other family members perceive the problems and their solutions, and to provide the family with appropriate education so that they can better understand their child’s problems and participate in his or her treatment. The final goal of the hospitalization should be to identify available treatment resources that will be appropriate once the patient is clinically stabilized.

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THE MILIEU As noted above, the primary goals of hospitalization are to protect the patient, to make an adequate diagnosis and initiate pharmacological treatment, to assess and educate the family, and to identify post-hospital treatment resources. In order to accomplish these goals it is necessary to have a general therapeutic philosophy which informs all of the interventions on the inpatient unit. Certainly the unit should be safe, supportive, and consistent. Beyond this, though, the treatment orientation should derive from a careful examination of the types of patients most often admitted to hospitals (and residential treatment facilities), and it should be designed to meet the specific needs of this population. If one looks at the typical adolescent inpatient, no matter what the presenting problem, one finds certain relatively common characteristics. Most hospitalized adolescents have problems with oppositionality and defiance. Had they been willing to follow family rules or participate in an outpatient program they probably would not have found themselves admitted to the hospital. The oppositionality and defiance are usually of longstanding duration and are a manifestation of a generalized mistrust of the caretaking environment. The failure of the caretaking environment is often related to problems of fit between the child’s unique developmental needs (many of these adolescents have constitutional problems with impulse control, inattention, learning, affect modulation, and/or interpersonal skills) and the caretaking characteristics of the parents. Most adolescent inpatients are angry, sad, and/or hopeless. Typically, they have proved themselves socially inept and have therefore ultimately come to affiliate themselves with an antisocial peer group. They frequently do poorly in school (many times despite average or high IQs). They often use drugs and/or alcohol to modulate their moods, and many of them subsequently develop significant problems with substance abuse and/or dependence. Most of these adolescents are unable to recognize or express their feelings, and they have an associated difficulty expressing their needs. Rather than asking directly for what they want, they tend to ‘manipulate’ the environment because of their expectation that if they are honest about their needs, they will be ignored and/or frustrated. Most adolescent inpatients are dysphoric and irritable even if they are not overtly depressed. And finally, most hospitalized teenagers come from dysfunctional families with high degrees of conflict, poor communication, impaired problem-solving skills, and extreme disciplinary inconsistency. Given the clinical traits of the typical hospitalized adolescent, the design of the treatment milieu must address the issue of oppositionality and defiance before it can focus on underlying feelings of mistrust, anger, social

incompetence, or hopelessness. The unit should therefore be highly structured and predictable, with easily understandable rules and an expectation that these rules will be followed. Treatment should of course be individualized, but the great majority of patients can comply with basic requirements to be polite and respectful to staff and other patients, to refrain from destructive and self-destructive behaviors, and to actively participate in the various milieu activities, most of which should focus on talking about feelings and motivations for behaviors – so that patients can begin to make connections between how they feel, what they do, and the consequences of their behavior. Most crises appear to be stabilized simply by admitting the patient to the hospital. The adolescent is placed in a safe, structured environment, and he is removed from the various precipitants and reinforcers that have initiated and/or maintained his various dangerous behaviors. In fact, Malone et al. (1997) noted that almost 50 per cent of children who were hospitalized for chronic and severe aggression improved in less than two weeks while taking no active medication. Instead, they appeared to benefit ‘from the inpatient milieu/structure and/or placebo.’ Factors which may contribute to effective crisis stabilization, and effective milieu management in general, include:

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An operant conditioning paradigm which rewards verbal communication, compliance with rules, and appropriate social interaction with peers and family; and which punishes lack of communication, behavioral impulsivity, and antisocial interactions. A cognitive treatment orientation which includes the requirement that patients talk and write about their thoughts and feelings rather than acting them out. An interpersonal treatment orientation which focuses on providing patients with adequate staff and peer support for the difficult work they are required to do. Early, intense family intervention that focuses on the identification of specific problems and specific solutions to those problems.

The above goals are best accomplished by creating an environment in which the staff provides a model for effective communication with each other. Frequent staff meetings allow members of the treatment team to ventilate frustration, obtain guidance in addressing complicated patients, and generate clear and consistent therapeutic management approaches when challenges arise. Frequent community meetings offer staff and patients the opportunity to deal promptly and effectively with day-to-day milieu problems. During these community meetings, patients should be encouraged to support and confront their peers regarding behavior on the unit, individual therapeutic goals, and family issues. Providing multiple group therapeutic interactions each day, in the form of group psychotherapy, psychoeducational groups

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(e.g., substance abuse, gender-related topics, social skills training, and anger management), activity therapy, and psychodrama; and requiring that patients participate in all milieu activities unless they are too psychotic, gives structure to the day and guarantees that there will be little free time during which patients might engage in less therapeutic activities. Cognitive interventions, as noted above, help patients to identify their feelings and to generate more effective strategies for dealing with them. Giving patients ‘feelings books,’ which are logs they are required to keep documenting their emotional responses throughout the day, often helps them to understand how they respond affectively to various interpersonal situations with peers, family members, and authority figures. When specific maladaptive behavioral and/or emotional patterns are identified, patients should be required to talk or write about them. Specific examples of such maladaptive patterns include dishonesty, disproportionate sarcasm, the overutilization of nonverbal communication, excessive dependence on staff and peers, and/or splitting. Requiring that patients do writing assignments whenever such behaviors are manifested both increases patients’ awareness of their self-defeating behaviors and decreases the likelihood that such behaviors will be utilized in the future. The writing assignments should include an identification of the maladaptive behavior, an assessment of the motivation for the behavior, an analysis of whether or not the behavior led to achievement of the intended goals, and the generation of an alternative, less costly strategy to deal with similar situations in the future. When patients are especially resistant to milieu interventions they can be placed on individualized intensive treatment programs which essentially remove them from group activities. These patients can then be given a series of cognitively oriented writing assignments that they must complete before returning to the milieu. These interventions are often surprisingly successful, primarily because patients are motivated to return to the milieu where there is more peer contact, and because being placed on an intensive treatment program results in considerably less acting out, more self-focus, and more one-to-one attention from staff. As was mentioned in the previous two sections, most hospitalized adolescents have had chronic psychological difficulties. The problems with which they present at the time of admission represent chronic adaptations to histories of behavioral impulsivity and poor affect modulation, functionally inadequate parenting (although not necessarily inadequate parents), social incompetence, and academic failure. These children have defended against these problems in a multitude of ways over the years, but their admission to the hospital has been precipitated by a breakdown in their adaptive competency. The nature of the inpatient treatment setting must thus be one that allows the patient to function adequately once again.

If the milieu (whether inpatient or residential) simply recapitulates the outpatient environment, the patient will be frustrated no matter what the length of stay, and the hospitalization will be wasted. One cannot overemphasize the importance of inter-staff communication, support, and consistency. If the atmosphere on the inpatient unit is like that of an unhealthy family, with poor communication, lack of mutual support, and inconsistent limits, then the offspring of that surrogate family, the patients, will continue to have problems. What Stanton and Schwartz (1954) said over forty years ago in their pioneering study of mental hospitals still pertains: the quality of the inpatient milieu has a direct impact on the manifest pathology of the patients, and ultimately the outcome of the hospitalization or residential care varies directly with the psychological health of the treatment milieu.

OTHER ASPECTS OF TREATMENT Even if the milieu is healthy, well-trained child and/or adolescent psychiatrists must take an active role in guiding the treatment of their patients. It is vitally important that physicians obtain a comprehensive history of past and present illness as well as family history so as to make an accurate psychiatric diagnosis. Once the diagnosis is established, pharmacological treatment should begin immediately (although in a residential setting every attempt should be made to establish a behavioral baseline before starting medication). Whereas in the past psychiatrists had the luxury of a two- to three-week baseline observation period, in the current economic environment, this simply will not occur. That is unfortunate because, as noted above, many behaviors stabilize without pharmacological intervention. Nevertheless, the risks associated with short-term medication administration are relatively minor, and therefore it makes sense under the current conditions to initiate aggressive pharmacological treatment as soon as possible with a longer-term goal of discontinuing this treatment if it proves to be unnecessary. With the recent development of antipsychotic medications such as risperidone, quetiapine, and olanzapine, which have generally benign side-effect profiles and a decreased risk for the development of tardive dyskinesia, aggressive treatment of presumptive psychosis has considerably less danger than it did when only conventional antipsychotics were available. Additionally, the serotonin reuptake inhibitors are effective in treating both depression, anxiety, and obsessive–compulsive disorder with very little risk of adverse side effects. Also, psychomotor stimulants should be strongly considered in children who have significant problems with impulsivity and may be suffering from attention deficit disorder. As was mentioned above, family intervention is important in stabilizing crises. Specifically, family sessions

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should be scheduled as soon as possible after admission. They should occur at least two to three times per week in an acute setting, and at least once a week in a residential setting, and they should focus on developing practical solutions to the acute problems that led to admission. It is often very helpful to require patients to prepare, with the help of the milieu staff, the family therapist, or the attending psychiatrist, a list of specific issues to be addressed in each family session. Providing this structure often prevents the initial sessions from deteriorating into shouting matches. If, however, the degree of expressed emotion in the initial family session reaches unacceptable levels, it is often helpful to families to terminate the session and administer appropriate consequences to the patient before continuing the session with the parents alone for the purpose of further history gathering and/or education. Such an intervention serves as a model for limit setting, conflict resolution, and the maintenance of patient and family safety. Finally, as noted by Harper (1989), the goal of every hospitalization is to discharge the patient from the hospital as soon as possible. To do this, however, requires not only that the crisis be stabilized, that the patient be diagnosed, and that the family be educated, it also requires that appropriate post-hospital treatment resources be identified so that the transition from an inpatient level of care to a less restrictive setting can be accomplished as efficiently, effectively, and smoothly as possible. Without an effective transition, ‘financial savings from brief hospital stays may be squandered on repeated admissions and diagnostic assessments, with little chance for therapeutic gain and much opportunity for families and children to feel powerless, hopeless, and alienated.’ (Masters 1997). The identification of post-hospital resources, however, is made difficult because each third-party payer has a menu of services it is willing to fund and a panel of providers it has certified to provide these services. Recent experience indicates that the most effective way to facilitate a smooth transition out of the hospital is to identify, at the time of admission, a case manager whose responsibilities include contacting the third-party payer so as to determine what services will be available to the patient upon his or her discharge.

CHALLENGES FOR THE FUTURE The provision of mental health services has undergone significant changes during the past decade, and one can only assume that these changes will continue in the foreseeable future. The challenge to us, as adolescent psychiatrists, is to find ways to continue to provide high-quality care for our patients while at the same time complying with the financial constraints that have been imposed upon us by the economic forces at work in society today. There is no question but that managed care has forced us

to find less costly ways to treat our patients, and almost every mental health professional now accepts the dictum that the least restrictive appropriate level of care is the optimum level of care. (Although, in a recent article, Petti [1998] has argued for a somewhat broader and more enlightened point of view.) Unfortunately, as noted above, the real problem is that since the changes in mental healthcare have occurred so rapidly, there has not been time to develop (and find funding for) creative intermediate levels of care. Therefore, although medical necessity criteria for inpatient hospitalization are frequently not met after a few days of inpatient care, there is no other service available to effectively treat the patient in a less restrictive setting. The task that confronts us, then, is to develop these less restrictive levels of care, and the goal that confronts third-party payers is to find a way to fund them. The changes that have occurred in the provision of inpatient treatment, although difficult to deal with because they have been externally imposed, are not necessarily bad (see Green et al. 2001). Although clinicians may not be happy with purely economically mandated changes in the nature of the treatment they provide, in point of fact, if child and adolescent psychiatrists can find more efficient methods of providing care to hospitalized adolescents, these lessons can be applied to other milieu treatments that are not under the same economic pressures to reduce length of stay. Thus, in the long run, adolescents with serious psychological and behavioral problems requiring hospitalization, residential treatment, and even day treatment will benefit from more aggressive, time-effective clinical interventions.

REFERENCES Bickman, L., Foster, E.M., Lambert, E.W. Who gets hospitalized in the continuum of care? Journal of the American Academy of Child and Adolescent Psychiatry 35: 74–80, 1996. Dicker, R., Morrissey, R., Abikoff, H., Alvir, J., Weissman, K., Grover, J., Koplewicz, H. Hospitalizing the suicidal adolescent: decision-making criteria of psychiatric residents. Journal of the American Academy of Child and Adolescent Psychiatry 36: 769–776, 1997. Gelman, D. Treating Teens in Trouble. Newsweek, January 20, 1986, pp. 52–54. Green, J., Kroll, L., Imrie, D., Frances, F.M., Begum, K., Harrison, L., Anson, R. Health gain and outcome predictors during inpatient and related day treatment in child and adolescent psychiatry. Journal of the American Academy of Child and Adolescent Psychiatry 43: 325–332, 2001. Gutterman, E. Is diagnosis relevant in the hospitalization of potentially dangerous children and adolescents? Journal of the American Academy of Child and Adolescent Psychiatry 37: 1030–1037, 1998.

402 Psychiatric treatment Harper, G. Focal inpatient treatment planning. Journal of the American Academy of Child and Adolescent Psychiatry 28: 31–37, 1989. Lewis, J.M. The changing face of adolescent inpatient psychiatric treatment. The Psychiatric Hospital 22: 165–173, 1991. Malone, R.P., Luebbert, J.F., Delaney, M., Biesecker, K.A., Blaney, B.L., Rowan, A.B., Campbell, M. Nonpharmacological response in hospitalized children with conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36: 242–247, 1997. Masters, K.J. Using a coordinated treatment system to minimize child psychiatric hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry 36: 566–568, 1997. Petti, T.A. Discussion: Diagnosis is relevant to psychiatric hospitalization. Journal of the American Academy of Child and Adolescent Psychiatry 37: 1038–1040, 1998. Pottick, K., McAlpine, D., Andelman, R. Changing patterns of psychiatric inpatient care for children and

adolescents in general hospitals, 1988–1995. American Journal of Psychiatry 157: 1267–1273, 2000. Sarles, R.M., Alessi, N. Resolved: two-week psychiatric hospitalizations of children and adolescents are useless. Journal of the American Academy of Child and Adolescent Psychiatry 32: 215–220, 1993. Schrodt, G.R., Fitzgerald, B.A., Ravitz, A.J., Reinecke, M.A. Adolescent inpatient treatment. In Reinecke, M.A., Dattilio, F.M., Freeman, A. (eds), Cognitive Therapy With Children and Adolescents. New York: The Guilford Press, 1996, pp. 278–298. Stanton, A.H., Schwartz, M.S. The Mental Hospital: A Study of Institutional Participation in Psychiatric Illness and Treatment. New York: Basic Books, 1954. Strauss, G., Chassin, M., Lock, J. Can experts agree when to hospitalize adolescents? Journal of the American Academy of Child and Adolescent Psychiatry 34: 418–424, 1995. Thompson, J.W., Rosenstein, M.J., Milazzo-Sayre, L.J., MacAskill, R.L. Psychiatric services to adolescents: 1970–1980. Hospital and Community Psychiatry 37: 584–590, 1986.

6.8 Community-based treatment HARINDER S. GHUMAN, LANCE D. CLAWSON, AND MARK D. WEIST

INTRODUCTION For the purposes of this chapter, community-based psychiatric treatment of adolescents is defined as those mental health interventions and intervention strategies which are ‘nontraditional.’ The term ‘nontraditional’ implies that these types of services are ‘non-clinic-based’ as they physically occur within various community settings and institutions, and may be modified in scope and goal depending on the site where the services are delivered. Delivering mental health services to youth within the community, apart from the traditional mental health clinics, has become a compelling need as the limitations of clinic-based services have become evident in recent years. In some community-based samples of mental health service utilization, only one-fifth to one-quarter of children and adolescents who have a psychiatric diagnosis, and are in need of treatment, find their way to a traditional mental health clinic (Leaf et al. 1996; Flaherty et al. 1996; Sawyer and Kosky 1995). This problem is especially evident in predominantly non-white communities, and communities of color have been shown to be less inclined to seek assistance from traditional clinic-based mental health services (McMiller and Weisz 1996). In addition to this disparity between services needed versus services available, the most severely disturbed and traumatized teenagers have rarely been easily managed or effectively treated through clinic-based services. The two observations noted above can be summarized as: 1 There are inadequate numbers of adolescents served within our communities owing to the practical and psychological barriers which stand between the patient and the traditional clinic (e.g., issues of finances, transportation, other commitments on time, stigma within the family and peer group, cultural barriers,

core difficulties in forming alliances and executing personal goals, etc.). 2 Severely disturbed teenagers are all too often underserved within a traditional clinic owing to the complexity of their needs and the multiple agencies of which they are a part (e.g., schools, juvenile justice, social services, etc.). There have been several types of service delivery models elaborated and that have been shown to enhance the numbers of children served, and successfully engage and treat complex cases. These can be broadly defined as school-based services and home-based/wraparound services. The underlying concepts which support both of these newer forms of community-based services for adolescents are manifold. Both are site-sensitive and ‘assertive’ in that they take the mental health practitioner/ case manager out to where the adolescent and his family reside, delivering needed services flexibly on site (i.e., outside of the mental health clinic). Additionally, both models engage and work closely with institutions in the community at large who have significant responsibility for the youth within the community setting. The resources of these community agencies can be coordinated with mental health interventions to assist in bringing about change. Finally, families are worked with in a different way. Families are engaged ‘assertively’ on more neutral turf (the school) or their own turf (the home), so that family issues which incite or maintain an adolescent’s difficulties may be addressed. Stroul and Friedman (1986) devised the concept of ‘wraparound’ services for seriously disturbed children and adolescents which has been put into action and has proved to be effective though the service delivery model of ‘Multisystemic Therapy’ developed at the Medical University of South Carolina (Henggeler et al. 1995). Multisystemic therapy is an ‘assertive’ therapeutic and

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case management paradigm which is fluid, mobile and flexible. It is philosophically based on an ‘ecological model’ of behavior, and emphasizes outcome-oriented treatment approaches, home-based interventions, linkages between mental health and the community agencies with whom the child is involved, and individualized goals and appropriate resourcing to attain these goals (Santos et al. 1995). This model, besides focusing on therapeutic change within the teenager and family, serves to empower the family, community, and agencies to effectively manage serious disturbances in youth. Variations on this basic model are manifold. Treatment duration may vary widely from brief, mobile crisis teams (Greenfield et al. 1995) to open-ended interventions. The design and intensity also varies. Home-based/ family-centered services may be the only intervention provided (where case management and therapeutic interventions are brought into the home exclusively to enact family systems change). With in-home services as a foundation, additional time and individualization may be layered on to eventually construct something more akin to the Multisystemic therapy model. A major question for future research is what the crucial elements are which effect positive outcomes in assertive community interventions, and what types of intensity and duration are required for which type of child and community population. School-based health and mental health services are rapidly sweeping the nation. Schools have become the de-facto mental health system for children and adolescents as studies continue to demonstrate a substantial amount of unmet need, even for the most severely disturbed children (Burns et al. 1995). School-based clinics have been very effective in accessing greater numbers of undeserved youth, especially in the realm of mental health (Walter et al. 1995; Flaherty et al. 1996). The types of services delivered range from clinic-based services at the school to informal consultation by a mental health professional to school personnel and staff. This chapter will discuss two well-developed community-based forms of treatment:

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an assertive community intervention model (the Child and Adolescent Mobile Team); and a school-based model of services (The School Mental Health Program) at the University of Maryland School of Medicine and Institute of Psychiatry and Human Behavior.

CHILD AND ADOLESCENT MOBILE TEAM The Child and Adolescent Mobile Team at the University of Maryland, Walter P. Carter center is a multidisciplinary treatment team that provides home and community-based interventions. This team was originally conceived in 1994 as an adjunct to the traditional outpatient services in order

to support and facilitate treatment for difficult to engage, seriously disturbed children, adolescents and their families. After its initial eighteen months of operation, it was transformed into a completely independent entity with regard to case assignment and daily operations. Also at this time, a program was started for juvenile offenders in collaboration with the Department of Juvenile Justice (DJJ). A majority of adolescents referred by DJJ met criteria for assignment to the mobile team due to seriousness of psychopathology in both the adolescent and the family.

Staffing The child and adolescent mobile team has a registered psychiatric nurse as team leader and a child and adolescent psychiatrist who provides clinical leadership as medical director. In addition, there are two masters level social workers and a bachelor level clinician on the team.

Team model The team incorporates the Program in Assertive Community Treatment (PACT) and Multisystemic Therapy models of treatment (Santos et al. 1995). The salient feature of the PACT model includes an interdisciplinary team-oriented, field-based individualized treatment approach. The team carries a small and shared caseload. The patient’s condition is discussed in daily rounds. The team functions as a continuous care team providing treatment longitudinally. Multisystemic therapy is designed to enhance communication and cooperation between families, schools and other community agencies and organizations. Interventions are geared towards parents to improve their parenting skills, including increased monitoring of school performance, peers and activities, and active encouragement of association with non-problem peers. The clinicians have small caseloads, and service duration ranges from three to five months. The principal difference in our child and adolescent mobile team is flexibility of service duration. Although the primary goal is family preservation, there are certain cases where the team works with the family to find an out-of-home placement, and maintains the adolescent in the home until placement is secured. The key elements to conceptualize this model are:

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a mobile team, especially the assigned clinician, provides extra ego and sometimes super ego structure to the adolescent and the family; and treating severely disturbed adolescents in an ‘outpatient milieu’ which extends from an individual clinician’s office to the clinic, into the school, home and community at large. The ‘core’ treatment team, with support of ‘associate’ team members including teachers, mentors, a department of social services’ worker and probation officer (if any) work together in providing

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containment, support and structure to the adolescent and family (Ghuman and Sarles 1998).

Team structure The team leader and clinicians meet every morning to briefly review all the cases. Important issues are identified and prioritized. Team members discuss plans of action and their schedules with each other. Once a week, there are extended rounds with a child and adolescent psychiatrist. In addition, there is a once-a-week intake meeting in which new referrals and admissions are discussed. Often the referring staff are invited to this meeting. There is a onceweekly treatment planning meeting in which one to two patients and their families are invited to develop the treatment plan. The probation officers of those adolescents who are involved with department of juvenile justice are encouraged to attend the treatment planning meetings.

during daily rounds and in treatment planning meetings. The team is involved in aggressive outreach. Continuity of care is maintained even if the adolescent is hospitalized or placed in day hospital, shelter or respite. There is seven days a week, twenty-four hours day beeper coverage available to the patients. The range of services includes:

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Admission criteria Patients admitted to the mobile team should meet the following criteria: 1 Be aged between four and eighteen years. 2 Should have DSM-IV diagnosis and current Global Assessment of Functioning (GAF) ⬍ 50 and a moderate to severe rating on the Child and Adolescent Functional Scale (CAFAS). 3 Pose three or more of the following problems: History of multiple or lengthy psychiatric hospitalization, residential treatment stays or other out of home placements. Frequent acute and/or severe clinical crises that require additional support to manage or prevent removal of the adolescent from the home; or to prevent the psychiatric hospitalization of adolescent or care taker. Extremely chaotic family that interferes with meeting the basic needs of the adolescent including traditional psychiatric outpatient treatment. Involvement with several agencies or entities requiring intensive coordination of services. Impulsivity of the adolescent and/or family which complicate the clinical picture (e.g., financial mismanagement, suicidal gestures, substance abuse, frequent moves, illegal activities, chronic truancy). In home assessment and interventions are a necessary and ongoing requirement to manage treatment adequately.

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Range of services Services are tailored towards each adolescent’s individual needs and identified at the time of intake and modified

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Evaluation services include in-home child and family assessment, ongoing mental status monitoring, alcohol and substance abuse evaluation, psychological testing, medication evaluation, medical work-up including blood work and referral for electrocardiogram and other medical work-up, and drug screening. The mobile team also provides crisis evaluation and interventions including transportation of the adolescent to the emergency room for further assessment, shelter or respite. Treatment services include behavioral and medication management. Therapies include individual, family and group therapy for adolescents and parents. Substance abuse services include individual and group counseling. During the summer months, the treatment team has a structured day program with emphasis on development of positive social and recreational skills. Case management services include advocacy with schools by attending parent/teacher conferences, Board of Education meetings and the Local Coordinating Council. Parents are assisted in dealing with an adolescent’s school refusal by the clinician’s presence at home in the morning, helping with transportation problems, and checking on the adolescent’s presence at school. The adolescent and his/her family are supported in obtaining and maintaining entitlements, assisted with housing needs, budgeting, and financial management. The team regularly maintains contact with probation officers, department of social services workers, and various health service agencies in the community. Adolescents involved with the Department of Juvenile Justice are often assisted by help with transportation, updating probation officers and courts regarding the adolescent’s compliance and mental health needs.

Monitoring progress In addition to ongoing clinical assessment of the adolescent’s progress, the mobile team uses Youth Self Report, CAFAS, and the Depression Inventory at the time of the initial admission and each treatment planning meeting. In addition, key events including hospitalization, emergency room visits, arrests, convictions, jail, school suspensions/expulsions, and out of home placement are recorded in the chart.

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SCHOOL-BASED MENTAL HEALTH SERVICES Related to growing recognition of the inadequacies of community mental health centers (CMHCs) and private offices in meeting the mental health needs of youth, more and more services are being developed in schools. These ‘expanded’ school mental health (ESMH) services go beyond services traditionally offered in schools (e.g., assessment and consultative services for youth referred for, or already in special education) to include focused evaluation; individual, group and family therapy; and a range of preventive programs such as mental health education and school-wide intervention (Weist 1997). There are many advantages to these ESMH programs, including greatly enhanced accessibility, reduced stigma (since services are offered in a natural environment), improved identification and intervention for youth with ‘internalizing’ disorders such as depression and anxiety, and enhanced capacity to provide preventive services. Moreover, compared to services offered in traditional clinicbased settings, therapists working in ESMH programs see more youth (usually over ten per day compared to five or six) and have broader roles, seeing youth not only for scheduled ‘50-minute’ sessions, but also at school assemblies, athletic events, and in the cafeteria, and in many cases over a number of years (e.g., 9th through 12th grade). Importantly, these ESMH services are reaching youth at risk for, and already showing emotional and behavioral problems who otherwise would not receive needed services. For example, in our program, which operates in fifteen Baltimore schools, almost 70 per cent of youth referred for serious problems such as Major Depression, and Post-Traumatic Stress Disorder (PTSD) have had no prior contact with the mental health system (Flaherty et al. 1996). Further, many school-based clinicians will readily relate their frustrations in trying to get a child with a significant mental health issue or problem from the school into a mental health program in the community. Many youth never make it from the school to the community clinic. Those that make it often do so after a considerable delay (sometimes three weeks or longer), and those that are seen for initial appointments in the community often do not go back. In combination, these factors result in a very small percentage of youth with concerning emotional/behavioral problems who are successfully referred from schools to community programs. As a result, many ESMH programs become the mental health ‘safety net,’ providing ongoing services to youth with severe and/or chronic mental health problems, even though they may not be fully equipped to do so. As awareness of the benefits of these ESMH programs has grown, so has their number. As yet, national statistics are not available. However, in Baltimore, ESMH programs operated in three schools in 1987, over thirty in 1994,

and approximately 70 in 1997. The number of these programs in Maryland has almost doubled from 90 in 1994 to around 160 in 1997. This local growth is consistent with regional and national trends (Flaherty et al. 1996; Weist 1997). A major driving force behind the development of ESMH programs has been the development and growth of school-based health centers (SBHCs). These offer comprehensive health services to youth including physical examinations, laboratory testing, treatment of acute illnesses and accidents, immunizations, and in some communities, family planning services (see Juszcak et al. 1995). Since the first SBHC was established in Dallas in 1973, they have increased to nearly 200 in 1990 (HycheWilliams and Waszak, 1990) and to over 1000 in 1997. Moreover, a new organization – the National Assembly on School-Based Health Care – has been established to provide support to this growing movement. Notably, mental health concerns are the first or second most frequent reason for referral in these SBHCs (Lear et al. 1991; Weist 1997). While most SBHCs provide some level of mental health services, in general, they have not been able to keep up with the ‘overwhelming’ demand for these services (Dryfoos 1994). As such, SBHCs have called attention to the need for school-based mental health services, and in many cases have served as the impetus for establishing ESMH programs, as is the case in Baltimore. Essentially, this national movement represents the development of primary health and mental health care for youth in schools. There are a number of forms of ESMH programs. These include: 1 Programs that operate out of SBHCs. In these programs, health and mental health services are provided in an integrated fashion, and there is significant and close collaboration between physical health and mental health providers. Many, if not most, of the referrals will be received from the health staff (usually nurse practitioners and nurses), who are particularly adept at identifying highly stressed youth and those with internalizing problems such as depression and PTSD. Since most SBHCs are developed in high schools, and to a lesser extent in middle schools, most programs involve work with adolescents. Usually, a full range of primary to tertiary preventive services (Caplan 1964) are offered. In many ways, programs that operate out of SBHCs represent an ideal arrangement for the delivery of mental health services. Funding for these programs is often related to fee-for-service billing and grants obtained by local health departments. 2 ‘Stand-alone’ programs that involve a mental health practitioner working from a CMHC, community health center, or university in a school that does not contain an SBHC. In these programs, a particular challenge is for the clinician to network with teachers and school administrative staff, who will provide most, if not all,

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referrals (this is not meant to downplay this challenge for staff working out of an SBHC). In our experience in Baltimore, many of these ‘stand-alone’ programs have been developed in elementary schools. Related to this, there is a greater need for outreach to, and involvement of, families. We have also observed that proportionally more referrals related to ‘externalizing’ problems such as attentional difficulties, and noncompliance are received in these programs, which may relate to the generally younger age of the children, and the fact that most referrals are coming from teachers. Most of these programs involve the provision of primary and secondary preventive services, with referral mechanisms in place to address needs for more seriously disturbed youth. Funding of these programs is variable, with some funding coming from billing of Medicaid by school districts for services addressed in students’ individual education plans (IEPs), other funding coming from grants, and other funding coming from feefor-service arrangements. 3 ‘Outstationing’ of clinicians from a CMHC or other community health center to provide services in a school. These programs are readily established as most CMHCs are able to bill for services provided off site. These programs are notable for the fact that the staff are clearly employees of the CMHC, and services typically need to be in compliance with state regulations for community mental health. These state requirements will often specify parameters of treatment planning, diagnosis, and emergency coverage, and are associated with rather extensive documentation; consequently, limits are placed on the number of children who can be seen each day (usually this will not exceed seven). These programs are usually tertiary preventive in nature as they predominantly serve youth with established disorders. Funding for these ‘outstation’ programs is usually fee-for-service. Although these are the three major forms of ESMH program, many other forms exist, as programs will vary based on relationships with existing school health programs and community agencies, funding patterns, and their preventive focus. An important issue is that as ESMH programs grow around the country, mental health professionals who have not been well trained to work in schools are beginning to work in them. Most mental health professionals are steeped in the culture of Health and Human Services, which is different from the culture of Education. For example, standards of confidentiality are often different (with health professionals holding a more ‘rigid’ standard). Goals for programs may clash. Health professionals are usually interested in reducing emotional and behavioral problems in youth as a goal in and of itself. Educational staff usually are not interested in this goal, but are interested in reducing problems that may serve as ‘barriers to children’s learning’. Language barriers, such

as differing nomenclatures for emotional and behavioral problems (e.g., DSM-IV diagnoses versus definitions for ‘severely emotionally disturbed’) will also be encountered. Furthermore, apart from school psychology and social work, most mental health professionals are not trained to provide comprehensive mental health services in schools. In psychiatry, a prevailing service delivery model is to provide consultation for youth in special education. The psychiatrist may work a few hours per week in a school, conducting brief evaluations, making recommendations, and signing off on reports. However, the reality is that these services are viewed as ‘ancillary’ and are reaching relatively few youth. A critical challenge for child and adolescent psychiatrists is to begin to provide primary mental health services in ESMH programs. These services would include full evaluations, psychopharmacological assessment and treatment, supervising staff on-site, and providing leadership in a full range of psychotherapies. While there are a few programs, such as those in Baltimore, Dallas, and New Mexico, that involve psychiatry more fully in ESMH services, integration of child and adolescent psychiatrists into these programs is still only limited at best. Beyond more intense involvement in primary mental health care in schools, there are a range of opportunities for child and adolescent psychiatrists to become more fully involved in issues that are critical for this national movement to advance. Unfortunately, of the approximately 500 members of the National Assembly on School-Based Health Care, as of this date, fewer than ten are psychiatrists. Pressing issues that are beginning to be addressed by leaders in the ESMH movement include the development of: 1 Quality assurance standards and programs, as these generally do not exist. 2 Evaluation strategies to document the effectiveness of these programs, and their cost versus benefit in relation to other models of mental health service delivery for youth. 3 Stable funding mechanisms, which is an issue of particular concern since funding has never been predictable (and is even more unstable related to the growth of managed care!). 4 Methods to increase family involvement. 5 Strategies to negotiate unique legal and ethical issues involved in school-based mental healthcare. 6 Methods to better integrate school- and communitybased programs. 7 Strategies to fund and provide primary preventive services in schools. These and other topics are being addressed by two national centers in Baltimore (at the University of Maryland Department of Psychiatry) and Los Angeles (at the University of California, Los Angeles) funded in 1995 to provide resources and technical assistance for ESMH programs to advance nationwide.

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CONCLUSION Community-based ambulatory care for adolescents has come of age. Given the realities of clinic-based services and their limitations, the need to preserve family integrity, and the ever-present specter of cost containment, new and innovative methods of securing positive outcomes is the challenge of contemporary society. These models of mental health intervention demand much of the clinician. One must be comfortable with the foreign ‘turf ’ where services are to be delivered. ‘Cultural competence’ in addressing and successfully managing the potentially divergent values and expectations of the school, family, juvenile justice and social services agencies with whom an adolescent is involved is essential. Finally, there is an overarching need to be creative and flexible while maintaining a therapeutic stance. These forms of treatment require an empirical,‘problem-solving,’ outcomes-oriented approach to the treatment and containment of emotional disorders in youth. The value of community-based models of mental health intervention are only beginning to be realized. Outcomes for school-based programs are not yet available, yet the issues surrounding access to services are certainly answered by this form of treatment delivery. How to integrate school-based mental health services with traditional clinic-based models is yet to be seen with regard to resource allocation. There are innovative programs under way which propose the delivery of all child and adolescent mental health services within the schools. A major question to be addressed in state and county legislatures is the desirability of this form of intervention, as it begins to address the unmet need for child and adolescent mental health, but is unlikely to save actual dollars owing to the increased service volumes. Wraparound, mobile treatment has clearly begun to demonstrate its effectiveness. Yet the need to prove the ability of this model to avoid residential, juvenile detention, and other out-of-home placements, with well established ‘good’ outcomes will need to be clearly articulated. Once again, this form of intervention will require strong advocacy on the part of care providers, as the population served traditionally has not been empowered to carry this out within our society. Mobile, wraparound services must be shown as a viable and effective model of service delivery in the political arena in this era of dwindling health resources.

REFERENCES Burns, B.J., Costello, E.J., Angold, A., et al. The Great Smoky Mountains Study of Youth: mental health service use across the child service system. Health Affairs 14: 147–157, 1995.

Caplan, G. The Principles of Preventive Psychiatry. New York: Basic Books, 1964. Dryfoos, J.G. Full-Service Schools. San Francisco: Jossey Bass, 1994. Flaherty, L.T., Weist, M.D., Warner, B.S. School-based mental health services in the United States: history, current models and needs. Community Mental Health Journal 32: 341–352, 1996. Ghuman, H.S., Sarles, R.M. Ambulatory services for children and adolescents: historical view, definition, present issues, challenges, and solutions. In Ghuman, H.S., Sarles, R.M. (eds), Handbook of Child and Adolescent Outpatient, Day Treatment and Community Psychiatry. New York: Brunner/Mazel, 1998, pp. 3–10. Greenfield, B., Hechtman, L., Tremblay, C. Short-term efficacy of interventions by a youth crisis team. Canadian Journal of Psychiatry 40: 320–324, 1995. Henggeler, S.W., Schoenwald, S.K., Pickrel, S.G. Multisystemic therapy: bridging the gap between university- and community-based treatment. Journal of Consulting Psychology 63: 709–717, 1995. Hyche-Williams, J., Waszak, C. School-Based Clinics. Washington, DC: Center for Population Options, 1990. Juszack, L., Fisher, M., Lear, J.G., et al. Back to school: training opportunities in school-based health centers. Journal of Developmental and Behavioral Pediatrics 16: 101–104, 1995. Leaf, P.J., Alegria, M., Cohen, P., et al. Mental Health Service Use in the Community and Schools: Results from the Four-Community MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry 35: 889–897, 1996. Lear, J.G., Gleicher, H.B., Germaine, A., et al. Reorganizing health care for adolescents: The experience of the school-based adolescent health care program. Journal of Adolescent Health 12: 450–458, 1991. McMiller, W.P., Weisz, J.R. Help-seeking preceding mental health clinic intake among African-American, Latino, and Caucasian youths. Journal of the American Academy of Child and Adolescent Psychiatry 35: 1086–1094, 1996. Santos, A.B., Henggeler, S.W., Burns, B.J., Arana, G.W., Meisler, N. Research on field-based services: model for reform in the deliver of mental health care to populations with complex clinical problems. American Journal of Psychiatry 152: 1111–1123, 1995. Sawyer, M.G., Kosky, R.J. Approaches to delivering child and adolescent mental health services: the South Australian experience. Australian and New Zealand Journal of Psychiatry 29: 230–237, 1995. Stroul, B.A., Friedman, R. A system of care for severely emotionally disturbed children and youth. Washington, DC: Georgetown University, CASSP Technical Assistance Center, 1986.

Community-based treatment 409 Walter, H.J., Vaughan, R.D., Armstrong, B., Krakoff, R.Y., Tiezzi, L., McCarthy, J.F. School-based health care for urban minority junior high school students. Archives of Pediatric and Adolescent Medicine 149: 1221–1225, 1995. Weist, M.D. Expanded school mental health services: a national movement in progress. In Ollendick, T., Prinz, R. (eds), Advances in Clinical Child Psychology, Volume 19. New York: Plenum, 1997, pp. 3190–3348.

Suggested reading Ghuman, H.S., Weist, M.D., Sarles, R.M. (eds) Providing Mental Health Services to Youth Where They Are: Schooland Community-Based Approaches. New York: BrunnerRoutledge, 2002. Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D., Cunningham, P.B. Multisystemic

treatment of antisocial behavior in children and adolescents. New York: Guilford Press, 1998. Mardock, J. In-home treatment. In Alessi, N.E., Coyle, J.T., Harrison, S., Spencer, E.; editor-in-chief Noshpitz, J.D. (eds), Handbook of Child and Adolescent Psychiatry, Volume 6. New York: John Wiley & Sons, 1998. Weist, M.D. Toward a public mental health promotion and intervention system for youth. Journal of School Health 71: 101–104, 2001. Weist, M.D., Cooley-Quille, M. Advancing efforts to address violence and youth. Journal of Clinical Child Psychology 30: 147–151, 2001. Weist, M.D., Lowie, J.A., Flaherty, L.T., Pruitt, D. Collaboration among the education, mental health, and public health systems to promote youth mental health. Psychiatric Services 52: 1348–1351, 2001.

6.9 Multimodal dynamic psychotherapy and the adolescent’s world MICHAEL G. KALOGERAKIS

INTRODUCTION Traditionally, the approach to helping emotionally disturbed adolescents has called for selection of the treatment modality best suited to the primary problem and proceeding to work within that framework, with only minor deviations from the chosen modality. Over time, however, clinicians who worked with adolescents recognized that greater flexibility of options was needed for the majority of adolescents they see and, in varying degrees and forms. Thus, these clinicians began to introduce modifications into the basic techniques that they employ. Today, it is rare to find an early to mid-adolescent in classical psychoanalysis, although some may doubtlessly benefit from this approach. For most adolescents in need of mental healthcare, the relevant clinical questions are: 1 How does diagnosis inform treatment choice? 2 What is the most appropriate treatment mix for the variety of problems presented? 3 How can these approaches be effectively combined into a comprehensive treatment plan? 4 What is the impact on the overall treatment goals of the dynamic interaction among the individual modalities used conjointly? The preceding chapters in this section have dealt with the major treatment modalities currently in use with adolescents. This chapter will consider how these modalities can be integrated into a systematic and comprehensive treatment of the presenting psychopathology in the context of the adolescent’s life. Research in psychotherapy with adult psychiatric patients has established the superiority of psychotherapeutic techniques compared to doing nothing or treating only with drugs (Bachar 1998). At the same time, work

with hard-to-treat adolescent populations (severely delinquent and violent youths) has demonstrated the usefulness of multisystemic treatment approaches (MST) (Henggeler et al. 1997; Brown et al. 1997; Borduin 1999). For more general adolescent populations, clinical experience and the earlier discussion in this section suggest the following:

•

• • • •

There is no single form of treatment that will be appropriate to all types of adolescent psychopathology. [However, Brent et al. (1997) compared cognitive, family and supportive therapy in the treatment of adolescent depression and found cognitive therapy to be the most efficacious.] Adolescents are most likely to benefit from a combination of therapies, e.g., individual and group, psychoand pharmacotherapy, cognitive and psychodynamic approaches, etc. A single therapist, if properly trained, may be able to provide the necessary mix of modalities to achieve maximum benefit for the youth. When this is not possible, it is important for achieving maximum benefit to supplement the work being done by the primary therapist with referrals to other clinicians specializing in specific interventions. Adolescent therapy – more so than therapy with younger children or adults – must deal constantly with the external life of adolescents, since their problems are so often associated with their family and peer relationships.

Therapists working with one particular modality can of course provide excellent care within the limitations of that method. The results achieved will accordingly be confined to the potential inherent in that modality, which may be all that is necessary. Many adolescents in treatment

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initially ask for little more than symptom relief, but it is often necessary to expand the treatment goals as the clinical picture unfolds.

THE INITIAL EVALUATION The sine qua non for arriving at a comprehensive treatment plan is a sensitive and thorough diagnostic evaluation. This should provide information sufficient to formulate a preliminary treatment plan. The principal goal of an initial consultation is to determine whether the current adjustment of the adolescent is so poor as to warrant intervention and, if so, of what kind. Opinions differ as to whether such a determination can be made by seeing only the adolescent or whether the youth’s parents, who are usually the referring parties, must also be seen. Clinicians used to working with younger adolescents find it essential to see the parents who can provide valuable information about early childhood, family interactions, and the youth’s behavior.

A review of systems The traditional psychiatric evaluation will search out all signs and symptoms of disturbance or maladjustment, emotional, cognitive, behavioral and social; perform a mental status examination; establish a diagnosis; and develop a comprehensive psychodynamic formulation of the problems presented. (Though the last has regrettably fallen into disuse in this era of biological psychiatry, it remains a cardinal element of a competent psychiatric assessment.) The unique nature of adolescent life necessitates some additions to this basic model. Adolescents are still growing, making a careful assessment of the youngster’s stage of development mandatory. They live with their parents and siblings so that the status of those relationships must be ascertained. They are likely to be attending school, making it essential to assess the quality of both the academic and behavioral adjustment. They are involved with one or more peer groups, whose make-up is a veritable window into the personality of the adolescent. Their life, though much more complex than that of the younger child, is still spared the major responsibilities and burdens of adult life. One way of organizing these clinical interests is to borrow from general medicine the review of systems (i.e., cardiovascular, gastrointestinal, neurological, etc.) that is a standard component of the comprehensive diagnostic evaluation. In this instance, we are concerned with a variety of systems, psychosocial in nature, that are essential elements of every adolescent’s life. They are both internal and external. Externally, they include the family, neighborhood, school, the immediate friends, the broader

network of peers, and, for some, a team, a community center, a gang, etc. Internal ‘systems’ include cognitive functioning, affect modulation, behavior, attitudes and beliefs, and, in general, the interrelationships among impulses, controls and the internalized value system. The review of systems proposed requires that all these components be evaluated in order that a complete diagnostic picture may be obtained. Since, as noted, it is unlikely that a full psychopathological profile can be developed during the initial evaluation (elements of history may be withheld, repression and denial may be operating), clues that may be associated with dysfunction in one or another of the listed systems can serve to alert the clinician to what remains to be elucidated. Important aspects of such a systems evaluation include the nature of the interactions within the system, the role played by the adolescent, its appropriateness and effectiveness, as well as any evidence of dysfunction.

THE SPHERES OF PSYCHOSOCIAL FUNCTIONING It is helpful, if somewhat arbitrary, to sort out the adolescent’s problems into three separate spheres of psychosocial functioning (Kalogerakis 1997). These are reality, the interpersonal, and the intrapsychic spheres. Many of the problems described by the adolescent and his or her parents do not necessarily fit neatly into one of these categories: they may bridge two or all three. Some may appear to be reality problems but on further exploration turn out to involve internalized conflict (‘reality in the service of the neurosis’). Interpersonal conflict – for example, between parents and child – may of course involve both reality and intrapsychic elements. Despite this, breaking out the problems into these categories helps to organize one’s thinking and points the way to the interventions that will be needed.

Reality It is vital to the success of any therapy to recognize as early as possible the reality factors that are present in virtually all adolescent disturbances. With adults, it is appropriate to the patient to assume responsibility for changing or, for example, to withdraw from a damaging relationship or change jobs. Such an option, however, is no more available to the adolescent than it is to the younger child who, for example, must deal with a psychotic or abusive parent. Pathogenic elements in the youth’s home life, or biological stigmata of one kind or another, are not items for analysis. They may call for validation by the therapist, empathic support, and, frequently, active intervention with the family or school. O’Brien (1992) points out how real life frustrations compound the problems of the

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Attention Deficit Hyperactivity Disorder (ADHD) child, and are responsible for much of the emotional disturbance. In instances where parental neglect or abuse is identified, referral to child protective services or the family court is invariably required by law.

Interpersonal issues The importance of the contributions of Sullivan (1953) and the family theorists to the understanding of interpersonal relations in human development and psychopathology is well established. Developmentally, adolescent life, as Offer and Offer (1976) have demonstrated, can be relatively conflict free. When it is not, it may be rife with conflict in relations to others, partly because it is characterized by increasingly vigorous moves towards individuation and independence, setting the youth repeatedly at odds with parents and other authorities; and partly because of the compelling hormonal changes and the corresponding heightened involvement with peers. In the main, the adolescent years are very social years and much psychic activity during this period involves human interaction. Not surprisingly, maladaptive behaviors likely to bring adolescents to the attention of mental health professionals include problems in the interpersonal arena. Although the main thrust of dealing with such interpersonal problems therapeutically is to assist the adolescent to understand the nature of the troublesome interactions, seeing cause and effect, and to develop improved techniques for dealing with them, it is equally important to validate the adolescent’s perceptions of others’ roles in their problems when these perceptions are not distorted.

Intrapsychic factors By definition, these are forces that exist solely within the individual, although they may originate in reality or interpersonal activity and inevitably affect these other spheres. Typically, they are represented by internalized conflicts of which the individual is only partially aware. These conflicts are then manifested by symptoms and signs, such as anxiety and depression. The distress caused by these symptoms and signs leads automatically to defensive operations designed to provide relief but which are only partly successful. They often compound the problems of the individual, resulting in increasing dysfunction. This is the situation that often precedes the resort to professional help. The central assumption of this formulation is that much of what transpires in the psychological life of the individual, and a great deal of what is pertinent to psychiatric disorders, is not readily available to conscious thought, although it may be retrievable. This would apply equally to cognitions and to emotions. (A good example would be racial prejudice, which consists of

both unfounded generalizations [beliefs] and hate, the origins of both being lost in memory.) A corollary assumption is that definitive change for at least some of what is maladaptive necessitates bringing such unconscious elements into awareness. This notion is central to psychoanalytic theory, but behaviorists and cognitive psychologists, among others, do not generally incorporate these assumptions into their theoretical formulations. The jury is still out on whether the basic structure of a neurosis or a personality disorder can be altered without treatment that elucidates unconscious mechanisms. Benjamin (1997) suggests that models of treatment appropriate for use with personality disorders must be based on a testable causal theory, which can then be linked to the process of therapy and outcome measures. Despite the fact that neither of the two major official nomenclatures, ICD-10 and DSM-IV, have included diagnostic categories that are based on clinical inferences about unconscious mechanisms in their descriptive terminology (e.g., psychoneurosis, once a part of the DSM listing, no longer appears), a large body of clinicians remains convinced that the basic elements of psychoanalytic theory, as originated by Freud and modified by many since, are valid and remain pillars of our art and our science. The contention, held by many, that adolescents are not generally, for developmental reasons, best treated by classical psychoanalytic methods, in no way diminishes the relevance of psychoanalytic theory to an adequate understanding of their psychopathology. The position taken here is that all elements identified as intrapsychic, which include internalized conflict, are best understood in psychodynamic terms. It is in the reality and interpersonal spheres, and in dealing directly with symptoms and behavior, that the contributions of behaviorists and cognitive specialists have found their greatest use. At the same time, Lewis (1997) affirms that, whatever interventions are brought into play, they must be ‘organized in the context of a psychodynamically based psychotherapy’ (Lewis 1997, p. 54). The section that follows explores how these distinct approaches can be used serially or concurrently to further the treatment goals when working with adolescent patients.

CLINICAL INTERVENTIONS As therapy begins and the adolescent’s life starts to unfold, as the problems that bring the youth into treatment are laid out, there is a natural order of priority that sets the agenda for the work to be done. Among the common criteria are: 1 The most pressing complaint of the adolescent patient, usually whatever is causing the greatest distress. 2 The major or most urgent concern of the parents (the major reason for seeking therapy for their child?),

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which may not necessarily coincide with the patient’s priorities, but which, in the therapist’s judgment, deserves immediate attention. An example would be a seriously deteriorating academic situation. 3 The therapist’s opinion of what should be tackled first, after the initial assessment. It is unlikely that the therapist’s judgment would conflict with both the adolescent’s and the parents’ concerns. However, the therapist may, for example, have picked up evidence of an incipient psychotic process totally unsuspected by the family, and decided to prescribe a neuroleptic. 4 Items that appear to be easily remediated, usually via some form of environmental adjustment. Typically, this might involve advice to the parents around an issue of overcontrol, or a brief consultation with the youth’s school regarding a problem with a teacher. This has the added advantage of demonstrating, early in therapy, that a therapist can be of practical value – a fact that may help to cement an early working relationship and the needed therapeutic alliance.

THE COURSE OF THERAPY Developmental considerations shape the form and progression of adolescent psychotherapy. In the majority of cases, the adolescent is not self-referred and a measure of resistance can be expected. Thus, one cannot assume that important or relevant data will necessarily be shared with the therapist. This is especially true of the behaviorally disordered adolescent who is guarded about his or her activities. For any teenage patient, shame can be a powerful factor impeding openness, certainly until a therapeutic alliance has developed. Commonly, the subject matter of therapy unfolds as a rough progression from dealing with reality issues, to sorting out interpersonal matters, to the eventual elucidation of internalized conflict. This process is generally not a smooth, sequential affair but more of a roller-coaster ride as it advances on a bumpy path from the evident to the unknown. Initially, the therapist may be confronted with confused ideas, idiosyncratic perceptions or other aberrations in the intellectual sphere. Alternatively, the presenting problem may be an intergenerational conflict. The causes of the current disruption may not be apparent, suggesting the presence of unconscious elements.

Therapy as a dynamic process Beyond the major interventions in use with adolescents, an adolescent therapist will, at one point or other, use specific techniques such as support, advice, clarification, confrontation, interpretation, intervening with parents, intervening with the school or tutors, etc. The therapist is thus alternately counselor, advocate, teacher, interpreter,

tutor, medical expert, as well as therapeutic agent. Ultimately, the therapist must decide precisely how and when to introduce specific interventions, based on the material emerging in therapy and on associated needs. Lewis (1997) makes the point that, beyond the mere mixing of different modalities, ‘the therapist must keep an eye on the effects of one intervention on another and on the overall psychodynamic process’. He adds that ‘when interventions are working synergistically, the dynamic material deepens’ (Lewis 1997, p. 62). This is often the case with concurrent individual and family therapy. The family therapy tackles the interpersonal issues, freeing the adolescent to focus on personal conflicts in the individual therapy. At the same time, the individual therapy may help to clarify intergenerational problems that the youth is then able to take up in family therapy. The adolescent’s reactions to the different therapeutic initiatives and to the therapist’s changing roles provide clues to the conscious and unconscious forces at play in his or her life. Transference reactions are likely to develop and must be analyzed (Tyson and Tyson 1986). Countertransference in work with adolescents can become as much an impediment to progress as with adults and must be dealt with (Marshall 1979).

THE WORLD OF THE ADOLESCENT Family In work with children, collateral treatment of parents and child is ‘central to the success of intervention for the child’ (Sperling 1997). With adults, the psychoanalytic ideal is to work exclusively with the patient, and the same applies to working with older adolescents; this approach, which is strongly advocated by Godenne (see Chapter 6.1), preserves confidentiality (Sperling 1997) and also avoids possible conflict of interest (not confusing primary responsibility with secondary concerns). Some would also maintain that this expedites the process, though this is by no means certain. All too often – and especially for younger adolescents – there are compelling reasons for sacrificing the one-on-one ideal, and many adolescent therapists have found that the arguments against doing so are manageable concerns. In addition to the occasional need to contact the parents and include them in the therapeutic process, the therapist may wish to be in contact with the school, a peer, the court, or a drug rehabilitation program that the youth is attending. The patient’s knowledge and support for such initiatives is essential. Success with such flexibility is facilitated by making it clear to the youth at the outset of treatment that this may occasionally be necessary and obtaining general approval to do so. This seems not to be a problem for most adolescents.

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The ambivalence with which many adolescents enter treatment often hinges on a belief that it is their parents who need help, not they. The therapist’s conditional acceptance of this view often serves to reassure the youth that he or she will not be uncritically blamed for every intergenerational disagreement. Many parents are quite anxious about their child and about what is happening in therapy, and so may require the therapist’s guidance periodically. This need not interfere with the treatment and may, in fact, facilitate it by mitigating parental suspicions or tendencies to interfere with the treatment process. The latter could arise if the parents feel threatened by the teenager’s increased moves towards independence or become competitive with the therapist. Short of this, they have a vested interest in their child and do pay the bill; consequently they often feel entitled to know something of what is going on. It is the paranoid patient who may be unable to tolerate this, and who must be handled gingerly. Sociopathic youths are commonly unable to benefit from traditional therapy unless the basic requirement of a willingness to trust can be met. Other conditions for involving the parents in the treatment process include:

• • • • •

• •

a significant problem of communication between patient and parents, when attempts to resolve it by working with the adolescent alone have not been fruitful; actual efforts by the parents to control the patient which have led to antagonism and become a point of resistance in the therapy; the parents, in other ways and perhaps unwittingly, creating problems for their child; evidence of mental disturbance on the part of one or the other parent, suggested by the adolescent’s productions; in such cases, referral for a fuller evaluation or treatment may be indicated; aspects of parental behavior that are proving detrimental to the youth’s efforts to establish control over his or her own impulses; for example, excessive drinking by one or both parents when the patient is struggling with personal substance abuse; ongoing strife between the parents that is proving destructive to the adolescent; parents who have failed to deal effectively with intersibling hostility.

Other indications warranting contact with the therapist may exist. In most instances, the contact can be quite brief, involving one or two sessions, either with the patient present or not, depending on the reason for the intervention and the adolescent’s wishes.

The school Contact with the patient’s school may be useful when academic issues exist, or if there are serious behavior

problems in the school. On occasion, the contact is initiated by the school, or the parents may request it. It may also be requested by the patient, in the hope that the therapist will prove a useful advocate. The therapist may also recommend it, seeing potential benefits in an exchange with a guidance counselor or principal, over either academic difficulties or behavior problems. A prime example of how valuable such exchanges can be occurs when the evaluation has revealed a previously undiagnosed learning disability or ADHD. This information is of some importance to a school attempting to develop an appropriate individual education plan (IEP) for the student. On the other hand, the school may be able to contribute valuable information about the youth’s behavior in the classroom which might otherwise not be known by the therapist. Occasionally, more extensive collaboration between therapist and a school guidance counselor may be indicated, as when family problems leading to dysthymic or anxiety symptoms are having a damaging effect on the student’s performance. A temporary adjustment in the usual academic demands in such cases can be of great value.

The peer group The importance of the peer group to the average adolescent cannot be overemphasized. We know that its influence over the youth increases in inverse proportion to the decline of parental influence as the adolescent moves through their teens. Its influence is also likely to be greater when the impact of the parents on the child’s development has been weak or negative. Some teenagers may fall in with one or another clique in school, typically (in recent years) nerds, jocks or druggies, or, for some, a gang. With whom the youth hooks up can play an important role in his or her future adjustment. Whoever the patient’s associates may be, therapist sensitivity to the importance of friends is a prerequisite for effective adolescent psychotherapy. It is a subject about which adolescents can be extremely defensive, as most parents of budding teenagers discover. Because of the sensitivity of the subject, critical examination of these relationships may have to be delayed until other conflict areas have been worked through. Such postponement may not be advisable when the therapist is convinced that a particular companion is a destructive influence. Group therapy, which does not generally involve adolescents known to each other, nonetheless offers the opportunity of examining ideas and behaviors common to the adolescent subculture, contributing to a better understanding of the patient’s personal relationships (see Chapter 6.6). Network therapy (Sugar 1971) on the other hand deals directly with the youth’s companions, providing an opportunity to explore actual interrelationships, as in family therapy.

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When an adolescent has been referred for family or group therapy, it is usually advisable to continue individual psychotherapy concurrently. This affords the youth the opportunity to raise issues in the one-to-one setting that are avoided in the group or family context. Conversely, personality traits such as shyness or hostility, which have a significant impact on social relationships, are more easily addressed in group therapy. Such cross-fertilization can be very productive and open up areas for exploration that might otherwise not be mentioned.

The Court Antisocial adolescents in therapy tend to be at the more benign end of the delinquency scale. Despite this, they are at risk of becoming involved with the juvenile or family court, bringing the two systems of care into contact. The court is usually receptive to psychiatric findings that could have a bearing on disposition. The therapist is in a position to serve as advocate for the adolescent, keeping him or her in the mental health system and out of the correctional system (Kalogerakis 1992). For youths who have been unable or unwilling to recognize the risks to which their behavior is exposing them, the court, by representing a harsh confrontation with reality, can have a therapeutic impact. For the more seriously delinquent or violent youths, one of the most promising treatments that has emerged is multisystemic therapy (MST) which is a communitybased, behavioral equivalent of the multimodal psychodynamic model being proposed here. Although there are important differences between the two approaches (see Borduin 1999), the basic recognition of the need for concurrent multiple approaches consistent with the multidetermined nature of many adolescent disturbances is common to both.

Drug programs As the use of illicit drugs and alcohol among adolescents has increased, the number of youths seen in psychotherapy who have abused or are continuing to abuse substances has increased dramatically. Experience has shown that psychotherapy of any kind with serious substance abusers is ineffective unless it is used in conjunction with a drug treatment program. The drug program may be an outpatient program, but needs to be based on total abstinence and offer a full activity program after school that keeps the youth away from drug-abusing friends. Not all such youths need individual psychotherapy, but those that do can benefit by addressing problems not necessarily related causally to the drug use, and the combined treatment approach can be mutually reinforcing. This requires close collaboration between drug program staff

and psychotherapist. Because of the nature of the problem, teenagers who use drugs are prone to lying about their habit, so that an agreement from the outset that allows for open contact between the treating agents is essential. Without it, the success of both drug rehabilitation and psychotherapy will be compromised. I have attempted in this chapter to make the case for a cohesive, comprehensive approach to the treatment of psychiatrically disturbed adolescents. The method, as described, is essentially bifocal: 1 Its centerpiece is psychodynamic individual psychotherapy, buttressed where necessary by additional modalities, each of which has a specific contribution to make. 2 Of equal importance is selective collaboration with the different systems in the environment of the adolescent. Advocacy of this approach is based on the belief that, for a large number of troubled teenagers, it offers their best opportunity for help, and that no single modality or theoretical framework is sufficient to achieve the treatment goals by itself.

REFERENCES Bachar, E. Psychotherapy – an active agent: assessing the effectiveness of psychotherapy and its curative factors. Israel Journal of Psychiatry and Related Sciences 35: 128–135, 1998. Benjamin, L.S. Special feature: personality disorders; models for treatment and strategies for treatment development. Journal of Personality Disorders 11: 307–324, 1997. Borduin, C.M. Multisystemic treatment of criminality and violence in adolescents. Journal of the American Academy of Child and Adolescent Psychiatry 38: 242–249, 1999. Brent, D.A., Holder, D., Kolko, D., Birmaher, M., Baugher, M., Roth, C., Ivengar, S., Johnson, B.A. A clinical psychotherapy trial for adolescent depression comparing cognitive, family, and supportive therapy. Archives of General Psychiatry 54: 877–885, 1997. Brown, T.L., Swenson, C.C., Cunningham, P.B. Henggeler, S.W., Schoenwald, S.K., Rowland, M.D. Multisystemic treatment of violent and chronic juvenile offenders: bridging the gap between research and practice. Administration and Policy in Mental Health 25: 221–238, 1997. Henggeler, S.W., Melton, G.B., Brondino, M.J., Scherer, D.G., Hanley, J.H. Multisystemic therapy with violent and chronic juvenile offenders and their families: the role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology 65: 821–833, 1997.

416 Psychiatric treatment Kalogerakis, M.G. (ed.) Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Association, 1992. Kalogerakis, M.G. Adolescent analyzability reconsidered. In Flaherty, L.T., Horowitz, H.A. (eds), Adolescent Psychiatry, Volume 21. Hillsdale, NJ: The Analytic Press, Inc., 1997, pp. 271–288. Lewis, O. Integrated psychodynamic psychotherapy with children. In O’Brien, J.D. (ed.), Child and Adolescent Psychiatric Clinics of North America. Philadelphia: W.B. Saunders, 1997, pp. 53–68. Marshall, R. Countertransference in the psychotherapy of children and adolescents. Contemporary Psychoanalysis 15: 595–629, 1979. O’Brien, J. Children with ADHD and their parents. In O’Brien, J., Pilowsky, D., Lewis, O. (eds), Psychotherapies with Children and Adolescents: Adapting the Psychodynamic Process. Washington, DC: American Psychiatric Press, 1992, pp. 109–124.

Offer, D., Offer, J.B. Three developmental routes through normal male adolescence. In Feinstein, S.C., Giovacchini, P.L. (eds), Adolescent Psychiatry, Volume 4. New York: Jason Aronson, 1976, pp. 121–141. Sperling, E. The collateral treatment of parents with children and adolescents in psychotherapy. In O’Brien, J.D. (ed.), Child and Adolescent Psychiatric Clinics of North America. Philadelphia: W.B. Saunders, 1997, pp. 81–96. Sugar, M. Network psychotherapy of an adolescent. In Feinstein, S.C., Giovacchini, P.L., Miller, A.A. (eds), Adolescent Psychiatry, Volume 1. New York: Basic Books, 1971, pp. 464–478. Sullivan, H.S. The Interpersonal Theory of Psychiatry. New York: W.W. Norton, 1953. Tyson, R., Tyson, P. The concept of transference in child psychoanalysis. Journal of the American Academy of Child Psychiatry 25: 30–39, 1986.

SECTION

7

Adolescent psychiatry and the law EDITED BY RICHARD A. RATNER

Introduction Richard A. Ratner

418

PART 1 LEGAL ASPECTS OF MENTAL HEALTH TREATMENT 7.1 Legal issues in inpatient and outpatient psychiatric treatment Abigail English

421 423

7.2

Custody, visitation and relocation issues in adolescence Alex Weintrob and Sandra G. Nye

430

PART 2 MENTAL HEALTH IN LEGAL SETTINGS 7.3 The juvenile justice system: delinquency and status offenders Wade C. Myers

441 443

7.4

The psychiatrist in the juvenile justice system: evaluation of offenders Richard A. Ratner

450

7.5

Treatment of juvenile offenders Lee H. Haller

456

PART 3 SPECIAL PROBLEMS IN DELINQUENCY ASSESSMENT AND TREATMENT 7.6 Substance abusers Steven L. Jaffe

463 465

7.7

Violent offenders Rusty Reeves

470

7.8

Adolescent sex offenders Roy J. O’Shaughnessy

482

7.9

Juveniles and the adult criminal justice system: transfer/waiver to adult court Carl P. Malmquist

489

7.10 Juveniles and the adult criminal justice system: the death penalty Richard A. Ratner

495

7.11 Dependency court: the handling of abuse and neglect cases Kathi L. Grasso

499

Introduction RICHARD A. RATNER

Forensic psychiatry is often defined as the field that employs psychiatric expertise for legal purposes and to achieve legal ends. In other words, forensic psychiatrists are experts in psychiatry who are consulted by the courts in order to shed the light of their expertise on problems the courts are trying to resolve. Accordingly, forensic psychiatrists (or forensic child and/or adolescent psychiatrists) are those individuals most likely to be involved at the interface of psychiatry and law. However, no psychiatrist can practice without regard for the laws of the society in which we live. We all operate within a framework of legal regulation and ethical guidelines in order to maintain our licensure, hospital privileges, authority to prescribe medication and membership in professional organizations. Thus, while forensic psychiatrists often choose to step out of the strictly medical and into the legal sphere to render services, every practitioner, including those who do not put themselves forward to do forensic work, must be aware of the legal context in which we live and practice. To reflect these realities, this section on adolescent psychiatry and the law is divided into three parts: Legal Aspects of Mental Health Treatment, Mental Health in Legal Settings and Special Problems in Delinquency Assessment and Treatment. The first considers areas in which the civil law shapes and regulates our relationships with our adolescent patients and their families, and with third parties to those relationships, such as psychiatric hospitals and domestic relations courts. The chapter by Abigail English discusses some areas of clinical practice that are substantially regulated by civil law: the legal rights of our adolescent patients and their families regarding such issues as consent, confidentiality, and the right to refuse treatment. Given the developmental status of adolescents as somewhere between children and adults, the degree of responsibility allowed them for decisions regarding themselves, as opposed to the prerogatives of parents or of treating psychiatrists, is regulated in each state by the laws of that jurisdiction.

Another area of adolescent mental health care where the law intervenes to shape our practices is when a psychiatrist involves him or herself in the thorny areas of custody and relocation resulting from divorce. While forensic psychiatrists are often retained to provide independent psychiatric evaluations by parties to a custody dispute, nonforensic child and adolescent psychiatrists not uncommonly find themselves deeply involved in such matters by virtue of having been treating the adolescent or his family. The chapter by Weintrob and Nye, one a forensic child psychiatrist and the other an attorney, considers the proper role of the psychiatrist, be (s)he a treater or an evaluator, under these difficult, typically adversarial conditions and attempts to provide guidance for psychiatrists whose knowledge of pertinent areas of the law is rudimentary. The second major area of interaction between psychiatry and the legal system occurs when the psychiatrist crosses into the legal sphere and involves him or herself in the juvenile justice system. Before the creation of a separate juvenile court system, juvenile offenders were dealt with in the criminal courts. Today, however, juvenile courts generally have jurisdiction over young people who come in conflict with the state. The remainder of this section discusses, in two parts, the origin, history and current status of the juvenile court system, the concepts of deliquency and status offences, the court’s responses to juvenile crime, including transfer to adult (criminal) court (where capital punishment may become a possibility), and the various roles that psychiatrists may play in this complex series of events. In part 2, the juvenile justice system is presented, along with chapters describing the psychiatrist within that system as evaluator and as a treatment resource respectively. Part 3 describes special issues in the evaluation and treatment of deliquent populations, including Jaffe on substance abuse, Reeves on violent offenders and O’Shaughnessy on adolescent sex offenders. Malmquist considers issues of transfer of juveniles to the adult criminal justice system, and Ratner discusses one sinister outcome that

Introduction 419

could await them: capital punishment. Finally, Grasso discusses abuse and neglect, situations where the adolescent is typically the victim rather than the perpetrator of a criminal offense. Certain topics at the interface of the law and psychiatry are beyond the scope of this section to explore in detail, but should be mentioned. One such area is that of medical malpractice suits against psychiatrists. Psychiatrists treating adolescents are as vulnerable as any other practitioner to claims of negligence and possibly more so as a result of a host of special factors. In fact, in a recent review article, Ash (2002) indicates that approximately 21 per cent of malpractice cases brought against psychiatrists involve patients who are under eighteen years of age. Issues peculiar to practice with minors can include the relatively greater emotional instability and impulsiveness of adolescents leading to, among other things, dangerous acting-out behavior, such as assault on other minors. Other cases may derive from the rights of parents versus teenagers or the anger of one party to a custody suit toward the psychiatrist who ‘finds for’ another parental figure. Nonetheless, the elements of a negligence claim and the principles of risk management are not unique to adolescent psychiatry but apply to medical malpractice in general. These issues in general are well covered in a plethora of texts (e.g., Macbeth et al. 1994); medical malpractice issues particular to the adolescent population are well surveyed by Ash. Accordingly, further consideration of malpractice is not included here. A crucial area in which forensic psychiatry differs from the clinical practice of psychiatry is that of ethics. While psychiatry, as the rest of medicine, bases its ethical codes upon its duty to the patient, the forensic psychiatrist often finds himself involved in clinical matters not on behalf of the patient but at the behest of third parties. One example would be psychiatrists employed by the state whose duty it is, for example, to evaluate patients for competency and treat them if necessary. Here, and in many other settings, the duty of the psychiatrist is to his employer, in this case the state, to tell the truth about his findings rather than to the patient. An overview of medical versus forensic ethics in regard to child and adolescent psychiatry can be found in Ratner (2002), and an exhaustive consideration of the kinds of ethical dilemmas in which adolescent psychiatrists can find themselves can be found in Koocher and Keith-Spiegel (1993). At some time in their careers, psychiatrists who specialize in nearly every area of psychiatry – including adolescent psychiatry – may find themselves asked to appear in court. Many colleagues, terrified at the prospect, do everything they can to avoid participation in the legal process, but if one feels committed to one’s patient and believes that participation will be in his or her best interests, one may be drawn into the fray. On other occasions one may be summoned to court by subpoena regardless of one’s unwillingness to take part in the process.

Generally, individuals with special expertise to share with a court may appear either as ‘fact’ witnesses or ‘expert’ witnesses. Typically, medical professionals appearing as fact witnesses do so by virtue of having – or having had – a treatment relationship with a person or family involved in a suit. On the other hand, expert witnesses are generally those who have involved themselves in the case for the specific purpose of performing an evaluation and rendering an expert opinion, such as regarding custody, competence, or amenability of a juvenile to treatment. Fact witnesses may be paid no more for their appearance in court than any lay witness (a nominal fee), but since it is rare that a psychiatrist on the stand does not, at some point, state an expert opinion, most psychiatrists are welladvised to request expert status. Entire volumes have been devoted to the nuts and bolts of running a forensic practice (e.g., Berger 1997; Gutheil 1998), including dealing with just such questions, and the reader is referred there for further information. Regardless of whether one appears voluntarily or involuntarily or as a fact or expert witness, it is important to be prepared in order to testify intelligently and effectively. Adequate preparation, as is understood by a forensic psychiatrist, concerns itself with two aspects of one’s testimony: content and process. ‘Content’ refers to one’s knowledge both of the facts of the case and of the pertinent law, the latter so that one understands exactly what information and opinions may be requested by the court. ‘Process’ refers, for our purposes, to the way one conducts oneself and communicates on the stand in order to maximize one’s believability and persuasiveness and to parry and neutralize the attacks upon one’s credibility and expertise during examination by opposing attorneys. This is as important to master as is a grasp of the facts and the law, as nearly all courts of law are adversarial in nature, and on most occasions when a psychiatrist is called to testify it is in order to bolster the view of one or another party. Accordingly, it is often in the interest of the opposing side to diminish the strength and credibility of that psychiatrist’s testimony through crossexamination, a process that is often harrowing, especially to the inexperienced professional. These issues are further discussed and referenced below in the chapter on the role of the psychiatrist in evaluation, but for a full-scale exposition of these issues, the reader is referred to, among others, Berger (1997), Gutheil (1998), and Rosner (1999). During the past thirty years, forensic psychiatry has become recognized as a distinct subspecialty of general psychiatry: the American Board of Psychiatry and Neurology now offers a certificate of Added Qualifications in Forensic Psychiatry. Training in forensic psychiatry is now achieved through a one-year fellowship that is offered by a number of different departments of psychiatry nationwide. These programs have developed in concert with the process of certification in forensic psychiatry, which had its beginnings through the efforts of the American

420 Adolescent psychiatry and the law

Academy of Psychiatry and Law (AAPL), a membership organization, and the American Academy of Forensic Sciences (AAFS), a multidisciplinary organization embracing many scientific specialties. For many years these organizations sponsored a certification examination until the process was taken over by the American Board of Psychiatry and Neurology. One example of a ‘model curriculum’ for forensic psychiatry as a subspecialty is embodied in the text often used for board preparation (Rosner 1999). Given that it has been produced largely by psychiatrists with expertise in both forensic and adolescent psychiatry, it may not be too much to hope that this section could be thought of as a model curriculum for adolescent forensic psychiatry. Finally, thanks to the introduction of the personal computer and the Internet, a vast library of information resources has opened up to anyone with the capacity to go on-line. In the chapters that follow, reference will be made not only to specific publications but also to such on-line resources as websites and search engines. Certain websites are especially pertinent for adolescent psychiatrists with an interest in forensic psychiatry, including those of the American Society of Adolescent Psychiatry (ASAP), the American Academy of Psychiatry and the Law (AAPL), and the Office of Juvenile Justice and Delinquency Prevention (OJJDP), which is linked to other databases maintained by the federal government through the Department of Justice (DOJ). These are listed below among the references. In particular, the AAPL site provides information not only about the organization itself but about fellowships and, through various links, to research tools with which one can look up important legal decisions that have a bearing on one’s current work. In a world grown increasingly litigious, there is a strong likelihood that many readers of this section will at some point be requested (or required) to make an appearance in court. For this reason and others, the

editors did not feel that this textbook would be complete without a section on legal psychiatry. We sincerely hope that it will prove useful to our colleagues.

REFERENCES American Academy of Psychiatry and the Law: website: www.AAPL.org American Society for Adolescent Psychiatry: website: www.adolpsych.org Ash, P. Malpractice in child and adolescent psychiatry. In Haller, L. (ed.), Child and Adolescent Psychiatric Clinics of North America: Forensic Psychiatry, Volume 11. Philadelphia: W.B. Saunders, 2002, pp. 869–886. Berger, S. Establishing a Forensic Psychiatric Practice: A Practical Guide. New York: W.W. Norton, 1997. Gutheil, T.J. The Psychiatrist in Court: A Survival Guide. Washington, DC: American Psychiatric Press, 1998. Koocher, P., Keith-Spiegel, P.C. Children, Ethics and the Law: Professional Issues and Cases. Lincoln (NE): University of Nebraska Press, 1993. Macbeth, J.E., Wheeler, A.M., Sither, J.W., Onek, J.N. Legal and Risk Management Issues in the Practice of Psychiatry. Washington, DC: Psychiatrists’ Purchasing Group, 1994. Office of Juvenile Justice and Delinquency Prevention: website: www.ojjdp.ncjrs.org Ratner, R. Ethics in child and adolescent forensic psychiatry. In Haller, L. (ed.), Child and Adolescent Psychiatric Clinics of North America: Forensic Psychiatry, Volume 11. Philadelphia: W.B. Saunders, 2002, pp. 887–904. Rosner, R. (ed.) Principles and Practice of Forensic Psychiatry. London: Edward Arnold Books (Oxford University Press), 1999.

PART 1 Legal aspects of mental health treatment

7.1

Legal issues in inpatient and outpatient psychiatric treatment Abigail English

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7.2

Custody, visitation and relocation issues in adolescence Alex Weintrob and Sandra G. Nye

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7.1 Legal issues in inpatient and outpatient psychiatric treatment ABIGAIL ENGLISH

A wide variety of legal issues are involved in the psychiatric treatment of adolescents in both inpatient and outpatient settings. Key legal issues that will be discussed in this section include the legal status of adolescents and the legal rights of minors, particularly with respect to consent for treatment, refusal of treatment, and confidentiality. It is critically important for practitioners to know and understand requirements that are drawn both from state and federal law, and a detailed discussion of all the relevant laws is beyond the scope of this chapter.

LEGAL STATUS OF ADOLESCENTS The legal status of an adolescent has a direct bearing on many of the legal issues involved in psychiatric treatment, determining, for example, who has the legal right to give consent for or to refuse treatment as well as the manner in which confidential information is protected. Some adolescents – those aged over eighteen years – are legally adults. As such, they have the same rights regarding psychiatric treatment as older adults. Adolescents who are under the age of eighteen years are legally minors, and their rights are limited by their status. However, the legal rights of adolescents who are minors are not limited to the same extent as those of younger children (Davis et al. 1997). Most adolescents who are minors are in the legal and physical custody of at least one parent. (For a more detailed discussion of legal issues in the lives of adolescents whose parents are separated or divorced, see Chapter 7.2.) The parent or parents of these minors are generally responsible for supporting them financially and, with some exceptions, have the legal right to make or to participate in many of the key decisions in their lives, including decisions about

psychiatric treatment. When an adolescent’s parents are divorced, the scope of each parent’s legal authority to make medical decisions for the adolescent often is specified in the court’s orders relating to custody of the minor. Some adolescents who are minors live apart from their parents or in other circumstances that affect their legal status. These adolescents include emancipated minors, runaways, teenage parents, youth in foster care, and wards of the court (Davis et al. 1997; English 1990, 1999). Only a small number of adolescents are legally emancipated, although a larger number are casually referred to as ‘emancipated minors.’ Legally emancipated minors have most of the legal rights of adults, but they also do not have the right to be financially supported by their parents. Traditionally, minors could be legally emancipated by marrying, serving in the armed forces, or living apart from their parents and managing their own financial affairs; and courts have recognized the legal emancipation of minors in each of these circumstances (Katz 1973). Today, a substantial number of states have enacted statutes incorporating the traditional criteria for legal emancipation, but few adolescents satisfy these criteria and seek decrees of emancipation (Davis et al. 1997; English 1999). A much larger number of adolescents live apart from their parents as runaways or homeless youth, either because they have left home voluntarily or because they have been rejected and forced out by their parents. While these adolescents may acquire some limited legal rights with respect to medical treatment as a result of their independent living status, they do not have most of the legal rights shared by emancipated minors and adults (English 1999; National Law Center on Homelessness and Poverty and National Network for Youth 2003). Even more adolescents live outside the legal and/or physical custody of their parents in state custody. These young people include those who are under the jurisdiction

424 Adolescent psychiatry and the law

of the juvenile court as delinquent youth, dependent (abused or neglected) youth, or status offenders. (For a detailed discussion of issues pertaining to these youth, see the following sections.) Some of these youth remain in the physical custody of their parents, while others are placed in foster homes, group homes, residential treatment centers, detention centers, boot camps, state training schools, or even adult jails. Whatever setting these youth are placed in, if they are under the jurisdiction of the court, the court has the authority to make significant decisions about their lives, often including medical decisions, although parents usually retain some authority as well, unless the parents’ authority has been limited by the court. Some authority is also frequently delegated to state officials such as probation officers or social workers or to a child welfare or juvenile justice agency (Gittler et al. 1990).

LEGAL RIGHTS OF MINORS The legal rights of minors vary not only based on their status, but also based on the states in which they live. Although a number of legal issues affecting the rights of minors are determined by federal law, either as a result of decisions of the United States Supreme Court or statutes enacted by Congress, many issues are determined by state law. Even with respect to issues on which the Supreme Court has spoken or Congress has acted, many of the specifics of how the federal law is implemented vary among the states. Some of the key areas in which these variations occur are consent to medical or psychiatric treatment and the confidentiality of information associated with that care (Holder 1985; Morrissey et al. 1986).

CONSENT FOR TREATMENT The laws governing consent to psychiatric or other medical treatment are mostly state laws, although, in specific areas such as reproductive health care and psychiatric hospital admission, they have been influenced in important ways by decisions of the United States Supreme Court and other federal courts interpreting the constitutional rights of minors. Key concepts in understanding the laws pertaining to consent for both outpatient and inpatient psychiatric treatment include informed consent, parental consent, and minor consent (Crosby and English 1991; English 1990, 1991; Holder 1985; Morrissey et al. 1986; Redding 1993; Rosovsky 1990).

Informed consent The informed consent of the patient or a person who is legally authorized to provide it is a prerequisite for

medical or psychiatric care. A health care professional who fails to obtain informed consent when it is legally required risks legal liability for negligence or malpractice. The basic legal doctrine of informed consent requires that the patient understand the risks and benefits of the proposed treatment or procedure, and of any alternatives to what is being proposed, and make a voluntary choice among those alternatives (Appelbaum et al. 1987).

Parental consent Generally, the consent of a parent is required for medical or psychiatric treatment provided to a minor child or adolescent. However, there are numerous exceptions to this requirement. In an emergency, consent is ‘implied’ and care may be provided without prior consent as long as parents are promptly informed. Ordinarily, the consent of a parent would be sufficient for either inpatient or outpatient psychiatric treatment provided to an adolescent who is a minor. Once an adolescent is an adult, parental consent generally would not be required and would not be sufficient to authorize care (English 1990; Holder 1985; Morrissey et al. 1986).

Consent of an adolescent who is an adult Adolescents who are over the age of eighteen years and, therefore, are adults may give consent to their own inpatient and outpatient psychiatric care on the same basis as other adults. This presumes that they have the capacity to give informed consent. If they are mentally impaired to the degree that they cannot give informed consent, court procedures must be invoked, either to obtain a court order authorizing necessary care or to empower some other individual to give consent (Brakel et al. 1985).

Minor consent Every state has some laws that authorize minors to give consent for medical or mental health care under specific circumstances. Some of these laws allow minors to give their own consent for all or most health care based on their legal status, while others authorize minors to give their own consent based on the specific services sought. The state statutes that provide for minor consent are sometimes referred to as ‘minor consent’ or ‘medical emancipation’ statutes (English 1990; English et al. 2003; Morrissey et al. 1986). The categories of minors who, in some states, are allowed to give consent for all care include emancipated minors, married minors, minors in the armed forces, mature minors, minors living apart from their parents, minors over a certain age, high school graduates, pregnant minors, or minor parents. In addition, although only a few states have statutes that explicitly incorporate

Legal issues in inpatient and outpatient psychiatric treatment 425

it, the mature minor doctrine provides a basis for mature minors – those who are capable of giving informed consent – to give their own consent for care that is not high risk and that is well within the scope of accepted treatment (English et al. 1995, 2003; Holder 1985; Morrissey et al. 1986). The categories of services for which, in some states, minors are allowed to give their own consent for include emergency care, pregnancy-related care, contraceptive services, abortion, diagnosis or treatment of venereal diseases (VD) or sexually transmitted diseases (STD), diagnosis or treatment of reportable, infectious, contagious, or communicable diseases, HIV/AIDS testing or treatment, treatment or counseling for drug or alcohol problems, collection of medical evidence or treatment for sexual assault, outpatient mental health services, and inpatient mental health services. Some of these statutes set limits on the care that minors may give consent for, excluding sterilization from a pregnancy-related care statute, for example. The variations among the states are significant: every state allows minors to obtain care for STD or VD without parental consent, while the majority of states, with some noteworthy exceptions, have enacted a law requiring parental consent or court orders when minors seek abortions (English et al. 2003; Holder 1985; Morrissey et al. 1986).

PSYCHIATRIC CARE Outpatient psychiatric care Outpatient psychiatric care – referred to variously as ‘outpatient mental health counseling,’ ‘outpatient mental health treatment,’ and in other ways – is one of the categories of service for which many states allow minors to give their own consent: almost half the states do so. The specific circumstances in which this is allowed vary from state to state. The limitations that are imposed may pertain to the characteristics of the minor giving consent, the consequences of the minor not receiving the treatment, the type of care, or the professional person providing it. Some statutes only allow minors who are above a certain age – such as twelve, fourteen, or fifteen years – to give their own consent, while others specifically delineate other required characteristics, limiting the right of consent to minors who are ‘mature enough to participate intelligently’ in the treatment, for example. Some states also condition the minor’s right of consent on the mental health professional’s determination that the provision of services is necessary to the minor’s well-being or that some adverse consequence, such as a danger of serious mental or physical harm to self or others, is likely to result if the minor does not receive the treatment. Some states

specify the professional persons who are authorized to provide care and may include psychiatrists, clinical psychologists, social workers, family therapists, or others. A few states explicitly specify the services to which minors may give their own consent – such as ‘counseling services or psychotherapy,’ ‘treatment for emotional or psychological problems’, or ‘any mental health services to determine the presence of, or to treat, pregnancy, venereal disease, drug dependency, alcohol toxicity or any reportable disease’ – while others explicitly exclude certain services – such as psychotropic medications, aversive stimuli, convulsive therapy, or psychosurgery – from the scope of care for which minors may give their own consent. Finally, several states limit the number of sessions, often setting the limit at six, for which a minor may be seen without parental consent, unless involving the parents would be seriously detrimental to the minor’s well-being (English et al. 2003).

Inpatient psychiatric care The range of laws affecting the admission of minors to inpatient psychiatric facilities is separate from and more complex than the laws governing consent for outpatient services. Traditionally, parents had the right to decide that a minor child should be admitted to an inpatient psychiatric facility. Their right to do so without judicial review was challenged in a case that reached the United States Supreme Court more than twenty years ago. In that case, children in Georgia who had been admitted to state psychiatric hospitals challenged the constitutionality of the ‘voluntary admission’ statutes that permitted their parents, or child welfare agencies acting in loco parentis, to sign them in. In a decision that has been frequently cited for the proposition that the constitutional rights of minors are more limited than those of adults, the Supreme Court ruled that while the full panoply of due process rights, including formal pre-commitment hearings, is not required for the admission of a minor to a state mental institution, some protections are required. Specifically, the Court decided that the ‘risk of error inherent in the parental decision to have a child institutionalized for mental health care is sufficiently great that some kind of inquiry should be made by a ‘neutral factfinder’ to determine whether the statutory requirements for admission are satisfied.’ That neutral factfinder could be a staff physician of the facility to which the child or adolescent was being admitted (Parham v. J.R. 1979). Since the Supreme Court decision in Parham, the issue of voluntary and involuntary admission to public and private inpatient psychiatric facilities has continued to be a subject of considerable controversy. During the intervening years, most states have passed stringent civil commitment laws restricting the involuntary commitment of adults, and thus adolescents who are adults. The laws

426 Adolescent psychiatry and the law

governing inpatient admission of adolescents who are minors, however, are less clear and more in flux. At the time of the Parham decision, approximately thirty states had statutes which allowed parents to admit their children ‘voluntarily’ to state psychiatric facilities. Since that time, a number of states have modified their statutes in a variety of ways. Some states have enacted provisions allowing minors to give their own consent for inpatient admission, while others have adopted rules allowing parents to admit a minor child, unless the minor objects, in which case a hearing must be held. The extent to which rules adopted for admission to state psychiatric facilities also apply to private institutions is even less clear. Generally, fewer constitutional protections of minors’ rights apply in the case of private facilities, but this is an evolving area of the law. In all cases, practicing psychiatrists must understand the rules governing inpatient admission for minors and adults in their own states (Brakel et al. 1985; Mason and Ellis 1994; Rozovsky 2001).

REFUSAL OF TREATMENT The patient’s legal right to refuse medical or psychiatric treatment is a complex and evolving area of the law. When the patient is a minor, the issues are even more complex. To the extent that the law recognizes a right to refuse psychiatric treatment, it is not always clear who may exercise that right – the parent, the minor, or both. Also, for adolescents, there may be psychiatric issues related to refusal of care other than mental health treatment: adolescents who refuse lifesaving treatment for a curable illness or who refuse invasive treatments for an end-stage terminal illness may require a psychiatric evaluation (Appelbaum et al. 1987; Brakel et al. 1985; Rozovsky 2001; Winick 1997). With respect to psychiatric treatment, some of the procedures most likely to trigger a refusal of care by either adult or adolescent patients are electroshock therapy (ECT), psychotropic medication, psychosurgery, and restraints. Most of the court decisions and statutory provisions that have addressed the issues surrounding the use of these procedures and the refusal of psychiatric patients to undergo them have involved adult patients rather than minors. These procedures, as others, require that the decision to accept the treatment be a fully informed one and be made by the patient or someone with the legal authority to do so. The fact that a patient is hospitalized does not automatically mean that a patient lacks the legal capacity to consent or withhold consent to specific procedures. Moreover, these procedures have been the subject of extensive legislative and judicial action. Therefore, the specific limitations in state law that apply to each procedure must be ascertained (Rozovsky 2001).

Refusal of care by parents The refusal by parents to give consent for medical care for their children also has been the subject of extensive litigation and legislative action. Whether the law recognizes the parents’ right to refuse care depends on a variety of factors, particularly whether the care being refused is lifesaving or elective. The law recognizes greater authority on the part of parents to refuse elective care, and is more likely to provide a basis for state intervention in the case of parental refusal to give consent for lifesaving treatment. Other significant factors include whether the refusal is based on religious grounds and whether the parents and the child are in conflict or in agreement, with less likelihood of state intervention in cases of refusal for religious reasons and ones in which parent and child agree. When parents refuse care that courts believe to be essential to save a child’s life, the jurisdiction of the court is invoked under child neglect laws to enable the court to remove the child, at least temporarily, from the parents’ legal custody and to authorize the treatment (Rozovsky 2001).

Refusal of care by minors The authority of minors to refuse treatment is far from clear. However, as the law increasingly recognizes the right of minors to consent to certain care, their right to refuse may receive increasing recognition as well (Costello 1998; Hartman (in press)). For example, some statutes that require the consent of a minor over a certain age to be sought prior to inpatient admission to a psychiatric facility also require a hearing if the adolescent objects. In some situations, a minor may effectively ‘refuse’ care simply by not cooperating with the treatment – as in psychotherapy – whether or not the law recognizes a legal right to refuse. Where a minor refuses care requiring informed consent – such as medication, ECT, or psychosurgery – but the parents consent, the situation is more likely to be one requiring a clinical rather than a legal resolution. Overriding the refusal of a mature minor or older adolescent should be undertaken with caution even where the law supports doing so (Brakel et al. 1985; Rozovsky 2001).

CONFIDENTIALITY Whenever an issue arises concerning the disclosure of confidential information about psychiatric treatment it is important to ask at least three basic questions: 1 What must not be disclosed? 2 What may be disclosed? 3 What must be disclosed?

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There are numerous legal and ethical bases for the confidentiality obligation. The source of confidentiality protection may determine, at least in part, who can authorize the disclosure of confidential information. In some situations, as in child abuse cases or where there is a duty to warn, disclosure may be required by law. While the specific scope of protections may vary, confidentiality protection for psychiatric information includes not only written records, but also computerized records, and verbal communications (Council on Scientific Affairs 1993; English 1990, 1991; Gans 1993; Nurcombe and Partlett 1994).

Sources of the confidentiality obligation The obligation of psychiatric and medical professionals to protect the confidentiality of patient information has numerous sources in law and ethics. These sources include the privacy provisions of the federal and state constitutions; federal statutes and regulations (such as the rules applicable in federally funded family planning and drug and alcohol programs as well as new federal privacy rules); state statutes including broad medical records laws as well as specific protections for particular records; the regulations and guidelines of social welfare, education, welfare, child welfare, health, and other agencies; statutory privileges, such as the physician–patient and psychotherapist–patient privilege; and the ethical standards of professional organizations. Protection of confidentiality is an area in which federal laws are of increasing importance. For example, the federal rules governing confidentiality in federally funded family planning services and those governing confidentiality and disclosure in drug and alcohol programs are particularly stringent. Specifically, the drug and alcohol rules, which apply in a broad range of public and private facilities and programs, provide protection for minors as well as adults. Moreover, in 2000, new federal regulations were issued that will have a major impact on the privacy of certain medical records, including mental health records (Department of Health and Human Services 2000). The federal medical privacy rules (often referred to as the ‘HIPAA’ rules because they were adopted pursuant to the Health Insurance Portability and Accountability Act of 1996) contain significant provisions affecting privacy of medical information related to unemancipated minors, particularly when minors have the right to consent to their own care (Department of Health and Human Services 2000). In August 2002, modifications of the minors’ provisions were made final (Department of Health and Human Services 2002). While the specific terms of each of these confidentiality protections vary, they share some basic principles. In general, confidential information that is protected must not be disclosed without the explicit permission of the patient or, in some cases when the patient is a minor,

of the parent. A major exception to this rule arises when disclosure is required by law.

Who controls disclosure? Generally, the right to control the disclosure of confidential medical or psychiatric information rests with the patient, but when the patient is a minor the situation is more complex. In those circumstances in which the parents are the ones to give consent for the care, the parents may well be the ones who have the right to authorize, or to withhold permission, to release confidential information about that care. Even when this is the case, it may be ethically appropriate if not legally required to seek the concurrence of the adolescent to release information. ‘Regardless of the locus of decision, the child psychiatrist will attempt to inform the child or adolescent of the need and intent to release information and will seek his/her concurrence even though such agreement is not required.’ (American Academy of Child Psychiatry 1980). In some situations, when the law authorizes the minor to consent to the care, it may also empower the minor to decide whether or not confidential information should be disclosed (English 1990; English et al. 2003; Nurcombe and Partlett 1994). The question of when and how mental health information pertaining to the care of an adolescent may or should be disclosed to parents remains an evolving area of law. Clearly, confidential information concerning an emancipated minor should not be disclosed to parents without the minor’s permission; for mature minors who are not emancipated, however, the situation is less clear, although disclosures to parents that would deter minors from seeking care should be avoided if possible (Nurcombe and Partlett 1994). In some states, which allow minors to give their own consent for outpatient and/or inpatient mental health treatment, minors have a legal right to make at least some decisions about disclosure (English et al. 2003; Nurcombe and Partlett 1994). In many states and many situations, the relative rights of minors and their parents with respect to decisions about disclosure remain open to interpretation. The new federal medical privacy regulations rely heavily on state laws: generally under the new federal rules, a minor who has the right to consent to care also acquires some rights to control the information about that care (Department of Health and Human Services 2000, 2002). When state or other laws are silent about disclosure to parents, however, under the modifications to the rules made final in 2002, health care professionals would have discretion to decide about sharing records with parents (Department of Health and Human Services 2002). Certainly, in situations where the risk of harm is great – such as when an adolescent is suicidal – preventive measures must be taken and, depending on the circumstances,

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these preventive measures may include notification of parents (Neisser 1993). Usually, the adolescent patient should be informed in advance of any limitations that apply to confidentiality, including whether and when parents will be informed. Of course, in this as in all areas, it is critically important that practitioners be aware of applicable federal and state laws.

consent; whether the law recognizes the right of parents and/or minor patients to refuse care in general or specific care; the scope of confidentiality protections under state and federal law; and the circumstances under which state or federal law mandates disclosure of confidential information.

Mandatory and permissive disclosure

REFERENCES

Psychiatrists treating adolescents must understand the situations in which disclosure is mandated, even over the objection or without the consent of the adolescent patient or the parent, as well as the circumstances in which the psychiatrist has the discretion to determine whether or not disclosure is appropriate. For example, some statutes which allow minors to consent to outpatient mental health services also vest discretion in the treating professional to decide whether or not to involve or inform the parents (English et al. 2003). There are at least three key situations, among others, in which disclosure of confidential information is mandatory: 1 When the psychiatrist determines that the adolescent patient is suicidal or presents a serious risk of harm to himself or others. While it may not always be mandatory to inform the parents, it is necessary, at minimum, to take preventive measures, particularly in cases of suicidality. 2 A psychiatrist may have a legal duty to warn the intended victim of a patient who has expressed a direct threat against an identifiable individual’s life or, in the alternative, to alert law enforcement authorities to that threat. 3 The duty to report physical or sexual abuse under state child abuse reporting laws generally abrogates the physician–patient and psychotherapist–patient privileges. A psychiatrist who suspects that an adolescent has been physically or sexually abused must, therefore, report those suspicions to a child welfare or law enforcement agency. The specific reporting procedures are specified in each individual state’s reporting statute (Brakel et al. 1985; English 1990; Holder 1985; Morrissey et al. 1986; Nurcombe and Partlett 1994).

CONCLUSION A psychiatrist who is treating an adolescent must, at minimum, understand several key issues: the legal status of the adolescent; whether the adolescent is an adult or a minor; whether state law allows minors to give their own consent for inpatient and outpatient psychiatric treatment; whether the adolescent is capable of giving informed

American Academy of Child Psychiatry: Code of Ethics, 1980. Appelbaum, P.S., Lidz, C.W., Meisel, A. Informed Consent: Legal Theory and Clinical Practice. New York, NY: Oxford University Press, 1987, pp. 35–65, 81–111, 190–207. Brakel, S.J., Parry, J., Weiner, B.A. The Mentally Disabled and the Law, 3rd edition. Chicago, IL: American Bar Foundation, 1985, pp. 21–176, 327–367, 559–605. Costello, J.C. Making Kids Take Their Medicine: The Privacy and Due Process Rights of De Facto Competent Minors. Loyola of Los Angeles Law Review 31: 907–927, 1998. Crosby, M.C., English, A. Mandatory parental involvement/judicial bypass laws: do they promote adolescents’ health? Journal of Adolescent Health 12: 143–147, 1991. Council on Scientific Affairs, American Medical Association: Confidential health services for adolescents. Journal of the American Medical Association 269: 1420–1424, 1993. Davis, S.M., Scott, E.S., Wadlington, W., et al. Children in the Legal System: Cases and Materials, 2nd edition. Westbury, NY: Foundation Press, 1997, pp. 99–242. Department of Health and Human Services. Standards For Privacy of Individually Identifiable Health Information; Final Rule – 45 CFR Parts 160 and 164. 65 Fed. Reg. 82462 (December 28, 2000), p. 82806. Department of Health and Human Services. Standards for Privacy of Individually Identifiable Health Information; Final Rule – 45 CFR Parts 160 and 164. 67 Fed. Reg. 53182 (August 14, 2002) p. 53267. English, A. Health care for the adolescent alone: a legal landscape. In Blustein, J., Levine, C., Dubler, N.N. (eds), The Adolescent Alone. New York: Cambridge University Press, 1999, pp. 78–99. English, A. Overcoming obstacles to adolescent care: legal issues. In Comerci, G.D., Daniel, W.A., Jr. (eds), Adolescent Medicine: State of the Art Reviews-Parenting the Adolescent: Practitioner Concerns, Volume 2, No. 2. Philadelphia, PA: Hanley & Belfus, Inc., 1991, pp. 429–436. English, A. Treating adolescents: legal and ethical considerations. Medical Clinics of North America 74: 1097–1112, 1990.

Legal issues in inpatient and outpatient psychiatric treatment 429 English, A., Morreale, M., Hersh, C.L., et al. State Minor Consent Laws: A Summary, 2nd edition. Chapel Hill, NC: Center for Adolescent Health & the Law, 2003. Gans, J. A Policy Compendium on Confidential Health Services for Adolescents. Chicago, IL: American Medical Association, 1993. Gittler, J., Quigley-Rick, M., Saks, M.J. Adolescent Health Care Decisionmaking: The Law and Public Policy. Washington, DC: Carnegie Council on Adolescent Development, 1990. Hartman, R.A. Dying young: cues from the courts. Archives of Pediatric and Adolescent Medicine, 2003 (in press). Holder, A. Legal Issues in Pediatric and Adolescent Medicine. New Haven, CT: Yale University Press, 1985. Katz, S.N. Emancipating our children: coming of legal age in America. Family Law Quarterly 7: 211–241, 1973. Mason, M.A., Ellis, J.W. Due process for adolescents. In Mason, M.A., Gambrill, E. (eds), Debating Children’s Lives: Current Controversies on Children and Adolescents. Thousand Oaks, CA: Sage Publications, 1994, pp. 272–284. Morrissey, J.M., Hoffman, A., Thorpe, J.C. Consent and Confidentiality in the Health Care of Children and

Adolescents: A Legal Guide. New York, NY: The Free Press, 1986. National Law Center on Poverty and Homelessness, National Network for Youth. Alone Without a Home: A State-by-State Review of Laws Affecting Unaccompanied Youth. Washington, DC: National Law Center on Poverty and Homelessness and National Network for Youth, 2003. Neisser, J. Disclosing adolescent suicidal impulses to parents: protecting the child of the confidence. Indiana Legal Reviews 26: 433, 1993. Nurcombe, B., Partlett, D.F. Child Mental Health and the Law. New York: The Free Press, 1994. Parham v. J.R., 442 U.S. 584 (1979). Redding, R.E. Children’s competence to provide informed consent for mental health treatment. Washington & Lee Legal Review 50: 695, 1993. Rozovsky, F.A. Consent to Treatment: A Practical Guide, 3rd edition. Gaithersburg, MD: Aspen Inc., 2001, pp. 5:1–5:99, 6:1–6:73, 7:1–7:93. Winick, B.J. The Right to Refuse Mental Health Treatment. Washington, DC: American Psychological Association, 1997.

7.2 Custody, visitation and relocation issues in adolescence ALEX WEINTROB AND SANDRA G. NYE

INTRODUCTION Divorce has become a common phenomenon in the United States, occurring in roughly one in two marriages, and leaving approximately 40–50 per cent of all children living with only one parent at some time during their lives. The great majority (two-thirds to three-quarters) of divorcing couples manage to work out issues of custody, visitation, and relocation for their children without the intervention of the courts. The cases that end up in the court system (approximately 5–10%) generally involve children aged younger than twelve years. However, while a minority of the cases involves adolescents, these situations may pose special problems for the courts, for the forensic psychiatrist and, most of all, for the adolescent. This is because of both the extraordinary animosity and hostility generally encountered in these situations and the special nature and needs of adolescents (as distinct from children) who are caught in the middle of their parents’ dispute. Additionally, there are indications that in recent years more parents of adolescents – particularly those parents who can afford the high costs associated with litigation – have sought judicial intervention. While the focus of this chapter will be on forensic issues, it will also offer brief overviews of divorce, custody, visitation and relocation. The various roles of the adolescent psychiatrist in divorce issues will be addressed briefly. Finally, focus will be centered on the forensic evaluation of custody, visitation, and relocation disputes involving adolescents. Given the prevalence of divorce and the numbers of children involved, any psychiatrist who treats adolescents will be confronted with the impact of the law whether or not he or she opts to play any role in the legal process. Divorce law is state specific, so that a detailed familiarity

with the local divorce and custody laws governing the lives of young patients is important for any psychiatrist seeing adolescents. While much has been written on the adverse effects of divorce upon children and adolescents, it has largely not been based upon carefully controlled studies. There is good documentation, however, that the greatest predictor of negative outcome lies in the level of animosity between the parents. (Often this both precedes and follows the divorce.) There is increasing evidence (Kelly 2000) that it may be the troubled marriages (preceding divorce) that affect children negatively rather than the divorce itself. There are also indications that the majority of children of divorce are quite resilient (Kelly 2000).

OVERVIEW OF DIVORCE, CUSTODY, VISITATION AND RELOCATION Divorce Divorce is often misunderstood as a single event in time. Rather, it must be seen as having significant antecedents (often many years of conflict preceding the divorce), current stresses (angry or frightened parents preoccupied with their own concerns, with significantly diminished ability to address the concerns of their children, who are now most in need of support and getting less than usual), and multiple sequelae (loss of on-going contact with one parent, move to new home and school, often diminished finances, new adults and often new families). Thus, even under the best of circumstances, it places children at significant risk for interference in their optimal development. When the divorcing parents end up in litigation (often referred to as highly contested disputes), the interferences

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in development multiply astronomically. Offspring, previously subjected to enormous ongoing parental hostility and to the outbursts of what are often personalitydisordered parents, are now placed in the middle of their parents’ disputes. Each parent not only vilifies the other but demands that the child take his/her side. Anything short of absolute loyalty is considered betrayal. While even younger children are turned to for support by their parents, demands upon adolescents are extraordinary. They are asked to provide the support and solace not available from the other parent, to be actively engaged in the parental dispute, often to act as detective to uncover misdeeds by the other parent, and subjected to the diatribes against each parent. This, of course, occurs just at the time the adolescent is attempting to separate from the family, to form an identity separate from his/her parents, and to become part of the peer community. Instead, the adolescent is drawn back into the family, asked to choose between parents, enmeshed in the family pathology from which adolescence at least offered some possibility of emerging. In reaction, he/she may turn to peer groups with a vengeance, often choosing deviant groups involved with alcohol, drugs, and precocious sexual activity, or may even go on to develop a psychiatric disorder. The divorce process itself can extend over a protracted period, with numerous interim court hearings on temporary custody, access, and support prior to the actual trial of the case. Each time the parents are in court, the children’s problems are exacerbated. In large urban areas, full dockets often make it impossible for judges to deal expeditiously with children’s issues, which are often inextricably bound up in the parents’ financial and personal concerns. In the chaos of divorce, the treatment sessions may provide the only oasis of calm and stability for the adolescent. The parents and their lawyers, caught up in the adversary process and the need to win, may seek to intrude into the therapeutic relationship or pervert it in the service of the legal battle. The psychiatrist may be hard pressed to stave off these assaults, but it is most urgent for the patient that the therapy remain a safe haven. The legal issues to be determined in every divorce case are child custody, visitation and support; division of property between the spouses; and spousal support. Each state has established criteria for decision-making on each of these issues, often by statue supplemented by case law (decisions by appellate courts which set precedents for other cases with similar facts). In some states, ‘marital wrong’ may be used as a factor in distributing property or awarding spousal support and custody. For example, an adulterous wife may be deprived of alimony, or a deserting husband may be punished by awarding the wife an inordinate share of the property. In other states, marital wrong is not to be considered. Similarly, some states ignore marital misconduct of a parent in awarding custody or visitation, unless it can be shown that the misconduct has

adversely affected the child or creates an endangerment. Others impose strict standards of morality (more often on mothers than on fathers!) in determining parental fitness and best interests of the child. Substance abuse, mental illness, physical illness, gender preference, or a criminal record will be viewed variously by the various states as factors in determining custody and visitation. The local court’s approach to these issues will influence the child’s life and is important information for the adolescent’s psychiatrist. In addressing issues of divorce as they apply to adolescents, the psychiatrist is well served to remind himself/ herself of adolescent development and then to determine what aspects have particular application to the issue of divorce as well as disputes over custody, visitation, and relocation.

Custody Custody is a legal concept that generally refers to overall responsibility for and control over one’s child. For the better part of the twentieth century, guided by the concepts of the ‘tender years’ doctrine, courts routinely awarded custody of children (at least younger, but often older) to mothers. Although this doctrine has been, over time, theoretically and legally replaced in all fifty states by the ‘best interests of the child’ test, for all practical purposes judges continue to this day to favor mothers in awarding custody. This is true despite the fact that on constitutional grounds gender-based custody decision-making is prohibited. It is helpful both for the adolescent and his or her psychiatrist to know what factors are mandated by state law to be considered by a judge in awarding custody. One should procure this information from an attorney if one is not able to do the legal research on one’s own. During the 1970s, as a means of preserving children’s contacts with both parents, the concept of joint custody, with each parent having legal rights and responsibilities, came into favor. Some states have either mandated such an arrangement or suggested that it be presumed the arrangement of choice. This has met with mixed results, in that joint custody works for parents who get along well, but tends to be quite problematic with angry parents involved in highly contested custody disputes. It is important to note that joint custody may, but need not necessarily be, equivalent to equal time with each parent. (Most joint custody awards involve joint legal custody rather than joint residential custody [equal time].) More often than not, children will still maintain a primary residence with one parent. After some years of experience with joint custody, a number of courts have sharply reversed the joint custody trend, or are taking a neutral stand. While joint legal custody is still being approved, split residential custody is rapidly falling into disfavor. Some courts have gone so far

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as to hold that permitting the shifting of children between parental homes is an abuse of judicial discretion. Frequently, fathers seek joint custody as a tactic, with the knowledge that it is likely that, unless they can prove the mother unfit (e.g., psychotic, drug-addicted or criminal), she will be awarded sole custody. During the past decade, however, fathers have achieved greater success in being awarded either joint or sole custody without proving the mothers unfit. This is a direct result of the substitution by the courts of the ‘best interests of the child’ doctrine for the earlier ‘tender years’ doctrine and Supreme Court pronouncements requiring gender equality in the courts. Other contributing factors are:

of International Child Abduction, which requires the return of a child under the age of sixteen years wrongfully removed or retained from its ‘state of habitual residence’ (home state). There are many countries that have not adopted the Convention (notably Asian, African and Latin American states), and it is often impossible to retrieve children brought to those countries. Federal law criminalizes international child abduction by a parent or others, which may act as a deterrent in some cases, but extradition of a kidnapping parent is not always possible, and some authorities feel that invoking criminal law complicates the family’s problems and may interfere with the child’s return.

• • •

Visitation

the high frequency of both parents working; the father’s ability to muster a very strong case; and the fathers’ ability, because they generally have more money than the mothers, to afford better attorneys and higher legal fees, and wear the mothers down. (The authors know of cases where legal and expert witness fees have approached 500,000 dollars.)

In order for a court to have power to adjudicate a case, it must have jurisdiction both over the subject matter of the dispute, the child, and in some instances, both of the parties. Child custody subject matter jurisdiction is determined by the Uniform Child Custody Jurisdiction Act (UCCJA). Under the UCCJA, the child’s home state has child custody jurisdiction unless one of the exceptions applies. Physical presence of the child in a state, or of the child and one of the contestants, does not, alone, confer jurisdiction on a court to make a child custody determination. While physical presence of the child in the adjudicating state is considered desirable, it is not a prerequisite for custody jurisdiction. Cases of ‘child-snatching’ have proliferated as parents attempt to ‘forum shop’ by taking a child to a jurisdiction perceived to be advantageous, or to evade an adverse custody determination. Removing the child for custody litigation purposes will not work unless the left-behind parent fails to act for a period of six months, at which point the child’s home-state shifts. To discourage parents from child-snatching and forum shopping, the federal Parental Kidnapping Prevention Act (PKPA) was enacted in 1988. Under PKPA, parental kidnapping is defined as wrongful removal by a parent from the physical custody of the other parent who has custodial (including visitation) rights without consent, or wrongfully retaining a child after a visit or other temporary relinquishment of physical custody. PKPA requires that states give full faith and credit to each other’s custody decrees, and generally prohibits modification by a state other than the home state. Parental kidnapping is also a criminal act under some state laws. The increasing number of international marriages has given rise to numerous inter-country custody and access disputes. The United States and forty-one other countries have adopted the Hague Convention on the Civil Aspects

In uncontested divorces, the couple generally works out a schedule of when and how the children will spend time with each parent. Often, this is flexible and will be adjusted according to the parents’ and the children’s needs. In contested divorces in which one party ends up being awarded custody, a fixed schedule of time is generally stipulated. This can involve a wide range of time, from minimal to what is often called ‘liberal’ visitation, although the concept of ‘liberal’ varies according to which parent is ‘giving’ it and which parent is ‘receiving’ it. A common schedule, sometimes referred to as the ‘Manhattan cocktail’ (once agreed upon by two attorneys, it became almost a fixed schedule for everyone), includes every other weekend, Wednesday nights for dinner, and some split of holidays, school vacations, and summers. At the other end of the spectrum is a schedule offering maximal amounts of time with the noncustodial parent. The issue of visitation is a particularly sensitive one for adolescents, many of whom wish to control their own schedules and do not want to feel obliged by a court decree to see their noncustodial parent when they do not wish to do so or have other activities. Later in life, they are noted to complain vociferously about what they view, in retrospect, as having had no choice about whether or when they spent time with their noncustodial parent, being ‘forced’ to spend time with that parent even when they had other things they preferred doing. Finally, note should be made that the concept of visitation is anathema to many noncustodial parents as it implies that they are individuals to be visited, like visiting day at camp, rather than involved parents. For this reason, some lawyers and judges prefer the terms ‘access’ and ‘exclusive parenting time’ to ‘visitation.’ The Hague Conference on Private International Law has adopted the term ‘parental responsibility,’ rather than ‘custody’ in recent draft conventions involving children’s matters. The adolescent’s psychiatrist may find it helpful in working with the patient, parents and lawyers, to reframe the issues in these alternative terms. Experience and the testimony of

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numerous expert witnesses in many courts have given rise to public policy encouraging the maintenance of the primacy of the parent–child relationship and strong family relationships, even in post-divorce situations. The general wisdom is that children need liberal access to their parents, and parents have a natural or inherent right of access to their children. The law views the rights to marry, procreate, engage in family relationships and rear and educate children as fundamental to the concept of ordered liberty and, therefore, constitutionally protected. The child’s best interests is the standard for custody determination, but within that context, the courts are bound by the United States Constitution and public policy also to preserve the noncustodial parent’s right to participate in the life of the child. Visitation, or access, is the vehicle by which divorce law attempts to achieve this balance. Some courts take the position that because the noncustodial parent’s constitutional liberty, property and procedural rights prohibit interference in parental access without due process of law, reasonable access (always consistent with the child’s age, needs and best interests) is mandatory unless it can be shown by clear and convincing evidence that it would seriously endanger the child’s physical, mental, moral or emotional health. Daytime, overnight, weekend and holiday visitation – as age and stage appropriate – are legally protected rights of both child and noncustodial parent.

Relocation Relocation involves a move, usually by a custodial parent, to a location distant from the noncustodial parent. Divorce settlements not infrequently include a stipulation that the custodial parent will not move outside a predetermined radius. Reasons offered for relocation often involve a parent remarrying or being offered a significantly better job in another state. States vary greatly in their responses to the parent who wishes to relocate, from allowing this for a number of reasons to limiting it severely. The argument in favor of allowing relocation is that custodial parents should have the right to determine both their and their children’s interests. The argument against is that relocation often causes significant interference in the relationship between the children and their noncustodial parent as a result of the contact being significantly less frequent. Among mental health professionals there is no agreement as to whether more frequent contact with a noncustodial parent is superior to less frequent but more extended contact. Adolescents present peculiar circumstances related to relocation in that their attachment to their peer group often has very special meaning, particularly when their relationship with two warring parents is already strained. Thus, both their needs and their preference must be considered

somewhat differently from the situation with younger children. Until relatively recently, the custodial parent had total control over the decision-making for the minor child, including location, living arrangements, medical care and education. This all-or-nothing view has been ameliorated so that in some jurisdictions, although sole custody is awarded, the noncustodial parent retains at least residual rights. For example, noncustodial parents may have access by statute or marital settlement agreement to their children’s medical and school information and rights as to elective and extraordinary medical and dental treatment, private schooling, extracurricular activities, etc. There is national incentive to strengthen father–child bonding and payment of child support. Noncustodial parents’ rights accompany their obligations. The courts’ views on relocation (known in some jurisdictions as ‘removal’) have evolved along with the fathers’ rights movement and the research of such experts as Wallerstein and Kelly indicating that the children who do best after a divorce are the ones with optimal access to both parents. Other social science literature, including the work of Maccoby and Mnookin (1992) and Wallerstein and Tanke (1996), emphasizes the child’s relationship with the primary caretaker as the single most important factor affecting its welfare when the parents do not live together. Reflecting the variety of mental health and social science theory on optimal approaches to divorced and other single-parent families, state statutes range from creating a legal presumption of a custodial parent’s right to change the children’s residence, to declaring a presumption that it is a child’s best interests not to be removed from a parent who exercises access rights. In at least one state, the parent wishing to remove the child to another state has the burden of establishing by clear and convincing evidence the following factors: 1 Whether the proposed move will enhance the quality of life for both the custodial parent and the children. 2 Whether the proposed move is a ruse designed to frustrate or defeat the noncustodial parent’s visitation. 3 The motives of the noncustodial parent in resisting removal. 4 The visitation rights of the noncustodial parent. 5 Whether a reasonable visitation schedule can be achieved if the move is allowed. A reasonable visitation schedule is one that would preserve and foster the children’s relationship with the noncustodial parent. The reality is that in some states, the custodial parent must choose between custody of the children and his or her chance at career, remarriage and an improved life circumstance.

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ROLES OF THE PSYCHIATRIST IN FORENSIC DISPUTES As noted above, most couples manage to resolve their disagreements over custody, visitation, or relocation without resorting to the courts or to using mental health professionals. However, once they become involved with litigation or potential litigation a psychiatrist may be turned to and be involved in one of several ways:

• • • • •

as an adolescent’s therapist; as a consultant, to offer the parents an opinion; as a consulting expert to the attorney; as mediator or arbitrator; and/or as a forensic evaluator, either for one of the parents (an adversary expert), or as the court’s appointed neutral evaluator.

Psychiatrist as therapist With rare exceptions, the psychiatrist who is treating an adolescent involved in such a divorce dispute should not assume the role of forensic evaluator. While it may be tempting to do so, and while one may be pressed by one (or even both) parent(s) to become involved – based upon the fact that the treating psychiatrist knows the adolescent best, very likely knows the adolescent’s preference, and probably has his/her own opinion regarding the issue at dispute – it is best to resist the temptation to act as a ‘double agent’ (Simon 1987) or to ‘wear two hats’ (Strasburger et al. 1997). Among the reasons for this are: 1 It may involve a betrayal of confidentiality, which may entail a breach of the fiduciary relationship to the adolescent as patient. 2 When the dust settles, the parent whom one has not supported will all too often sabotage the treatment. 3 Most importantly, what the teenager desperately needs is to have his/her psychiatrist remain both neutral and available to help him/her negotiate a most difficult situation. This cannot be done if the psychiatrist assumes the forensic role which will, by necessity, involve taking one parent’s side when a recommendation is made. On the other hand, it is not inappropriate for the treating psychiatrist to speak with a neutral forensic mental health professional if one has been appointed, and it may even be helpful to advise the parents of the importance of requesting appointment of a neutral evaluator. However, it is important to consult a lawyer on the confidentiality/ privilege issue and to be quite circumspect about what is said, offering impressions rather than a definitive opinion on what is referred to as the ultimate issue, that is, the disputed issue. It is also a good idea to note carefully in one’s record just what one has reported in the event that one is later misquoted.

On occasion, one or even both parents may threaten to subpoena the psychiatrist to testify at trial. Privilege law varies from jurisdiction to jurisdiction. In some jurisdictions, a parent has the power to waive or assert a communications privilege on behalf of a minor child. Some jurisdictions except custody cases from a general psychiatric testimonial privilege; others do not. Every psychiatrist must have detailed knowledge of the nuances of local confidentiality and privilege law so that he or she can respond knowledgeably when demands for disclosure or testimony are made. If a parent or attorney insists on exerting pressure to testify, the psychiatrist should strongly advise the party or parties that in the adolescent patient’s interest, it is essential that he/she remain neutral regarding their dispute so as to be available to their child. Should one be subpoenaed, it may be possible to have the subpoena quashed by advising the other parent’s attorney, the attorney for the child, or the psychiatrist’s own attorney. In the event that the psychiatrist is called to court, a formal motion may be made to the court for an in camera examination of records and/or oral examination of the therapist so that the judge may issue such protective orders, or in limine orders, limiting the psychiatrist’s testimony in the child’s best interests. The psychiatrist cannot always rely on a parent’s or the child’s lawyer to protect him/her or the treatment process. It is wise to develop a relationship with an attorney who is available for consultation or representation, as required. Once a subpoena has been received, a psychiatrist cannot refuse to appear, although he/she can ask for accommodation as to the time and date of appearance. Further, if his/her records are subpoenaed, the psychiatrist should not send them to an attorney unless both parties and the adolescent are in agreement and sign a release and if the treater feels the disclosure will not adversely affect the treatment. The records may be sent under seal to the judge pending an in camera proceeding on discovery and admissibility. It is always wise to consult with an attorney with any questions.

Psychiatrist as consultant Because parents often wish to avoid the emotional and financial toll of litigation, they may well wish to consult with a psychiatrist. Unless the psychiatrist is willing to be involved as a testifying expert, there should be a signed letter of agreement that neither party will attempt to call him or her into court. This should be reduced to a stipulation signed by both attorneys and approved by the judge. Otherwise, one or both parties will be highly reluctant (appropriately so) to be open and honest. The psychiatrist may be asked to serve as a consultant in one of the following ways.

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Parents may ask the psychiatrist to offer them an opinion as to their teenager’s interests by: 1 Seeing the teenager to determine what he/she wants. In this case, one must advise the teenager what the parameters of the consultation are and not offer the usual confidentiality. 2 Speaking to the psychiatrist as a couple, without their adolescent being seen. In this case, one should offer only a general opinion, advising the parents that it is inappropriate to offer a specific opinion without seeing the adolescent. 3 Mediating to help the parents take the responsibility for resolving their difficulties. The mediator does not take one side. The goal of mediation is to facilitate agreement between the parties; this may or may not be consistent with clinical treatment of goals. This role is best avoided by a treating psychiatrist. 4 Rarely: seeing the parents, and sometimes the adolescent, to act as an arbitrator offering an opinion as to which side should prevail. Again, the treater should not blur boundaries by arbitrating. An arbitrator should be a completely neutral party with ‘loyalty’ to neither parent. Lawyers also consult psychiatrists for information and guidance in their cases and to assist in trial preparation and coping with the adversary or independent psychiatric reports and testimony. The consultant may or may not also serve as an expert witness in the case. Here, again, the issues of confidentiality and privilege must be considered. The lawyer’s consultant is covered under the lawyer’s work product privilege; the expert witness is not, and may be required to disclose communications and information, including conversations with the lawyer, patient, or parent, which might negatively affect the litigation.

Psychiatrist as forensic evaluator Once the parents have reached the stage of litigation, each having retained her and his own attorney, a forensic evaluation may be either requested by the parents and their attorneys or ordered by the court. The two attorneys may agree upon a particular psychiatrist as a joint evaluator, or the court may appoint a neutral psychiatrist to conduct an evaluation and offer the court recommendations regarding custody, visitation, and possibly, relocation. In many jurisdictions, parents may also hire their own adversarial experts. It is not unknown to have three psychiatrists involved in a case, all of whom write reports and testify: the well-known ‘battle of the experts.’ Some forensic psychiatrists see this as an unnecessary and expensive method of performing evaluations, but in most states the court cannot refuse permission for it. Sometimes a psychiatrist will be asked by one parent to see that parent and an adolescent and to write a report and/or appear in court to offer an opinion regarding an

issue in dispute. While one can offer an opinion regarding that parent’s parenting abilities, it is inappropriate, unwise to the extreme, and unethical to offer an opinion regarding a parent who has not been seen. A psychiatrist as an adversarial expert must avoid even the appearance of a ‘hired gun.’ No custody or visitation opinion should be offered until all the parties and any necessary collaterals have been interviewed, records reviewed, any necessary psychological tests have been done, and the psychiatrist is prepared to write a thorough report, well-grounded and documented from meticulous notes, and defensible against the most intense hostile scrutiny and cross-examination. The psychiatrist who involves herself/himself as a forensic expert should have knowledge regarding adolescent development as well as about issues involved in divorce, clinical experience with adolescents, and thorough and detailed familiarity with forensic issues as they apply in his/her particular community (the different states have very different standards). The psychiatrist should be extremely wary about seeing an adolescent brought by a noncustodial parent or, before a custody determination has been made, by one parent without knowledge of the other. Legal consultation should be obtained in any such instance. In recent years, lawsuits and complaints to ethical and professional licensing boards have resulted in such cases.

THE FORENSIC EVALUATION If involved as the forensic psychiatrist, one should be prepared to spend considerable time interviewing both parents, the adolescent, and other figures meaningful in the adolescent’s life. Reference should be made to two excellent guidelines issued by The American Psychiatric Association (1982) and The American Academy of Child and Adolescent Psychiatry (1997). Among those factors to be evaluated include: 1 The nature of the attachment between the adolescent and each parent. 2 Who has been the primary caregiver if one parent, rather than both, has assumed that role. 3 Parenting abilities, both physical (physical availability, the current and anticipated future consistency and stability of the home environment, and financial stability) and nonphysical aspects (each parent’s ability to provide emotional nurturance and support and to encourage the adolescent’s intellectual, social, and moral development; each parent’s personality strengths and weaknesses as they affect parenting). 4 Each parent’s ability to put aside his/her own needs and feelings so as to address the adolescent’s needs. 5 The degree to which each parent can be supportive of versus interfering with the adolescent’s relationship with the opposite parent.

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6 The degree of flexibility that each parent demonstrates; this will be particularly important with regard to visitation. 7 The adolescent’s needs and the anticipated or potential effects of the proposed custody, visitation, or relocation arrangements. 8 Last, but by no means least, the adolescent’s preference. The evaluator should request a written statement from the court or hiring attorney of the questions to be answered and other information being sought from the evaluation. The report should address the specific questions asked and provide information in terms of the legal criteria the judge is mandated to consider. To do the job adequately the evaluator must understand the legal issues and the standard of proof involved in each question. For example, an initial determination of custody or visitation may be based upon the best interests of the child as shown by a preponderance of the evidence; modification of an order may require a showing by clear and convincing evidence that a change of circumstances has arisen since the original order that adversely affects the child. The factual predicates and theoretical basis for the psychiatrist’s opinion should be stated without jargon. The evaluator is well advised to assume no clinical training on the part of the lawyers and judge; clinical concepts and terms of art should be explained in their most simple terms. Pontification, impressions and speculations weaken a report, which should be approached as an opportunity to inform and advise. The most helpful report is one that not only answers the questions, but also offers recommendations to guide the litigants and judge towards the child’s well-being. The issue of preference is particularly important with adolescents, in part because they often have quite strong preferences, although they may be reluctant to state them, and in part because their preference has great weight in judge’s decisions. One should not underestimate the importance of this role. (One study [Kunin et al. 1992] noted that the two factors judges most depended upon in their opinions were the forensic recommendation and the child or adolescent’s preference.) When a preference is stated, it must be evaluated within the context of:

• •

the teenager’s emotional and cognitive development – in order to determine to what degree that preference is based upon reasonable and rational considerations; and to what degree it has been arrived at independently of parental input or pressure.

An assessment must be made regarding the degree of direct or indirect parental influence upon any such preference and the degree to which the teenager’s preference has been determined, either by concern about hurting one parent, or alternatively a wish to punish a parent. While the

adolescent’s preferences are extremely important, the motivation behind an expression of preference must be addressed. The forensic psychiatrist must remember that his/her role is to offer the judge an expert opinion on the issues. It is the judge’s responsibility to make the ultimate decision, not the psychiatrist’s. Not only is this reasonable and appropriate as a matter of law, but also because the judge often has information not available to the psychiatrist. On the other hand, the bases of the expert’s opinions and whether they are ‘scientific’ are likely to be an issue, and he or she must be prepared to defend the validity of his or her opinion (Galatzer-Levy and Kraus 1999). Whether or not such opinions can rise to the level of rigor necessary to be termed ‘scientific’ is a matter of dispute (Levy 1998), but at the least one must know the facts and have drawn logical conclusions therefrom. Lastly, in the authors’ opinion, the most important guiding principles in performing forensic evaluations are to maintain scrupulous professional objectivity and even-handedness, and to avoid the generalizations often heard and instead to address the specific needs of the adolescent involved. (Some of the generalizations often heard in divorce disputes are: siblings should never be separated; girls belong with mothers, boys with fathers; there can have been only one primary caregiver; young children cannot tolerate overnight visitation; it is too confusing for children to move back and forth between two homes.)

CUSTODY DISPUTES While fortunately uncommon, litigated custody disputes – whether for children or adolescents – are exceedingly contentious and often bring out the worst qualities of both parents. The bitterness involved in such disputes is difficult to imagine. Parents will make allegations regarding the other’s behavior which are frequently hard to believe, understandably so given the nature of the exaggeration and distortion of the other parent’s behavior, motivations, etc. Adolescents, often already angry at one or both parents, can easily become embroiled in their parents’ disputes. On occasion, pressed to take one parent’s side, they have been known to allege a variety of misbehaviors on the other parent’s part, including, but not limited to, allegations of physical or sexual abuse, substance abuse, etc. Children are left confused and troubled when those who were previously involved in their care are now highly invested, not so much in the children, as in ‘winning’ custody of them. Adolescents are not so much confused as unhappy, angry, and resentful that their ordinary lives have been so disrupted. A very common complaint stated in these or similar words is: “Why don’t they just get it over with and let me go on

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with my life?” Younger adolescents may suggest that they don’t even care who gets custody. Older teenagers generally have some preference, although often they may not wish to state as much, because they are caught in the middle between two parents whom they love. Motivations of one or both parents seeking sole custody vary. However, common to all divorce disputes is the high level of anger, often to the degree of rage and absolute hatred for the other parent. While each parent insists that he/she is only interested in what is best for his/her child, the wish to remove the other parent from the child’s life is often strong, if rarely acknowledged. Instead, the parent may assert that he/she wants the child to have maximum contact with the other parent. Another common motivational factor is involved with money, for example who will provide child support, or who will get to keep the marital apartment. Whilst judges are not supposed to take gender into consideration in determining the best interests of the child, more often than not, as noted previously, there is an actual – though not legal – judicial bias toward awarding mothers custody.

The initial custody determination Because they have generally told their parents their preference, custody disputes involving adolescents are uncommon unless there is a younger sibling. The forensic psychiatrist will then have to address the individual needs of both the adolescent and his/her younger sibling(s). The courts are generally reluctant to separate siblings and have often been given support by mental health professionals for this position, although there are no empirical data to support this. Often this makes sense because siblings generally give considerable support to each other during divorce disputes. Some professionals suggest, however, that when there is a significant difference in age between siblings, there is more reason to consider separation (Levy 1998). The issue becomes particularly thorny when the interests of the adolescent favor his or her being with one parent while the interests of the younger sibling lie with his or her being with the other parent together with the adolescent. One is thus weighing competing interests. If the situation is one in which either the children involved are teenagers or in which separation of siblings is reasonable, considerable weight can be given preference. However, as indicated above, it is essential to determine what dynamics underlie the stated preference. Has there been coercion? Or promises made? Is the preference determined by anger at one parent for imposing structure and limitations or having rules that the adolescent objects to? Is the teenager attempting to ‘rescue’ a parent perceived as more wounded or needy? Also, teenagers may prefer to remain with the same-sex parent.

A request for a change in custody A custody decision is res judicata (adjudicated, decided) as to any factors that existed and were known to the court at the time of entry of the order. Once a matter is res judicata, it may not be revisited between the same parties on the same facts and issues except on appeal. The court’s decree is binding. Thus, although courts retain jurisdiction over child custody after a divorce for purposes of enforcement and modification, any modification must be based upon a material change of circumstances since entry of the last order. What constitutes a material change in circumstances sufficient to warrant a custody modification is the subject of thousands of appellate court decisions, and courts vary widely as to criteria for modification. Stability and permanence in a child’s life is perceived as presumptively in his or her best interests. The presumption must be overcome by a preponderance of evidence (in some states, ‘clear and convincing’ evidence) by the party moving for modification. Remarriage of a parent, illness, move of household, a change of the child’s preference, may be factors to support a custody modification, but only if they can be shown to adversely affect the child; single factors are rarely enough by themselves to support a custody modification. For this reason, it may be a mistake to push a custody agreement over a parent’s grave misgivings. When there is concern for the child’s welfare, this should be brought to the judge’s attention before entry of a custody order. Otherwise, when the custody arrangement does not work out, but the circumstances really have not changed, the parties may be left in status quo, to the child’s detriment. More often, there may be a request for a change in custody based upon a change in the circumstances of either the parent or the adolescent. Examples of such changes include: the custodial parent has married and the adolescent and his/her step-parent are having a great deal of difficulty with each other, leading the custodial parent to fear for his/her new marriage; the custodial parent is planning to move far away, disrupting the teenager’s close relationship with his/her peers, particularly in situations in which attachment to school and peers has taken on more-than-usual importance as a result of the parental divorce; the noncustodial parent has remarried and started her/his own family, while the custodial parent has remained single, this situation inducing in the teenager a wish for a new ‘intact’ family; there has been a prolonged period of major tension between adolescent and custodial parent secondary to the teenager’s demands (appropriate or inappropriate) for more autonomy; where the adolescent has a fantasy of an idealized relationship with the noncustodial parent, this happening most often with a female adolescent and her father. Again, the dynamics of the request for a change must be examined. Often, the most reasonable recommendation is that the adolescent be given the opportunity to change

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his/her residence without a change in custody. Not to grant this opportunity often leads to an escalation of the difficulties between custodial parent and teenager, leading to the not-infrequent situation in which the custodial parent, in anger, demands that the teen leave the parental home and go to live with the other parent (often the father). Changing custody, at the other extreme, can be highly problematic, particularly when the teenager has idealized the other parent. Often what will follow will be great disillusionment with that parent and a wish to move back to the first parent. By not changing custody, one leaves open the opportunity for the adolescent to return to the original parent.

VISITATION DISPUTES Disagreements regarding visitation may occur either within the context of a custody dispute or post judgment, when the underlying personal issues between the parents remain unresolved and festering. When a forensic evaluator has been appointed to offer the court an opinion regarding custody, he/she is also asked to offer an opinion regarding the extent of visitation with the noncustodial parent. Visitation schedules are originally set up to meet the child’s need to preserve a relationship with the noncustodial parent (sometimes over the objections of the custodial parent) and the rights of a parent to see his or her child. In making recommendations, the forensic evaluator must be careful not to offer an etched-in-stone schedule that, while it might serve a child’s needs at one time, will not at a later time. Most importantly, some attempt at maintaining flexibility must be considered. After judgment, the custodial parent, with or without the urging of the teenager, may request a change in the schedule to grant less time to the noncustodial parent, or, less commonly, a noncustodial parent, with or without the teenager’s urging, will seek court intervention to increase the amount of access time. This tends to occur in high-conflict families in which one parent or both insist upon gratifying their own needs or asserting their own ‘rights’ at the expense of the particular needs of the child. This can take on immense proportions when the child reaches adolescence and prefers to spend time with friends rather than be obliged to see the noncustodial parent. Added to this is the anger the adolescent feels that she/ he has no choice about the time spent with that parent. Judith Wallerstein (personal communication) noted that when they were older, adults complained bitterly of this lack of control when they were younger. When the request is for a change in the visitation schedule, the evaluator of an adolescent needs to address the past history of conflict and the current status of the adolescent’s need for flexibility and for greater autonomy over any schedule. Often it is helpful to suggest to the noncustodial parent that not

insisting upon a rigid schedule now is more likely to result in a better relationship in the future. If the teen is requesting greater visitation, this is a preference that should be given considerable respect. Visitation problems are some of the most unpleasant and difficult for the psychiatrist, as well as the parties and attorneys. Much publicity has attended cases in which minor children have flatly refused visitation with their noncustodial parents. The role of the treater in such cases is obviously complex. Invariably, the adolescent’s therapist will be drawn into the fray, by the patient if by no one else. The psychiatrist should know the local legal standards which a court must apply in deciding these cases because it is the court who will make the ultimate determination, and the child will have to live with the consequences. The concept of parental alienation syndrome, a phenomenon described by Gardner (1987), has found its way into the courtroom. Testimony as to such has been both accepted and rejected. One often-referred-to law review article (Wood 1994) concluded that the syndrome did not have general expert acceptance. Many, if not most, mental health professionals have not accepted the validity of the ‘syndrome,’ nor has it been accepted as a syndrome or disorder by the DSM-IV. Two recent articles (Sullivan and Kelly 2001; Kelly and Johnston 2001) address the legal and psychological issues involved. Certainly, however, they do accept the fact that some parents actively attempt to destroy the child’s relationship with the opposite parent by demonizing him/her. The alienation that does occur often serves as fuel for custody and visitation disputes. In such cases, conjoint therapy with one or both parents may be clinically indicated, but this must be determined in light of the legal confidentiality and privilege issues. A powerful tool for separating the treatment from the litigation is a stipulation entered into by the parties and their lawyers, and approved by the judge, that the treatment will be private, confidential and privileged, and that under no circumstances will a subpoena be issued, nor records or testimony sought or permitted, regarding the conjoint treatment.

RELOCATION DISPUTES In recent years, some state legislatures have begun granting custodial parents greater leeway in relocating. However, disputes still arise, particularly when there has been ongoing contact between noncustodial parent and his/her children. While some judges may appoint a forensic evaluator to offer information regarding the child’s interests, others question whether relocation is a matter of psychiatric expertise, rather than a judicial determination as to what rights custodial and noncustodial parents should have. When appointed in cases of younger children, the

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evaluator needs to address the complicated issue of more frequent contact with the noncustodial parent, or less frequent but more extended contact. When an adolescent is involved, the evaluator needs to address not only the relationship between adolescent and noncustodial parent, but also the adolescent’s preference and his or her ties to the school and friends. While it is obvious that all adolescents will resent moving away from friends, when there has been a bitter divorce in which the rancor has continued, the adolescent’s ties to his or her community may take on a much different flavor in that the community may represent his or her major source of stability.

REFERENCES American Academy of Child and Adolescent Psychiatry. Practice Parameters for Child Custody Evaluations. Journal of the American Academy of Child and Adolescent Psychiatry (Supplement) 36: 57S–68S, 1997. American Psychiatric Association. Child Custody Consultation: A Report of the Task Force on Clinical Assessment in Child Custody. Washington, DC: American Psychiatric Association, 1982; 1988 (revised). Galatzer-Levy, R., Kraus, L. (eds) The Scientific Basis of Child Custody Decisions. New York: John Wiley & Sons, 1999. Gardner, R.A. The Parental Alienation Syndrome and the Differentiation Between Fabricated and Genuine Child Sex Abuse. Cresskill, NJ: Creative Therapeutics, 1987. Kelly, J.B. Children’s adjustment in conflicted marriage and divorce: a decade review of research. Journal of the American Academy of Child and Adolescent Psychiatry 39: 963–973, 2000. Kelly, J.B., Johnston, J.R. The alienated child: a reformulation of parental alienation syndrome. Family Court Review 39: 249–266, 2001. Kunin, C.C., Ebbesen, E.B., Konecni, V.J. An archival study of decision-making in child custody disputes. Journal of Clinical Psychology 48: 564–573, 1992. Levy, R.J. (ed.) Legal and Mental Health Perspectives on Child Custody Law: A Deskbook for Judges. Eagan, MN: West Group, 1998. Maccoby, E.E., Mnookin, R.H. Dividing the Child: Social and Legal Dimensions of Custody. Cambridge, MA: Harvard University Press, 1992. Simon, R.I. Clinical Psychiatry and the Law. Washington, DC: American Psychiatric Press, Inc., 1987. Strasburger, L.S., Gutheil, T.G., Brodsky, A. On wearing two hats: role conflict in serving as both psychotherapist and expert witness. American Journal of Psychiatry 154: 448–456, 1997. Sullivan, M.J., Kelly, J.B. Legal and psychological management of cases with an alienated child. Family Court Review 39: 299–316, 2001.

Wallerstein, J.S., Tanke, T.J. To move or not to move: psychological and legal considerations in the relocation of children following divorce. Family Law Quarterly 30: 304, 1996. Wood, C. The parental alienation syndrome: a dangerous aura of reliability. Loyola of Los Angeles Law Review 1367–1415, 1994.

Suggested reading American Psychiatric Association. Disclosure of Psychiatric Treatment Records in Child Custody Disputes: A Report of a Task Force. Washington, DC: American Psychiatric Association, 1992. Bruch, C.S., Browermeiseter, J.M. The relocation of children and custodial parents: public policy, past and present. Family Law Quarterly 30: 245–303, 1996. Custody Law and Practice Symposium. Family Law Quarterly 36(No. 1), Spring Issue, 2002. Derdeyn, A., Scott, E. Joint custody: a critical analysis and appraisal. American Journal of Orthopsychiatry 54: 199–209. Furstenberg, F.F. Jr, Cherlin, A.J. Divided Families: What Happens to Children When Parents Part? Cambridge, MA: Harvard University Press, 75, 1991. Gold, J.D. (ed.) Divorce as a Developmental Process. Washington, DC: American Psychiatric Press, Inc., 1988. Herman, S.P. Child custody evaluations. In Schetky, D.H., Benedek, E.P. (eds), Clinical Handbook of Child Psychiatry and the Law. New York: Brunner/Mazel, Inc., 1980, pp. 91–103. Kelly, J.B., Lamb, M.E. Using child development research to make appropriate custody and access decisions for young children. Family and Conciliation Courts Review 38: 297–311, 2000. King, V. Nonresident father involvement and child well-being: can dads make a difference? Journal of Family Issues 15: 78, 1994. Nurcombe, B., Partlett, D.F. Child Mental Health and the Law. New York: The Free Press, 1994. Schetky, D.H., Benedek, E.P. Child Psychiatry and the Law. New York: Brunner/Mazel, Inc., 1980. Schetky, D.H., Benedek, E.P. Clinical Handbook of Child Psychiatry and the Law. Baltimore: Williams & Wilkins, 1992. Tibbits-Kleber, A., et al. Joint custody: a comprehensive review. Bulletin of the American Academy of Psychiatry and the Law 15: 27–43, 1987. Wallerstein, J.S. The long-term effects of divorce on children: a review. Journal of the American Academy of Child and Adolescent Psychiatry 30: 349–360, 1991. Wallerstein, J.S., Blakeslee, S. Second Chances: Men, Women and Children a Decade after Divorce. New York: Basic Books, 1989.

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PART 2 Mental health in legal settings

7.3 The juvenile justice system: delinquency and status offenders Wade C. Myers

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7.4 The psychiatrist in the juvenile justice system: evaluation of offenders Richard A. Ratner

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7.5 Treatment of juvenile offenders Lee H. Haller

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7.3 The juvenile justice system: delinquency and status offenders WADE C. MYERS

DELINQUENCY: THE JUVENILE COURT

Nineteenth and twentieth centuries

Origins and early history

The late nineteenth century saw a gradual shift from these historically harsh disciplinary practices to a more humane and rehabilitative approach to youthful offenders. Binder (1987) has documented significant changes in the handling of juvenile delinquents by the state including:

Throughout most of recorded history, children have been considered the property or chattel of their parents. Until the advent of recent and slowly developing reforms over the past few centuries, children were historically regularly subjected to the same criminal procedures and punishments as adults, including capital punishment. Even under English common law, children and adults were typically handled in a similar fashion in criminal matters. For example, the Code of Hammurabi (ca. 1792–1750 BC) included a provision (law #195) that ‘If a son strike his father, they shall cut off his hand.’ (Bailkey 1976). Similarly cruel treatment for children with antisocial behavior (Binder 1987) is found in the Old Testament. In Exodus 21:15 it states, ‘And he that curseth his father, or his mother, shall surely be put to death.’ In Deuteronomy (21: 18–21), death by stoning was prescribed for stubborn, rebellious sons who would not obey their parents. By the Justinian period (527–565 AD), children under the age of seven years had come to be presumed incapable of forming criminal intent, and full criminal responsibility was not assumed until puberty: age fourteen years for boys and twelve for girls (Binder 1987). Centuries later, the Anglo-Saxon king Athelstan (895–939 AD) lamented that boys aged twelve years were being executed for ‘less serious offenses’ (Wood 1987). He announced that no man younger than fifteen years should be killed, as had obviously been customary until that point.

1 In New York, the establishment of the first facility to provide separate detention of youthful offenders from adult criminals (1825). 2 In Massachusetts, the opening of the first reformatory supported by the state (1848). 3 In Boston, the beginning of trials for children less than sixteen years as a proceeding separate from adult criminal trials (1870). In 1899, these trends resulted in the Illinois legislature’s passing of the Juvenile Court Act which created the first juvenile court in the United States; by the late 1920s nearly all states had followed suit (Schetky and Benedek 1992), and by the 1940s every state in the union had a juvenile court. The rationale for the establishment of these courts was the principle of parens patriae (the right of the state to act as protector of those citizens unable to protect themselves), and the primary goal was rehabilitation rather than retribution. To further these goals, court clinics were created as an extension of the court, and these clinics originated the Child Guidance movement in this country. The first juvenile court clinic, founded by William Healy in Chicago at the turn of the century, became the model for all other clinics. Healy, who studied with Freud, established a team approach to the disturbed adolescent and

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his family, utilizing a social worker, psychologist, and psychiatrist working together. These clinics are widely understood to have been the origin of modern child psychiatry in this country (Levine et al. 1987). Since these first juvenile courts did not see their goal as prosecution or punishment, they did not rely upon socalled due process, which in the adult criminal system is deemed crucial to safeguarding the rights of the accused. Due process, as understood in adult courts, includes such rights as a right to counsel, to a transcript of the proceedings, to a certain standard of proof being employed for conviction, and others. In place of these rights, the new juvenile courts promised informal, confidential proceedings with ample opportunity for charges to be dropped, ‘treatment’ in specialized juvenile facilities, and a paternalistic orientation. Little, if any, distinction was made between dependent and delinquent youths; both were thought of as errant and worthy of being saved. Even the language of the juvenile court was different from that of its adult counterpart. Rather than a felon or a criminal, juveniles were delinquents; rather than being tried they were adjudicated; rather than sentencing, they received a disposition. For the entire first half of this century, the theory and practice of delinquency treatment occurred primarily in the context of the psychoanalytic movement. The seminal figure in applying the principles of psychoanalysis to delinquency was August Aichhorn, a student of Freud’s. A book published in 1949 and dedicated to Aichhorn included papers by many of the giants of psychoanalytic theory and contained much of the collected wisdom regarding delinquency treatment to that time (Eissler 1949). While most of the papers concentrate on individual dynamics it is worth noting that group therapies were already being used, and the role of the delinquent’s family in his or her behavior was already being delineated (Johnson and Szurek 1952). With time, the failure of the juvenile court system’s handling of many delinquents using this ‘wise, merciful father’ (Mack 1905) approach became apparent. Sadly, despite the beneficent dreams of the originators of the juvenile court system, over time the system that was supposed to provide rehabilitation and treatment for juveniles provided less and less of both. Facilities for properly treating delinquent youth fell into substandard conditions. By the 1960s, many children were being institutionalized and warehoused without receiving rehabilitation, and the state schools and receiving homes which were meant to save children had become little different from adult prisons. As one example of this problem, at the time of the Kent decision (see below) the District of Columbia had a single judge assigned to the entire Juvenile Court. Yet, until the mid-1960s juvenile courts continued to handle children in court with a relative absence of the due process rights accorded adult criminal defendants. Thus, juvenile courts had the authority to make major

life decisions for juveniles, often on the basis of flimsy evidence and without the juvenile’s having so much as the right to an attorney. In essence, the juvenile justice system had become one that looked every bit as punitive as the adult criminal courts albeit without the protections of due process rights. This state of affairs came to an end when the Supreme Court, acting in response, issued a series of historic decisions in matters regarding juvenile justice which led to far-reaching reforms. One can view these reforms as having introduced the long overdue protections of due process into the juvenile court but also as having resulted in the ‘criminalization’ of the juvenile court (Fitch 1989).

Key cases: the Gault era The transformation of the juvenile court into something more akin to adult court with its attendant rights and safeguards is symbolized by the US Supreme Court’s Gault decision (see below), but actually began with its decision in Kent v. United States (1966). In this case, a sixteen-year-old male resident of the District of Columbia was arrested and charged with housebreaking, robbery and rape. Despite his age, a juvenile court judge ‘waived’ (i.e., transferred) him to an adult court for trial as an adult without an actual hearing. His attorney appealed on various grounds, one of which was that the decision to send Kent to an adult court was improperly made. The Supreme Court agreed, finding circumstances of his detention and interrogation unlawful. More specifically, however, the Court was critical of the manner in which the overworked judge sent Kent out of juvenile and into adult court. The judge had done so without a hearing, having simply reviewed some paperwork about the case. The specific legacy of Kent was to establish that in cases where a juvenile was being considered for transfer to adult court, a hearing had to be held regarding the matter by the juvenile court. If, as a result of this hearing a youth was considered rehabilitatable and amenable to treatment, then he/she should be retained for adjudication in juvenile court. More generally, however, Kent is remembered as one of several decisions that together inaugurated a new era in which due process rights were extended to protect minors in juvenile court. Some of the rights established in Kent included access to those records considered by the court and entitlement to both a hearing and to a statement enumerating the juvenile court’s reasons for transfer of the case to adult court. In its decision, the Court explained that up until that time the child in juvenile proceedings got ‘the worst of both worlds’, in that he/she received ‘neither the protection accorded to adults nor the solicitous care and rejuvenative treatment postulated for children.’ The Court’s decision in the case of In Re Gault (1967) is often considered the seminal decision regarding the

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establishment of due process rights for juveniles undergoing delinquency proceedings. The application of parens patriae in such cases was to be held unconstitutional. In this case, a fifteen-year-old Arizona boy was charged with making obscene phone calls to a female neighbor. He was convicted on hearsay and sentenced to six years in an industrial training school until adulthood (age twentyone). A similar crime committed by an adult would bring a maximum penalty of two months in jail or a fine of up to $50. In appeal, Gault’s lawyers challenged the denial of several procedural due process rights. The Supreme Court reiterated that delinquents are entitled to procedural regularity, and many elements of due process. These included the right to an adequate and timely notice of the specific nature of the charges, the right to counsel, the right to a written record of the proceedings, the right to subpoena witnesses, the privilege to confront and cross examine witnesses, and protection against self-incrimination. Only the right to a trial by jury was not provided in comparison with the rights of adults. In the decision of the Court, it was noted that ‘… the condition of being a boy does not justify a kangaroo court.’ An additional procedural safeguard was established for juvenile delinquents through In Re Winship (1970). In this case, a young boy was charged with larceny and subsequently adjudicated delinquent. The standard of proof in the New York City Court at that time was a ‘preponderance of evidence’ for those between the ages of seven and sixteen years. The Supreme Court found this evidentiary standard inadequate and reversed the decision, as an adult charged with the same offense would require proof ‘beyond a reasonable doubt.’ This decision brought juvenile trials even closer to procedural equality with adults by creating an identical burden of proof. Juveniles have not been given all the rights afforded to adults in criminal trials. In McKeiver v. Pennsylvania (1971), the Supreme Court refused to rule that juveniles have the constitutional right to a jury trial. However, some states have extended the right to juveniles to request a trial by jury. Breed v. Jones (1975) held that minors could not be tried in both juvenile and adult court, thus extending to juveniles in delinquency proceedings a constitutional protection against ‘double jeopardy.’ What have courts decided concerning the issues of competency to stand trial and the insanity defense for juveniles? Regarding competency to stand trial, the adult standard set forth in Dusky v. United States (1960) is typically applied. It requires that the defendant have the ability to consult with a lawyer with a reasonable degree of understanding, and to have a rational as well as factual understanding of the judicial proceedings before a trial can go forward. However, not all states have directly addressed the competency issue for youth (Woolard et al. 1992), and less than half of all states have explicitly recognized (through statute or case law) the right of a youth

charged with a crime to be competent before undergoing adjudication (Grisso et al. 1987). The Supreme Court of Wisconsin, in reviewing the case of an adolescent boy suffering from schizophrenia who killed his mother (In Re Winburn 1966), became the first state to extend the insanity defense to juveniles, and other states have likewise ruled favorably for this defense (Woolard et al. 1992). Most states allow the use of the insanity defense for juveniles. For instance, the Louisiana Supreme Court, in the case of In Re Causey (1978), established that juveniles have the right under the due process clause of the 14th amendment to raise the issues of incompetency to stand trial and legal insanity. However, at least one court (In Re C.W.M., District of Columbia 1979) has explicitly held that the use of the insanity defense was improper as it would interfere with the rehabilitative mission of the court (Woolard et al. 1992).

Structure and function of the juvenile court Juvenile courts handle delinquency offenses – those acts which if committed by an adult could result in prosecution (US Department of Justice 1996a). Juveniles commit roughly one-fifth of violent crimes, and one-third of property crimes. Procedurally, cases referred to juvenile court are screened by an intake officer, prosecutor, or judge to decide whether to dismiss the case, handle it formally through the juvenile court, or transfer it to adult court. Just over one-half of delinquency cases are handled formally (US Department of Justice 1996a). Juvenile delinquency cases can be transferred to adult criminal court by the prosecutor, a juvenile court judge, or statute. In many states serious crimes, such as murder and rape, are automatically transferred if the youth is of a certain minimum age. The subject of juveniles being transferred to adult courts is covered later in this section. In crimes that are relatively less serious and where the perpetrator is willing to admit his/her culpability, intake workers are often authorized to place the offender in a diversion program. This may involve such things as community service or mental health treatment. Though juvenile records have traditionally been confidential (compared to adult criminal proceedings which are public record), diversion programs benefit the juvenile by not leaving even a juvenile court record. In more serious crimes or in those where a juvenile does not admit involvement, the case is sent forward for adjudication. Prior to Kent, Gault, and the other cases, the juvenile court process was informal in the extreme, with abuses such as those noted in the Gault case sometimes the result. Subsequently, with the introduction of due process safeguards, the juvenile court has become more like its adult counterpart. While this has resulted in greater protections for the juvenile, it has also made the character of the court more adversarial. Experts who testify in juvenile

446 Adolescent psychiatry and the law

court have had to become used to this change which includes, among other things, cross-examination. While it may still feel more ‘informal’ than adult court, the juvenile court is certainly more procedural and official in nature than it was thirty years ago. Should a youth be adjudicated a delinquent (equivalent to being convicted of a crime in adult court), then the court moves on to the ‘disposition’ phase. This is equivalent to the sentencing phase of an adult trial, though here again the language used is different in order to underline the rehabilitative orientation of the juvenile court. Typically, the jurisdiction of juvenile court over a youth extends only to a certain age; after that the individual can no longer be detained through juvenile court authority. A fuller description of the range of dispositions available to the judge can be obtained in the article by Kalogerakis (1992a). Juvenile courts have continued to face growing numbers of youth and increasingly challenging cases (e.g., the case of Nathaniel Hawthorne, who at the age of eleven years was charged with first-degree murder). Data published by the US Department of Justice (1996a,b) demonstrate the increasing demand that delinquency places upon society and our legal system. For instance, the juvenile courts processed an estimated 1.5 million cases in 1993 – an increase of almost 25 per cent from four years previously. The most common offenses were the property crimes of theft, burglary, and vandalism. Of those cases formally adjudicated, approximately 1.5 per cent (12 300 youth) were transferred to adult criminal court. Of those delinquency cases adjudicated in juvenile court, 56 per cent were placed on probation and 28 per cent were sent to out-of-home placements. More recently, the National Center for Juvenile Justice (1997) reported that nearly three million children were being arrested annually, and approximately one-fifth of these youth who are referred to juvenile court will be placed in a secure detention facility. A census carried out by the Office of Juvenile Justice and Delinquency Prevention (1999) for the day of 29 October, 1997 found that 125 805 youths under the age of twenty-one years were being held in public or private facilities by virtue of having been charged with or court adjudicated for an offense. Over 40 per cent of these youths were placed in these facilities for serious personal property offenses (i.e., violent sexual assault, and robbery). Although most juvenile crimes are committed by boys, arrests of girls have risen sharply in the past fifteen years. For example, between 1993 and 1997, arrests of girls for violent offenses increased by 12 per cent while declining by 9 per cent for boys. Arrests for drug abuse violations increased by 117 per cent, and for offenses against family and children by 82 per cent; in 1997, almost one-third of serious crimes committed by females were by girls under eighteen years of age (Loper 2000). About 20 per cent of youths brought before the juvenile court were held in secure detention facilities. Interestingly,

the distribution of length of stay in detention facilities is bimodal: most youth stay only a short time, whereas those who stay longer are not necessarily accused of more serious crimes, but may instead have difficult to achieve placement needs (Mulvay and Saunders 1982; Woolard et al. 1992).

Recent trends in juvenile justice Two trends issued from the fundamental changes that were brought about by Gault and its related decisions. A series of studies performed during the 1970s on treatment outcomes for delinquents led to a widespread belief that ‘nothing’ worked. As a result, treatment came under attack both from the left, which felt that juveniles were sacrificing their rights for no gains, and from the right, which felt justified in cutting down on treatment programs. ‘Liberal’ interests began to raise the banner of deinstitutionalization of delinquents through community-based treatment programs. One consequence was the passage in 1974 of the Juvenile Justice Act, which created the federal Office of Juvenile Justice and Delinquency Prevention (OJJDP). The original mandate of this agency included inducing states to separate youthful offenders from adult criminals and to remove status offenders from secure facilities (incarceration). However, citizens of the United States have come to perceive crime as one of their main life concerns, and since the 1980s the pendulum of public opinion has continued its swing toward the retributive. Despite the fact that more recent studies of treatment have found the earlier ones to be methodologically unsound and thus unreliable (Basta and Davidson 1988), a few spectacular failures continue to lead many in society to believe that no form of treatment or rehabilitation works. A spate of mass murders committed by students at their schools in 1998 and 1999 has caused anger in many and soulsearching on every level. Ever sensitive to the public pulse, lawmakers have been overhauling juvenile justice statutes in nearly every state. The trend has been away from offender-based sentencing and toward offense-based dispositions. As Slovenko (2000) has noted, the slogan has become: ‘adult crime, adult time.’ Among other areas, confidentiality of juvenile court records and the statutes governing waiver have been altered in different ways (Torbet and Szymanski 1998). One manifestation of these changes at the state level is that juveniles are being transferred (waived) to adult criminal court for trial in greater numbers and at lower ages. Between 1992 and 1995, eighteen states broadened the definitions of crimes or lowered the age of transfer to adult court for juveniles (US Department of Justice 1995), and since 1992, forty-four states have amended juvenile justice laws to allow more youth to be tried as

The juvenile justice system: delinquency and status offenders 447

adults (Slovenko 2000). As of 1995, ten states do not even have a minimum age below which a youth cannot be waived to adult court (US Department of Justice 1995). Of the fifty states, only Hawaii does not have a mechanism for trying youth in adult criminal court. At the other end of the spectrum is Florida, the leader of the fifty states for the number of juveniles prosecuted as adults. One bittersweet compromise that has come out of the legal overhaul of juvenile justice laws is the addition of ‘blended’ sentences in some states. This allows the judge some leeway in handling the juvenile offender once he reaches adulthood. The youth may then be released, continued in a juvenile offender program, or finish out his sentence in adult prison. Fitch (1989) has succinctly summed up the evolution of the juvenile court system over the past few decades: ‘The image of the juvenile court as a grand, benevolent child guidance clinic has lost all credibility … retribution is one of the primary purposes of the juvenile court in America.’ For a further discussion of waiver of juveniles to adult court, see the section below on juveniles in adult courts.

STATUS OFFENDERS Status offenses are those acts by youth under the age of majority which if committed by an adult would not be considered a crime, and includes such behaviors as running away, truancy, unruly behavior, curfew violation, and drinking alcohol (Sacks and Sacks 1980). Other terms for status offenders include ‘persons in need of supervision’ (PINS) and ‘children in need of supervision’ (CHINS) (Sacks and Reader 1992). With the passage of the Juvenile Justice and Delinquency Prevention Act of 1974, status offenders were no longer to be detained in juvenile facilities with delinquent youths. This Act was in response to Congressional concern over crime by youths, and it established the Office of Juvenile Delinquency and Prevention that assumed responsibility for funding and overseeing community-based programs targeting juvenile delinquency (Kalogerakis 1992b; Nurcombe and Partlett 1994). This Act also eliminated juvenile court authority over status offenders, thus leading to their decriminalization and deinstitutionalization (Sacks and Reader 1992). To date, the Supreme Court has not ruled on the due process rights of status offenders (Nurcombe and Partlett 1994). However, are status offenders really being effectively separated from delinquent youths? Moore (1993) reported statistics that raise some suspicion about the effectiveness of public policy toward status offenders. Public facilities housing juveniles reported 683 636 admissions and 674 597 releases during 1991. These facilities included juvenile

detention centers, shelters, reception centers, training schools, camps, and halfway houses. Of particular concern is that almost 7 per cent of these youths (about 45 000 individuals) were incarcerated merely for status offenses such as running away, truancy, or curfew violations. There is also evidence to suggest that status offender and juvenile delinquent populations can overlap to a significant extent (Stott and Olezak 1978; Thomas 1976). In fact, there are studies that show that status offenders may have greater degrees of personality disturbance (Arbuthnot et al. 1987; Stott and Olezak 1978). In any event, the problem of how to handle the more serious status offenders remains. Now that status offenders are no longer within the jurisdiction of juvenile court systems, there is little that the state can effectively or legally do to assist parents with children who are ungovernable but are not technically breaking the law. In many cases, all the parent can do is wait for the child to commit an illegal act so that the juvenile justice system can then intervene. Other parents face the dilemma of officially abandoning their child so that child welfare agencies can take responsibility and the youth can receive help. Unfortunately, this results in legal charges against the parents in some states. In certain circumstances, the status offender may be taken into custody if he or she violates a court order, such as by running away from a court-ordered placement (Nurcombe and Partlett 1994). Adding to the problem are stringent, often unreasonable managed care guidelines severely limiting or preventing inpatient or residential psychiatric care for this population. Historically, psychiatrists have been in the ‘liberal’ ideological camp regarding juvenile justice, because historically this approach has favored treatment over punishment. During the 1970s, however, the liberal camp shifted from an emphasis on treatment to an emphasis on the rights of individuals. Deinstitutionalization has been the result, and while it has achieved some worthy goals, many would argue that it has left many parents with less authority and fewer options to help their children. Continued vigorous political action is needed to help increase the treatment options (as opposed to the further expansion of punitive approaches) available to assist beleaguered children and their families. Such efforts can help foster a proliferation of effective community-based programs, some of which are already being funded through the OJJDP or State grants, but at a woefully inadequate level.

REFERENCES Arbuthnot, J., Gordon, D.A., Jurkovic, G.J. Personality. In Quay, H.C. (ed.), Handbook of Juvenile Delinquency. New York: John Wiley and Sons, 1987, pp. 139–183.

448 Adolescent psychiatry and the law Bailkey, N.M. (ed.) Readings in Ancient History, 2nd edition. Lexington, Massachusetts: D.C. Heath and Co., 1976. Basta, J.M., Davidson, W.S., II. Treatment of juvenile offenders: study outcomes since 1980. Behavioral Science and the Law 6: 355–384, 1988. Binder, A. An historical and theoretical introduction. In Quay, H.C. (ed.), Handbook of Juvenile Delinquency. New York: John Wiley and Sons, 1987, pp. 1–32. Breed v. Jones, 421 U.S. 519 S.CT. (1975). Dusky v. United States, 362 U.S. 402 S.CT. (1960). Eissler, K.R. Searchlights on Delinquency. New York: International Universities Press, 1949. Fitch, W.L. Competence to stand trial and criminal responsibility in the juvenile court. In Benedek, E.P., Cornell, D.G. (eds), Juvenile Homicide. Washington, DC: American Psychiatric Press, 1989, pp. 143–162. Grisso, T., Miller, M.O., Sales, B. Competency in juvenile court. International Journal of Law and Psychiatry 10: 1–20, 1987. In re Causey, 363 So.2d 472 (La. 1978). In Re C.W.M., 407 A.2d 617 District of Columbia (1979). In Re Gault, 387 U.S. 1,7 S.CT. 1428 (1967). In Re Winburn, 145 N.W.2d 158 (1966). In Re Winship, 397 U.S. 358, 90 S.CT. 1068 (1970). Johnson, A.M., Szurek, S.A. The genesis of antisocial acting out in children and adults. Psychoanalytic Quarterly 21: 323–343, 1952. Kalogerakis, M.G. Disposition. In Kalogerakis, M.G. (ed.), Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Press, Inc., 1992a, pp. 71–77. Kalogerakis, M.G. Juvenile delinquency. In Schetky, D.H., Benedek, E.P. (eds), Clinical Handbook of Child Psychiatry and the Law. Baltimore: Williams & Wilkins, 1992b, pp. 191–215. Kent v. United States, 383 U.S. 541, 86 S.CT. 1045 (1966). Levine, M., Ewing, C.P., Hager, R. Juvenile and family mental health law in sociohistorical context. International Journal of Law and Psychiatry 10: 91–110, 1987. Loper, A.B. Female Juvenile Delinquency: Risk Factors and Promising Interventions. Juvenile Forensic Evaluation Resource Center of the University of Virginia, 2000. Online at: http://ness.sys.virginia.edu/juv/FemJuv.html Mack, J. The juvenile court. Harvard Law Review 23: 104–122, 1905. McKeiver v. Pennsylvania, 403 U.S. 528, 91 S.CT. 1976 (1971). Moore, J. Children in Custody 1991: Public Juvenile Facilities. Fact Sheet #5. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, U.S. Department of Justice, 1993. Mulvay, E.P., Saunders, J.T. Juvenile detention criteria: state of the art and guidelines for change. Criminal Justice Abstracts 14: 261–289, 1982.

National Center for Juvenile Justice. Crime in the United States, 1996. Washington, DC: U.S. Government Printing Office, 1997. Nurcombe, B., Partlett, D.F. Juvenile delinquency. In Child Mental Health and the Law. New York: The Free Press, 1994, pp. 273–317. Office of Juvenile Justice and Delinquency Prevention. OJJDP Fact Sheet #96: Juvenile Offenders in Residential Placement. Washington, DC: U.S. Department of Justice, March, 1999. Sacks, H., Reader, W.D. History of the Juvenile Court. In Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Association, 1992, pp. 5–12. Sacks, H.S., Sacks, H.L. Status offenders: emerging issues and new approaches. In Schetky, D.H., Benedek, E.P. (eds), Child Psychiatry and the Law. New York: Brunner Mazel, 1980, pp. 156–193. Schetky, D.H., Benedek, E.P. History of forensic child psychiatry. In Schetky, D.H., Benedek, E.P. (eds), Clinical Handbook of Child Psychiatry and the Law. Baltimore: Williams & Wilkins, 1992, pp. 1–4. Slovenko, R. The Prosecution of Nathaniel Abraham – a minor. Journal of the American Academy of Psychiatry and the Law 28: 89–101, 2000. Stott, M.W., Olezak, P.V. Relating personality characteristics to juvenile offense categories: differences between status offenders and juvenile delinquents. Journal of Clinical Psychology 34: 80–84, 1978. Thomas, C.W. Are status offenders really so different? Crime and Delinquency 22: 438–460, 1976. Torbet, P., Szymanski, L. State Legislative Responses to Violent Juvenile Crime: 1996–97 Update. Juvenile Justice Bulletin. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, November 1998. US Department of Justice. Offenders Under Age 18 in State Adult Correctional Systems: A National Picture. Washington, DC: National Institute of Corrections, 1995. US Department of Justice. Offenders in Juvenile Court, 1993. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, 1996a. US Department of Justice. Female Offenders in Juvenile Justice System. Washington, DC: Office of Juvenile Justice and Delinquency Prevention, 1996b. Wood, M. In Search of the Dark Ages. New York: Facts on File Publications, 1987. Woolard, J.L., Gross, S.L., Mulvey, E.P., Repucci, N.D. Legal issues affecting mentally disordered youth in the juvenile justice system. In Cocozza, J.J. (ed.), Responding to the Mental Health Needs of Youth in the Juvenile Justice System. Seattle: The National Coalition for the Mentally Ill in the Criminal Justice System, 1992.

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Suggested reading Coalition for Juvenile Justice. Handle with Care: Serving the Mental Health Needs of Young Offenders. 2000 Annual Report. Washington, DC: Coalition for Juvenile Justice, 2000. Hayes, L.M., Loughran, E.J., Godfrey, K., Maziarz, T., Nasiakos, S. Suicide Prevention in Juvenile Correction

and Detention Facilities: Resource Guide. Washington, DC: Office of Juvenile Justice and Delinquency Prevention (OJJDP), 1999. Snyder, H., Sickmund, M. Juvenile Offenders and Victims: 1999 National Report. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 1999.

7.4 The psychiatrist in the juvenile justice system: evaluation of offenders RICHARD A. RATNER

INTRODUCTION A psychiatrist involved with the juvenile court may be expected to perform various different tasks in different cases, but nearly all have as their basis a careful clinical evaluation. The request may come from the court itself or from either of the two ‘sides’ involved: the state’s attorney or the teenager’s advocate. Typically, the court may want a comprehensive evaluation for the purpose of deciding upon a proper course of treatment. This may occur when the court is considering whether to divert a troubled youth to a treatment program or as part of disposition planning once an adjudication of delinquency has been made. Such an evaluation will resemble those performed in clinical practice, and the reader is referred to the assessments section of this textbook. However, the court psychiatrist must keep in mind that he is operating in a setting very different from his office, with all that this implies. The unique features of assessments done for the juvenile courts have been discussed at length by experienced clinicians (Grisso 1998; Malmquist 1992; Ratner 1992; Rosner 1989; Schetky 1980; Weinstock 1989), and the reader is referred to these sources. However, it is important to keep in mind that unless an evaluation can point the way to a feasible treatment plan for the youth, it may be worth very little to the court. This means that the evaluator must have some notion of what is available in the community and what the likelihood is that the offender being evaluated will benefit from the recommendations made. From time to time, the court psychiatrist must be prepared to respond to other requests, such as to evaluate competency to stand trial or criminal responsibility. While the insanity defense is still rather rarely raised in juvenile

courts, the evolving nature of juvenile justice has set the stage for the more frequent appearance of this plea. Yet another type of request may be to evaluate a youthful offender for amenability to treatment and rehabilitative potential in connection with a waiver or transfer hearing. In states where such hearings are still required, the conclusions of the court in this regard will bear directly upon whether the youth is adjudicated in juvenile court or is transferred to adult court to be tried. In still other jurisdictions where the procedure called ‘reverse waiver’ is in effect, a psychiatrist may also be involved.

COMPETENCY, CRIMINAL RESPONSIBILITY, AND WAIVER (TRANSFER) Competency In adult court, one cannot ordinarily be tried unless (s)he is considered competent for trial. As described in the Supreme Court case that established the criteria, Dusky v. United States (1960), a defendant competent to stand trial possesses both a ‘rational’ and a ‘factual’ grasp of the charges and proceedings against him as well as the ability to consult with his attorney in his own defense with a reasonable degree of rational understanding. If a person is too mentally ill to be able to demonstrate these capacities, he/she could not truly be ‘present’ for his or her trial to confront the accusers, aid in the defense, and make decisions in his or her own best interests. If the court finds an adult incompetent, he/she is generally placed in a mental health facility where efforts are made to treat the individual with the goal of returning him/her to competency. In some cases, many months of

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treatment can go by without significant improvement, and in the past an individual might languish in a state mental hospital for years in a ‘pre-trial’ status awaiting a finding of competency. This situation changed with the Supreme Court decision in Jackson v. Indiana (1972), which established that individuals could no longer be held indefinitely in any facility while waiting to become competent. The Court established that after a ‘reasonable’ period of time – generally construed to be no more than one year – if an individual is still not competent for trial he/she must be either released or, if considered dangerous, civilly committed. The requirement that someone be competent for trial before being tried is an essential safeguard in the criminal justice system. Despite this fact, however, and for reasons related to the unique nature of the juvenile court (see Chapter 7.3) it has become a factor in juvenile courts only relatively recently. To this day not every state recognizes competency as a right in juvenile court (Grisso et al. 1987), though as the juvenile court becomes more like its adult counterpart, the number that will is expected to grow. Indeed, in a recent study, 14 per cent of a sample of adolescents referred for competency to stand trial evaluations were found incompetent compared to typical rates of 10 per cent in the adult population (McKee and Shea 1999). The authors indicate that this suggests not only the presence of other incompetents among the many juveniles who are not sent for evaluation but also that the presumption of competence among juveniles, especially younger ones, may be unwarranted. The examination for competency must incorporate but go beyond the usual mental status examination to concentrate on specific areas. Not everyone who is mentally ill is incompetent, and while mental illness is by no means irrelevant to an assessment of competency, one must supplement the usual diagnostic interviewing with a careful assessment of the individual’s understanding of the nature of the crime (or delinquent act) with which he has been charged and with his/her grasp of, among other things, the pleas available, the consequences of entering certain pleas, the nature of court procedure, and the roles of the various actors in the courtroom. It is also important to keep in mind that because a person’s mental state may fluctuate significantly over time, he/she may correspondingly gain or lose the ability to function in a competent fashion. A person who is found competent a month before his trial may have regressed and become incompetent by the time the trial begins. Competency evaluations are sometimes called for on the spot if court personnel have reason to believe that the individual is no longer competent. Competency is sometimes confused with criminal responsibility. The distinction is that competency, by virtue of its concern for the individual’s state of mind as he/she approaches trial, is a present-state examination. In contrast, criminal responsibility evaluations concern themselves with the individual’s state of mind at the time

of the offense and are therefore always based upon retrospective judgments of an individual’s behavior prior to being examined (see below). The assessment of criminal competency is a specialty of the forensic psychiatrist or psychologist. Other than the Dusky criteria noted above, there is no guidance from the courts regarding how to actually determine competency. While most forensic experts use their own systematic interviewing to satisfy themselves that someone is or is not competent, various authors have attempted to construct rating systems for competency to make the determination more systematic and standardized. At least two such instruments, the Competency Assessment Instrument (CAI), and the Competency Screening Test (CST) were developed during the 1970s as a two-step process for determining competency using a semi-structured interview (Grisso and Siegel 1986). Other more refined instruments have been developed over the years (Ustad et al. 1996), but despite these efforts it is probably fair to say that none is yet in widespread use in clinical practice. However, the prestigious MacArthur Foundation has been supporting extensive research into the nature and measurement of competencies, and under their auspices Hoge and colleagues at the University of Virginia have developed a new research instrument which is also showing promise for clinical use (Hoge et al. 1996). In essence, the approach of this group is to dissect competency to stand trial (called ‘adjudicative competence’ to include similar types of competency) into two components: competency to assist counsel and ‘decisional’ competency. Each of these can be further broken down into capacities to understand, reason, and ‘appreciate,’ and each of these six functions are tested and evaluated in a standardized fashion using the MacArthur instrument. A more detailed description of this instrument goes beyond the scope of this chapter, but for a more comprehensive discussion of competency the reader is referred to the chapter by Miller (1999a) regarding competency in general and, for juvenile competency, Grisso (1998). Adolescents may be found incompetent for many of the same reasons as adults: cognitive deficits, psychosis, or severe learning problems. What makes them unique relative to adults, however, is the influence of their developmental level either alone or in concert with these psychological and psychiatric deficits. Heilbrun et al. (1996) surveyed the literature and noted that research supports a distinction roughly equivalent to early, middle and late adolescence with respect to four parameters of trial competence: understanding of the legal system, the belief that legal circumstances applied to them, ability to communicate with counsel, and decision-making. For the youngest group, those aged under twelve years, developmental immaturity was found to pose ‘a significant impediment to performance in all four areas,’ while the middle group (thirteen- and fourteen-year-olds) was mixed in that some individuals had and others had not

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developed the requisite capacities; most of those aged fifteen years and over had developed these capacities sufficient to be found competent absent serious mental illness or developmental delays. For more specific concentration on the application of competency to the juvenile court, see Grisso (1998), Grisso and Miller (1987), Heilbrun et al. (1996), and Ratner (1992).

Criminal responsibility (the insanity defense) The insanity defense is a complete defense (i.e., an acquittal) to a crime that may be invoked when it is believed that the perpetrator of the crime was, by virtue of mental illness, not responsible for his or her criminal acts. Prior to the changes made in the juvenile courts since the 1960s, the insanity defense was generally considered a redundancy and rarely invoked; since the juvenile court never saw its mission as one of convicting in the first place, there seemed no reason to employ a method to avoid conviction. In fact the insanity defense’s rationale is based upon an analogy between the ‘insane’ person and a child too young to appreciate the wrong that he or she might be doing. Not surprisingly, the insanity defense, like the notion of competency, is beginning to become an issue in juvenile courts as they have grown more adversarial and adultoriented. In essence, the insanity defense is based on the premise that the person was too seriously mentally ill at the time of the crime to have intended to perform a criminal act even though such an act was perpetrated. Again as in the case of competency, ‘insanity’ is not synonymous with either mental illness in general or psychosis in particular. In fact, both ‘insanity’ and ‘competency’ are legal rather than medical or psychiatric terms, and the courts define both. Indeed, the courts ultimately make all of these determinations after hearing the views of one or more expert psychiatric witnesses. For a person to be convicted of a crime, two elements must be proven:

• •

that the person performed the illegal act; and that he or she intended to do so, knowing it to be a crime.

The substrate for all defenses based upon intent (such as insanity) is the latter of these elements, the defendant’s state of mind at the time of the crime. It is said that if a person lacked the requisite mental state to form the intent to offend, then he/she is not to be held criminally responsible for the offenses he/she may commit. Another example of a defense based upon intent but not related to insanity is ‘self-defense.’ Even if a person causes bodily injury to another, if he/she does so solely to protect himor herself from the threat of severe injury or death and uses no more than the minimal necessary force to prevent harm to oneself, he/she would likely be acquitted of

the crime, because he/she did not intend to commit a criminal act. While the notion of competency is defined fairly uniformly using the Dusky criteria, the definition of what constitutes an ‘insane’ state of mind differs in different jurisdictions. One example of an insanity statute states that a person will be held not guilty by reason of insanity for a crime he/she has committed if, by virtue of mental illness, he/she were unable, at the time of the crime, to appreciate the wrongfulness of his/her acts or to conform his/her behavior to the requirements of the law. This particular statute consists of a ‘cognitive’ prong (could not appreciate wrongfulness) and a ‘volitional’ prong (could not conform behavior), the latter being related to what has sometimes been termed ‘irresistible impulse.’ In other jurisdictions, the criterion is purely cognitive: whether the individual knew what he/she was doing at the time of the crime and, if so, whether he/she recognized that it was wrong.1 Thus, if an acutely psychotic man ‘sees’ Satan walking toward him threateningly and as a result assaults a totally innocent stranger, he might well be found insane under either statute. It might be concluded under the first statute that he could not have appreciated the wrongfulness of attacking a stranger and/or could not have conformed his behavior to the law’s requirements; using the second test, he could be seen as not realizing that he was committing a criminal act. Insofar as such a defendant never intended to commit a criminal act but acted instead in response to delusions and hallucinations, the absence of criminal intent could qualify him for an insanity defense. If the evaluator feels that the conditions for such a defense are met using the particular standard of the jurisdiction, then he/she might opine that the individual was ‘not guilty by reason of insanity’ (NGBRI) or ‘not criminally responsible’ (NCR). Should the court so find, these individuals are acquitted: they do not lose their rights to vote (as do felons) and are not incarcerated in penitentiaries. While they may be confined, it is to a mental hospital rather than a prison, and rather than receiving a sentence proportional to the gravity of their crime, they are generally released when they are sufficiently recovered no longer to be a danger to society. In performing a criminal responsibility evaluation, the psychiatrist must supplement his overall evaluation with special questioning regarding the state of mind at the time of the crime. In doing so, the evaluator must be aware of the precise criteria for ‘insanity’ in the jurisdiction where he/she is working. For example, it would do no good to attempt to persuade a court that a youth was NCR because 1 A discussion of the historical background of the insanity defense, which would shed light on how differing definitions of insanity have developed, is beyond the scope of this chapter. The interested reader is referred to appropriate chapters in textbooks of forensic psychiatry (e.g., Miller 1999b; Shah 1986).

The psychiatrist in the juvenile justice system: evaluation of offenders 453

of an inability to conform his behavior to the requirements of the law if that state did not recognize a ‘volitional’ prong as a criterion for insanity. It should also be clear that inferences about a person’s state of mind at some time in the past are inherently open to question – a fact that often leads to different experts reaching different conclusions. Thus ‘battles of the experts’ sometimes take place in court, but typically this results from honest differences of opinion about the defendant’s past mental state, which may often be simply unknowable, rather than from either expert simply acting as a ‘hired gun.’ It should be re-emphasized that the final decisions regarding such matters as competency and criminal responsibility are made by the so-called finder of fact, which in juvenile (as opposed to criminal) court is always the judge. In theory, experts, even when retained by the court itself, do not decide upon the ‘ultimate questions’ such as competency or criminal responsibility. Nonetheless, in practice mental health experts are routinely asked their opinions regarding these matters, and on many occasions, particularly if there is only one expert in the courtroom, the judge will ratify the conclusions of that expert. Insanity defenses in adult court rarely succeed, and when they do it is typically because the prosecution is willing to ‘stipulate’ to the serious mental illness of the defendant. Adults are typically tried in front of juries, and many lay people are suspicious that insanity pleas are largely attempts by defendants to escape punishment. Insanity defenses in juvenile court are still fairly rare, but to the degree they are put forth because they lead to the best disposition possible for a defendant (a mental hospital instead of prison or even death), there is less need for them in juvenile courts, where other forms of treatment and rehabilitation with less stringent controls on the adolescent are available.

Waiver (Transfer) In those jurisdictions where it remains up to the courts whether or not to transfer a juvenile to adult court, transfer, or waiver, hearings still take place. In this situation the psychiatrist may be called in to make a comprehensive assessment of the adolescent with special emphasis on the issues of amenability to treatment, or ‘rehabilitative potential.’ Here, the psychiatrist is not bound by particular criteria defining these terms but must depend upon his best judgment and his experience. In contrast to the more restricted competency evaluation, which concentrates upon the individual’s frame of mind at the moment, or to the criminal responsibility evaluation which seeks to make determinations about the youth at the time of the crime, the evaluation for transfer to adult court must be wide-ranging, taking into account the longitudinal development of the teenager over the years. Despite the

difficulties of prediction, the psychiatrist must formulate an opinion about the teenager’s prospects for responding to treatment. While including conversations with family members and others who know the teenager intimately may be helpful for any evaluation, they may be especially important components of this kind of evaluation. Further, psychological testing may also be wisely employed in order to help a psychiatrist formulate his opinions. For more information regarding the current status of the waiver or transfer process, see Chapter 7.9.

MALINGERING One issue that presents itself from time to time in all areas of forensic psychiatry to a greater degree than in ordinary clinical practice is the issue of malingering. One must expect, whether evaluating for competency, criminal responsibility, transfer to adult court, or a host of other kinds of court-related issues, that the interviewee is not unaware of his/her circumstances and may have a strong desire to be perceived as incompetent, not criminally responsible, suffering from a serious mental illness, or ‘mad’ rather than ‘bad.’ Thus, some individuals may be highly motivated either to ‘fake bad’ or to ‘fake good’ because of the effects of the Court’s judgements upon their ultimate dispositions. For these reasons the clinician dealing with forensic populations, adult or adolescent, must maintain a higher index of suspicion when performing court-ordered evaluations. It is often desirable to perform such evaluations on inpatient units when such are available. This makes it more likely that malingering will be recognized, often because the face presented by the individual to the clinician differs in significant ways from his/her behavior with the staff when ‘off camera.’ Especially when such an option is not available the clinician must consider other sources of information about the examinee. One major approach is through the adjunctive use of psychological testing. For example, adolescent versions of standardized ‘objective’ psychological tests like the Minnesota Multiphasic Personality Inventory (MMPI-A) and the Millon Adolescent Personality Inventory (MAPI) are commonly used in forensic evaluations because of, among other things, dissimulation scales that indicate ‘fake good’ or ‘fake bad’ profiles. Because most psychiatrists are not trained in the use of psychological testing, we are generally well advised to consult with colleagues in clinical psychology who are adept not only in interpreting the results of individual psychological tests but in selecting appropriate batteries of tests to be given and making sense of the results. Further discussion of malingering and its detection is beyond the scope of this chapter, but numerous publications (McCann 1997; Rogers 1997) have become available

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in recent years to aid the forensic examiner in understanding and recognizing malingering.

REPORT WRITING AND COURT APPEARANCES In addition to performing evaluations and formulating opinions, forensic psychiatrists, whether working with adults or adolescents, are typically expected to prepare a written report of their findings. This report will become part of the court record and will ‘follow’ the juvenile, regardless of where he/she is placed; as such it may be used as the basis not only for the decisions at hand but often in connection with future dispositions. As such the report should be carefully written, meticulous in its recording of accurate information, and clearly focused to provide the court with the information it has requested. For a comprehensive discussion of report writing in the juvenile justice system, see Malmquist (1992). Another function of psychiatrists working in a forensic context, whether with adolescents or adults, is the appearance in court. While the juvenile court has not yet approached the adversarial level of adult courts, the would-be expert witness must be prepared to be crossexamined thoroughly by the lawyer on the other side of the case. For psychiatrists new to the system, the crossexamination can be an exercise in unexpected humiliation, and all psychiatrists who go to court for the first time are likely to have a similar reaction. This problem is much relieved by experience, but no amount of experience will substitute for a lack of preparation for the appearance. Most fundamental to an effective presentation of one’s view in court are two qualities, one regarding content, and the other process. The ‘content’ criterion is that one must have thought through and be prepared to express the factual basis for one’s opinions as opposed to being unable to explain how and why one arrived at them. The ‘process’ criterion is that one must be able to communicate one’s views in a manner that is fairly free of jargon and understandable to an educated lay person. The psychiatrist in juvenile court is freed of the responsibility of attempting to communicate with a jury, which is a rather different task, since the judge is the ultimate finder of fact; however, one does a disservice to the client and the court if one’s communications can only be understood by another psychiatrist, often of the same doctrinal persuasion. Experience proves to all forensic psychiatrists that in addition to preparing to discuss his/her ideas, actual preparation with the attorney including a virtual rehearsal of one’s direct testimony greatly improves the effectiveness of the presentation. By helping the attorney structure his questions in such a way that the psychiatrist’s ideas can emerge in a clear and logical fashion and that his/her

conclusions can be seen to emerge logically from his/her findings, a powerful impression can be made upon the judge. For a fuller discussion of the psychiatrist as an expert witness see the articles by Ratner and Nye (1992) and Gutheil (1998a), and for keys to witness effectiveness on the stand, Bank and Poythress (1982), Brodsky (1991), and Gutheil (1998b) among many others.

REFERENCES Bank, S.C., Poythress, N.G., Jr. The elements of persuasion in expert testimony. Journal of Psychiatry and the Law 10: 173–204, 1982. Brodsky, S.L. Testifying in Court: Guidelines and Maxims for the Expert Witness. Washington, DC: American Psychological Association, 1991. Dusky v. United States, 362 US 402, 1960. Grisso, T. Forensic Evaluation of Juveniles. Sarasota, FL: Professional Resource Press, 1998. Grisso, T., Miller, M.O., Sales, B. Competency to stand trial in juvenile court. International Journal of Law and Psychiatry 10: 1–20, 1987. Grisso, T., Siegel, S.K. Assessment of competency to stand criminal trial. In Curran, W.J., McGarry, A.L., Shah, S.A. (eds), Forensic Psychiatry and Psychology. Philadelphia: F.A. Davis Co., 1986, pp. 145–166. Gutheil, T.G. The Psychiatrist as Expert Witness. Washington, DC: American Psychiatric Press, 1998a. Gutheil, T.G. The Psychiatrist in Court: A Survival Guide. Washington, DC: American Psychiatric Press, 1998b. Heilbrun, K., Hawk, G., Tate, D.C. Juvenile competence to stand trial: research issues in practice. Law and Human Behavior 20: 573–578, 1996. Hoge, S.K., Bonnie, R.J., Poythress, N., Monahan, J., Eisenberg, M., Feucht-Haviar, T. The MacArthur adjudicative competence study: development and validation of a research instrument. Law and Human Behavior 21: 141–179, 1996. Jackson v. Indiana, 406 US 715, 92 SCt 1845, 32 L.Ed.2d 435 (1972). Malmquist, C. The psychiatric report in the juvenile justice system. In Kalogerakis, M.G. (ed.), Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Press, Inc., 1992, pp. 47–57. McCann, J.T. Malingering and Deception in Adolescents: Assessing Credibility in Clinical and Forensic Settings. Washington, DC: American Psychological Association, 1997. McKee, G.R., Shea, S.J. Competency to stand trial in juvenile court: characteristics of competent and incompetent juveniles. Journal of the American Academy of Psychiatry and Law 27: 65–73, 1999. Miller, R.D. Criminal competence. In Rosner, R. (ed.), Principles and Practice of Forensic Psychiatry.

The psychiatrist in the juvenile justice system: evaluation of offenders 455 London: Edward Arnold Books (Oxford University Press), 1999a, pp. 174–197. Miller, R.D. Criminal responsibility. In Rosner, R. (ed.), Principles and Practice of Forensic Psychiatry. London: Edward Arnold Books (Oxford University Press), 1999b, pp. 198–215. Ratner, R.A. Role of the psychiatrist. In Kalogerakis, M.G. (ed.), Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Press, Inc., 1992, pp. 25–36. Rogers, R. (ed.) Malingering and Deception. New York: Guilford Press, 1997. Ratner, R.A., Nye, S.G. Court testimony: the psychiatrist as witness. In Kalogerakis, M.G. (ed.), Handbook of Psychiatric Practice in the Juvenile Court. Washington, DC: American Psychiatric Press, Inc., 1992, pp. 59–70. Rosner, R. Assessment of juvenile psychopathy for legal purposes. In Rosner, R., Schwartz, H.I. (eds), Juvenile

Psychiatry and the Law. New York: Plenum, 1989, pp. 183–198. Schetky, D.H. Introduction to court evaluations. In Schetky, D.H., Benedek, E.P. (eds), Child Psychiatry and the Law. New York: Brunner/Mazel, 1980, pp. 21–32. Shah, S.A. Criminal responsibility. In Curran, W.J., McGarry, A.L., Shah, S.A. (eds), Forensic Psychiatry and Psychology. Philadelphia: F.A. Davis Co., 1986, pp. 167–208. Ustad, K.L., Rogers, R., Sewell, K.W., Guarnaccia, C.A. Restoration of competency to stand trial: assessment with the Georgia Court Competency Test and the Competency Screening Test. Law and Human Behavior 20: 131–146, 1996. Weinstock, R. Emotional, cognitive, and moral developmental considerations in interviews of adolescents for forensic purposes. In Rosner, R., Schwartz, H.I. (eds), Juvenile Psychiatry and the Law. New York: Plenum, 1989, pp. 199–218.

7.5 Treatment of juvenile offenders LEE H. HALLER

ASSESSMENT OF JUVENILE OFFENDERS The student of antisocial behavior in juveniles soon becomes aware that he/she is dealing with a complex social phenomenon that cannot be reduced to a single parameter, such as the presence or absence of a mental disease. In few other areas does the notion of biopsychosocial explanation seem as applicable. A glance at the seminal text of Rutter et al. (1998), carefully entitled ‘Antisocial behavior by young people,’ indicates the multifactorial nature of delinquency causation including, in addition to the profusion of individual features (genetic, temperament, toxins, androgens, intelligence), a host of psychosocial (broken home, age of parents, coercion and hostility, poverty, peer groups), and social (media, ethnicity, school effects, guns and drugs) factors. Nonetheless, and despite this overwhelming complexity, psychiatrists have historically played an important role in the treatment of, and continuing research into, juvenile delinquency and antisocial behavior. For the past seventy-five years we have attempted to understand the reasons for delinquent behavior and to find ways to rehabilitate the perpetrators. Many authors have attempted to classify delinquents according to factors that might suggest differing avenues of treatment (e.g., Rogers et al. 1997; Myers et al. 1995). From a psychiatric point of view, the vast majority of juvenile delinquents meet current criteria for a diagnosis of Conduct Disorder (CD). However, studies have also shown a high level of comorbidity with other psychiatric conditions. In one study, 11 per cent of serious delinquents suffered from schizophrenic spectrum disorders, 15 per cent from major affective disorder, and 63 per cent from substance abuse (McManus et al. 1984). Borderline Personality Disorder was also widely diagnosed. De Prato and Hammer (2002) report studies which showed 29.7 per cent of delinquents to have an anxiety disorder, 12.7

per cent with a bipolar disorder, 4–19 per cent with mental retardation, and 22 per cent with learning disabilities. In those youth with both Borderline and Substance Abuse pathology, the likelihood of violent behavior was greatest. A study by Myers et al. (1995) found similar indications of psychiatric illness in serious delinquents; some 96 per cent of their sample of twenty-five homicidal adolescents met criteria for a DSM-III-R diagnosis, of which conduct disorder was most frequent. In addition to a profusion of other diagnoses, Myers and colleagues also found that 43 per cent of patients had a history of serious head trauma, and 8 per cent a history of seizures. All of them had serious problems functioning in school. Sadly, only a few (14%) had ever received any mental health care. Perhaps the most powerful association with another condition, however, is with Attention Deficit Hyperactivity Disorder (ADHD). Numerous studies (e.g., Satterfield and Schell 1997; Taylor et al. 1996) have documented its connection with antisocial behavior and Conduct Disorder in long-term follow-up studies. Since many in this population come from violent backgrounds where they have witnessed and/or been victims of violence, post-traumatic stress disorder (PTSD) is also not uncommonly seen. Steiner et al. (1997) found that 52 per cent of incarcerated male juvenile delinquents suffered from at least partial PTSD, while more recently Schwab-Stone et al. (1999) reported a positive correlation between exposure to violence and later externalizing behaviors. Anxiety was negatively correlated with such behaviors. While the treatment of delinquent youth must focus on the delinquent conduct and its prevention, one must also make provision for treatment of these and other comorbid conditions, which can run the gamut from physical illness to illiteracy. The frequent presence of comorbid psychiatric conditions among adolescent offenders is one powerful reason for the presence of a psychiatrist in a prominent position on the treatment team.

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HISTORICAL CONSIDERATIONS REGARDING OFFENDER TREATMENT Treatment for juvenile offenders over the years has generally paralleled those treatments that have been in vogue in society at large. In effect, the ascendancy of psychoanalytic thinking in the early and mid-twentieth centuries led to individual psychodynamic treatment methods when such were available. During these years, adolescent delinquent behavior was conceptualized as a function of the individual delinquent, and though the effects of the family were being noticed beginning in the late 1940s, treatment (when it existed) tended to be individual and often in an institutional setting. Great contributors to the early literature on treatment include Aichhorn, Redl, Johnson and Szurek, the Gluecks, Glover and even Anna Freud (Eissler 1949). While it became the vogue during the 1970s to view all treatment for delinquents as futile, this view itself turned out to be based on flawed studies with ineffective research methodologies (Basta and Davidson 1988). Nonetheless, it became clear over time that traditional psychodynamic approaches in isolation were less effective in the society that we have become than more integrated forms of intervention including notions of ‘family preservation.’ Cognitivebehavioral individual techniques have also come into vogue as interest in analytically based therapies has faded. Aiding and abetting the trend away from individual psychodynamic treatment for delinquent youth was the trend toward deinstitutionalization that gripped American psychiatry during the 1970s. The notion that individual delinquents could be cured by removing them from their families and environments and sending them to remote state schools or even private treatment facilities fell out of favor in contrast to the practice of treating in the family and neighborhood context when possible. Emblematic of this trend was when Massachusetts closed all its state schools in the 1970s. Private residential treatment centers still exist however, and represent a possible disposition for delinquent youth, but even in these settings psychiatrists have come to appreciate the importance of integrating family consultation and therapy into their work with the adolescent (Fowler and Rosenberg 2000). Nonetheless, psychiatrists are finding themselves increasingly as members of teams working in public facilities to implement family and community approaches to delinquency reduction.

CURRENT TRENDS IN TREATMENT Effective treatments for delinquency are constantly being sought. The Office of Juvenile Justice and Delinquency Prevention (OJJDP) published an Action Plan (Coordinating Council on Juvenile Justice and Delinquency Prevention 1996) with eight objectives designed to assist communities in attaining their efforts at optimally

handling juvenile offenders. These objectives embrace certain themes: the careful balancing of the needs of youth for assistance with the need to be accountable and take responsibility; prominent consideration for public safety; the emphasis on small community based facilities when secure confinement is required; enhancing opportunity by early intervention for at-risk children; initiating programs to target guns and drugs; addressing abuse and neglect of teens to ‘break the cycle’ of violence; supporting community efforts to organize and promote prosocial goals; and prosecuting certain serious and chronic offenders aggressively. Most rehabilitation efforts and programs are geared to that segment of the delinquent population whose primary difficulties are those of conduct. In developing treatments for them, it is essential that each individual be thoroughly assessed not only for the presence/absence of this illness but for other physical and mental health problems as well. The Massachusetts Youth Screening Instrument – Second Version (MAYSI-2) is a useful tool to aid in the early identification of mental health issues (Grisso et al. 2001). It is a self-report screening measure which is easily readable, thereby increasing the percentage of youth for whom it is useful. One must be careful not to diagnose conduct disorder merely on the basis of some minor delinquent activity which can be part of normal adolescent development, a single acting-out behavior in response to an acute situational stress in an otherwise healthy individual, truancy, or a minor status offense that is a manifestation of some other problem (such as learning disability, depression, or adjustment disorder.) Within the set of conduct-disordered youth there are differences in prognosis for the two subsets of early- and late-onset CD, with the latter having a much more favorable prognosis. In general, those with adolescent onset do not have nearly as malignant a course of illness as do those with early-onset CD. A further subset of the early-onset group is a small number who, when they become older adolescents, act with extreme violence towards others and who have no remorse. These offenders represent a treatment-resistant group who should be separated from the CD program. Having separated out youths who either do not need or could not benefit from an intensive treatment program, one is still left with the vast majority of the delinquent population who have early-onset CD. Increasingly we have come to recognize that these children have problems in multiple areas, including intrapsychic, family relations, educational development and community involvement. Treatment programs have thus been designed to address each of these needs.

Social and psychological treatment strategies One of the programs that has been showing markedly positive results is Multi-Systemic Therapy (MST), developed by

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Henggeler and his associates (Henggeler 1997; Henggeler et al. 1993, 1996, 1998). Efforts are being made to replicate this program, because it has met with success in terms of significant and long-lasting reductions in recidivism. Henggeler has built careful follow-up into his program design; his research has shown that MST is significantly more effective than more traditional treatments for innercity juvenile offenders and that the results were maintained, in at least one demonstration project, for up to four years. There are several keys to Henggeler’s program that differ from previous approaches. Much of the service that is provided to the families is done in the community, either at the home, school, or other neighborhood buildings, instead of an office or hospital setting. The services are delivered by several different providers, each focusing on a specific problem area, such as social, educational or psychological. Thus, the treatment modality is described as ‘total care.’ There is a case coordinator who actually provides service rather than simple monitoring. Of note is that a caseload for a team member is only four to six clients. This is a reflection of the intensity of the service that is delivered to every single client and family: up to 60 hours of contact over four months. At the beginning, contact is daily and team members are available 24 hours a day, seven days a week. The goal of the program is family preservation with improved functioning in the family and a drop in the recidivism rate. Another aspect of Henggeler’s program that has made it attractive to granting agencies is that it is remarkably economical to run. Even though it is very staff-intensive, the program estimates that a three-month course of treatment in one locale in South Carolina came to less than 20 per cent of the cost of institutionalization for the same period. Not only has MST been shown to be effective with delinquent offenders, it also has demonstrated efficacy for adolescent sexual offenders and youth substance abusers. Although it is of more limited value in treating the older, more violent juvenile offender, there are some youth in this category who will respond. Even though this program is markedly effective according to follow-up studies carried out two to four years post treatment, it is by no means curative for all offenders. In one study, by the end of two and a half years, some 60 per cent of the treatment group had re-offended, whereas in a comparison group receiving the usual services, over 80 per cent had re-offended. In another study, MST completers showed a 22 per cent re-arrest rate after four years, which compared with a 72 per cent recidivism for those receiving the standard treatment. These figures reflect a treatment program that is more successful than others but which still has many failures. Another treatment paradigm which has achieved at least a modicum of success is termed Parent Management Training (PMT) (Kazdin 1997). This treatment modality is a behavior-modification program that is taught to parents who can then use it with their children. Its goal is to

develop or increase pro-social behaviors while decreasing deviant behaviors. This ‘cognitive’ approach teaches parents to focus not only on the child’s behavior, but also on its antecedents and consequences. The parent is taught to use positive reinforcement and behavior modification to reward pro-social behaviors rather than merely condemn or punish negative behaviors. When there are two parents in the home, PMT training is provided to each, enabling both to participate in the program. The duration of the program can be as little as six to eight weeks for parents of young children who have mild oppositional problems, but may also last up to twenty-five weeks. The author has adapted a technique for use in small parent groups in the community and has used videotaped materials. Both of these modifications have proved beneficial. Recognizing that these are multi-problem families, PMT is supplemented with sessions addressing family stressors. This has had the effect of reducing the number of families who drop out. PMT has also been combined with problem-solving skills training provided to the child (Kazdin et al. 1992), which further improves outcome. Although this treatment modality has shown effectiveness, significant problems exist. First, there is a large dropout rate; second, the technique has mainly been used with children ages three to ten years, and research data show that adolescents respond less well than do children (Dishion and Patterson 1992). Cognitive approaches, which address distortions in thinking processes, also have a place in treatment, as when aggressive youth erroneously perceive hostile intent directed at them from others (Crick and Dodge 1994). Problem-solving skills training (PSST) is one treatment paradigm that has been successful in altering such distorted perceptions, with a consequent reduction in violent behavior (Kazdin 2000). PSST teaches the youth ways to approach interpersonal situations and how to evaluate them more realistically via modeling by the therapists, role playing, and structured games. Children with comorbidity, learning disabilities, and conduct disorder who come from families with a relatively high degree of dysfunction and psychopathology respond less positively to this treatment modality (Kazdin and Crowley 1997). The Island Youth Program in Galveston, Texas is an example of a multi-system and multi-focal approach, which has been successful in the abatement of youth violence (Thomas 2001). Interestingly, a major focus of the program has been on truant youth. The role of the police is to pick up the youth and take him to a screening center to determine what problems he has and what services might be helpful. A follow-up evening visit with the parents in their home is made by the police officer. The role of the school is to teach the children how to recognize feelings in themselves and others, as well as conflict resolution. Another aspect of the program has been peer court, which focuses on first-time offenders.

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Yet another approach to conduct-disordered youth is based on attachment theory (Moretti 1994). This theory works with an ‘appreciation of the youth’s internal working models of self and others.’ In a sample of fifty-five conduct-disordered adolescents, Moretti and colleagues found their attachment patterns to be as follows: fearful (46%); dismissing (20%); secure (9%); and preoccupied (25%) (Moretti et al. 1997). These attachment styles are then utilized in formulating and implementing a broadbased, multi-system treatment intervention. The goal of the program, which involves not only the child but also the significant others in the child’s life, is to alter responses by the child from projection to empathy (Holland 1997). Various types of family therapy have been utilized with some degree of success. Chamberlain and Rosicky (1995) identified three such programs. Structured Family Therapy (SFT), Social Learning Family Therapy (SLFT), and MultiTarget Ecological Treatment (MET). In general, family therapy tends to work better with younger children. A significant problem with family therapy is the high dropout rate, but this difficulty can be overcome if the therapy is conducted at the family’s home rather than at the therapist’s office (Gordon et al. 1998). Despite the promising results of several multimodal treatment programs, much more work remains to be done in this area. Early intervention efforts, geared towards prevention as well as treatment, have been found more effective than interventions that come later (Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry 1997). Thus, identifying and intervening with these individuals before they become adolescents heightens the likelihood of success.

Psychopharmacological approaches When the psychiatrist is working in the context of a treatment team that is providing services for the multiple needs of these youths (such as educational for learning disabilities, other medical, working with families, etc.), his or her involvement often revolves around establishing a diagnosis and prescribing medication. The necessity of differentiating normal behavior or transient behavioral abnormalities from conduct disorder and/or serious mental illness has already been noted. One essential reason for so doing is that psychopharmacological treatment of each condition is different. Appropriate treatment will substantially improve both the ability of a teenager to work in treatment and the capacity to control violent behavior, whereas misdiagnosis and inappropriate use of medication impairs progress and may create side effects. Although there is no specific psychopharmacologic treatment for CD, there are medications that have been used for their anti-aggressive properties (Candilis 1996), even in the absence of a more specific psychiatric diagnosis. Lithium, phenytoin, and carbamazepine have all been prescribed in certain types of aggressive patient. Valproate

has been used in aggressive adolescents with success (Steiner et al. 1997), although its use in females is problematic due to its propensity to induce polycystic ovary disease. ␤-Blockers such as propranolol, pindolol, and nadolol have all been tried and shown to be effective in controlling certain types of aggressive behavior (Shreeram and Kruesi 1999). Care must be exercised to avoid the use of ␤-blockers in patients with asthma, chronic obstructive pulmonary disease, insulin-dependent diabetes, certain cardiac diseases, or hyperthyroidism. Serotonin reuptake inhibitors, such as fluoxetine and citalopram, have shown effectiveness in treating violence in adults. Although benzodiazepines have been used to calm agitated patients, these medications are not recommended for this population since they may cause behavioral disinhibition and are also drugs of abuse. Buspirone has helped in developmentally disabled populations. Neuroleptics, particularly risperidone and clozapine, may be used; these are not first-line medications, and should be reserved for treatment-resistant cases as the results are variable in children (Halperin 1997). Other medications that have been tried are opiate antagonists such as naloxone and naltrexone; these have been used for self-injurious behavior but may also be tried with other types of behavior problem. Antihistamines such as diphenhydramine have also been used to control aggression. As a general rule, the psychiatrist must remain cognizant at all times that this population includes a high percentage who misuse medications. Tablets or capsules may be chewed, crushed, cooked, or combined with other substances to achieve a ‘high.’ Alternatively, medications may be taken impulsively in response to a suicidal urge. Furthermore, these drugs are often sold on the street for profit. When prescribing, potentially serious side effects and possible drug interactions due to the cytochrome P450 enzyme system must be borne in mind and explained in layman’s terms to both the adolescent and the responsible adult. Care must be taken to ensure that the material is understood, bearing in mind the likelihood that learning disability, ADHD, and/or limited intellectual capacities may interfere with comprehension. Similarly, psychological factors such as suspicion of the physician’s motives or feelings of invincibility also may affect an adolescent’s approach to medication. In attempting to treat aggression via psychopharmacology, care must be taken to ensure that one is obtaining a medication response rather than a placebo response. For example, in one study, twenty-one of forty-four conductdisordered aggressive hospitalized children improved on placebo (Malone et al. 1997).

ALTERNATIVE PROGRAMS Several jurisdictions have created programs designed for specific types of offenders in order to ease the caseload of

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the traditional juvenile courts. Some of these have turned out to be quite successful. For example, juvenile drug courts were authorized via public law 103-322 and have been in operation since 1996. Youth who come to the attention of the juvenile court because of behavior related to a drug problem are eligible. The ‘sentence’ involves not only drug treatment, but also a comprehensive and coordinated community-based remediation plan for addressing mental health, educational, and family needs. Professionals in various disciplines are involved with both the youth and family. Court supervision occurs as well. According to Kessler (2001), 80 per cent of juvenile participants return or remain in school full time. Peer courts represent another means of handling juvenile cases. In this model, youth function not only as the jury, but also as the defense and prosecution attorneys, bailiff, and, sometimes, even as judge. Dispositions that are meted out are reparative community service, rather than incarceration. The idea is to teach young offenders how their behavior affects others. With proper case selection and administration, such programs can be both successful and cost-effective. For example, one New York City court claims a mere 5 per cent recidivism rate at a cost of $300–500 per youth per year (Kessler 2001). Yet another possible disposition for youth which has proved useful is placement in a group home. Typically, a small number of children are housed in each setting with foster parents who are specially trained. The homes function like a regular family. The children attend the local public school, participate in therapy, and even earn the right to hold a part time job. Parents may visit and participate in family therapy. In contrast to these successful programs, other programs have been glaring failures. Boot camps, which are run in military style involving strict rules, work, and exercise, are designed to shock the delinquent. Although there is some evidence with adults that the program may heighten moral development, it is ineffective in reducing recidivism (DePrato and Hammer 2002). Similarly, ‘scared straight’ programs, where youthful offenders are brought into adult prisons, have been found not to be helpful, and may even be harmful.

relational conflict, whereas for males it usually occurs in conjunction with another crime. The girls’ victims were under three years old in 24 per cent of cases, and most of them were the children of the offender (Loper 2000). Female offenders are also known to have higher rates of depression, eating disorders, suicidal behaviors, and psychiatric hospitalizations than their male counterparts. Further, they are more likely to have been victims of physical or sexual abuse than are male delinquents. Sexual promiscuity and prostitution are also relatively common behaviors in female offenders. These factors must be taken into account when formulating successful treatment programs. Interventions which prove to be fruitful focus on teaching the girls about developing healthy relationships and assisting them (as well as their families and communities) to become more interconnected.

SUMMARY Effective handling of youthful offenders in the juvenile justice system represents a tremendous challenge. For decades, they were placed in institutions where rehabilitation was the goal, but scant/absent resources made that task impossible. Worse yet, they were put in isolation or even beaten for misbehavior. Thus, when they were released, they were certainly no better off and probably were worse off than when they entered. It is no wonder that re-offending within a year of release was common. During the past decade, finally, comprehensive strategies have been devised. The success of these programs is demonstrated by markedly reduced rates of recidivism. Successful programs are labor-intensive. Workers need to be trained. Multiple different disciplines must be involved and coordination among the various treatment providers is essential. When the youth are finished with the program, arrangements must be made for after care which means that community follow up step down services must be provided in order to assist the youth and families with transition back into normal life. By utilizing the types of treatment described here, youthful offenders are given a reasonable chance of staying within the bounds of the law which benefits both them and society.

FEMALE OFFENDERS

REFERENCES

The information provided so far in this chapter relates primarily to male offenders, because seriously violent delinquents are far more likely to be male. However, the percentage of female offenders is rising: between 1993 and 1997 arrests of females for violent offenses increased by 13 per cent whereas those of males fell by 9 per cent. The context of the violence tends to be different: homicide committed by a girl is most likely to occur as part of a

Basta, J.M., Davidson, W.S., II. Treatment of juvenile offenders: study outcomes since 1980. Behavioral Science and the Law 6: 355–384, 1988. Candilis, P. The Pharmacology of Violence. American Society of Clinical Psychopharmacology Progress Notes, Volume 7, No. 2, 1996. Coordinating Council on Juvenile Justice and Delinquency Prevention. Combating Violence and Delinquency: The

Treatment of juvenile offenders 461 National Juvenile Justice Action Plan Report. Washington, DC: U.S. Department of Justice, Office of Justice Programs, Office of Juvenile Justice and Delinquency Prevention, 1996. Crick, N.R., Dodge, K.A. A review and reformulation of social information processing mechanism in children’s social adjustment. Psychological Bulletin 115: 74–101, 1994. DePrato, D.K., Hammer, J.H. Assessment and treatment of juvenile offenders. In Schetky, D.H., Benedek, E.P. (eds), Principles and Practice of Child and Adolescent Forensic Psychiatry. Washington, DC: American Psychiatric Publishing Inc., 2002. Dishion, T.J., Patterson, G.R. Age effects in parenting training outcomes. Behavioral Therapy 23: 719–729, 1992. Eissler, K. (ed.) Searchlights on Delinquency. New York: International Universities Press, 1949. Fowler, J.C., Rosenberg, C. Integrated treatment in the care of seriously disturbed adolescents and their families. In Esman, A.H., Flaherty, L., Horowitz, H.A. (eds), Adolescent Psychiatry. Hillsdale, NJ: The Analytic Press, 2000, pp. 169–186. Gordon, D.A., Jurkovic, G., Arbuthnot, J. Treatment of the juvenile offender. In Wettstein, R.M. (ed.), Treatment of Offenders with Mental Disorders. New York: Guilford Press, 1998. Grisso, T., Barnum, R., Fletcher, K.E., et al. Massachusetts youth screening instrument for mental health needs of juvenile justice youth. Journal of the American Academy of Child and Adolescent Psychiatry 40: 541–548, 2001. Halperin, J. Serotonin in childhood aggressive behavior. Paper presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Toronto, October 1997. Henggeler, S.W. Treating serious anti-social behavior in youth: the MST approach. Juvenile Justice Bulletin 1–7, 1997. Henggeler, S.W., Melton, G.B., Smith, L.A., et al. Family preservation using multi-systemic treatment: a long term follow-up to a clinical trial with serious juvenile offenders. Journal of Child and Family Studies 2: 283–293, 1993. Henggeler, S.W., Pickrel, S.G., Biondino, M.J., et al. Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home based multi-systemic therapy. American Journal of Psychiatry 153: 427–428, 1996. Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D., Cunningham, P.B. Multi-Systemic Treatment of Antisocial Behavior in Children & Adolescents. New York: Guilford Press, 1998. Holland, R. Integrating care for troubled youth: using attachment theory as an organizational framework for community based multi-systemic interventions. Paper

presented at the Annual Meeting of the American Academy of Child and Adolescent Psychiatry, Toronto, October, 1997. Kazdin, A.E. Parent management training: evidence, outcomes, and issues. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1349–1356, 1997. Kazdin, A.E. Treatment for aggressive and antisocial children. In Lewis, D.O., Yeager, C.A. (eds), Child and Adolescent Psychiatric Clinics of North America: Juvenile Violence. Philadelphia: W.B. Saunders, 2000, pp. 841–858. Kazdin, A.E., Crowley, M. Moderators of treatment outcome in cognitively based treatment of antisocial behavior. Cognitive Therapy and Research 21: 185–207, 1997. Kazdin, A.E., Siegel, T., Bass, D. Cognitive problem-solving skills training and parent management training in the treatment of anti-social behavior in children. Journal of Consulting and Clinical Psychology 60: 733–747, 1992. Kessler, C. Alternatives to adjudication: drug courts, mental health courts peer courts in Chamberlain, P, Rosicky, JG: The effectiveness of family therapy in the treatment of adolescents with conduct disorders and delinquency. Journal of Marital and Family Therapy 21:441–459, 1995. Loper, A.B. Female Juvenile Delinquency: Risk Factors and Promising Interventions: Juvenile Forensic Evaluation Resource Center of the University of Virginia Institute of Law, Psychiatry and Social Policy, 2000. On the Internet at: http://ness.sys.virginia.edu/juv/FemJuv.html Malone, R., Luebbert, J.F., Delaney, M.A., et al. Nonpharmacological response in hospitalized children with Conduct Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36: 242–247, 1997. McManus, M., Alessi, N.E., Grapentine, W.L., Brickman, A. Psychiatric disturbance in serious delinquents. Journal of the American Academy of Child Psychiatry 23: 602–615, 1984. Moretti, M. Long-term treatment of an attachment based program for Conduct Disorder. Canadian Journal of Psychiatry 39: 360–370, 1994. Moretti, M.M., Emmrys, C., Brizenko, N., et al. The treatment of Conduct Disorder: perspectives from across Canada. Canadian Journal of Psychiatry 42: 637–648, 1997. Myers, W.C., Scott, K., Burgess, A.W., et al. Psychopathology, biopsychosocial factors, crime characteristics, and classification of 25 homicidal youths. Journal of the American Academy of Child and Adolescent Psychiatry 34: 1483–1489, 1995. Rogers, R., Johansen, J., Chang, J.J., et al. Predictors of adolescent psychopathy: oppositional and conduct

462 Adolescent psychiatry and the law disorder systems. Journal of the American Academy of Psychiatry and Law 25: 261–271, 1997. Rutter, M., Giller, H., Hagell, A. Antisocial Behavior by Young People. Cambridge, New York: Cambridge University Press, 1998. Satterfield, J.H., Schell, A. A prospective study of hyperactive boys with conduct problems and normal boys: adolescent and adult criminality. Journal of the American Academy of Child and Adolescent Psychiatry 36: 1726–1735, 1997. Schwab-Stone, M., Chen, C., Greenberger, E., Silver, D., Lichtman, J., Voyce, C. No safe haven II: the effects of violence exposure on urban youth. Journal of the American Academy of Child and Adolescent Psychiatry 38: 359–367, 1999. Shreeram, S.S., Kruesi, M.J.P. Pharmacologic treatment of behavior disorders in adolescents. In Esman, A.H., Flaherty, L., Horowitz, H.A. (eds), Adolescent Psychiatry. Hillsdale, NJ: The Analytic Press, 1999, pp. 179–212.

Steiner, H., Garcia, I.G., Matthews, Z. Post-Traumatic Stress Disorder in incarcerated juvenile delinquents. Journal of the American Academy of Child and Adolescent Psychiatry 36: 357–365, 1997. Taylor, E., Chadwick, O., Heptinstall, E., Danckaerts, M. Hyperactivity and conduct problems as risk factors for adolescent development. Journal of the American Academy of Child and Adolescent Psychiatry 35: 1213–1226, 1996. Thomas, C.R. A Model Program – The Island Youth Program. In Kraus, L., Arrogo, W. (eds), American Academy of Child and Adolescent Psychiatry (AACAP) Task Force on Juvenile Justice Reform, October 1999–October 2001. Washington, DC: AACAP, 2001. Work Group on Quality Issues of the American Academy of Child and Adolescent Psychiatry: Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36: 122S–139S, 1997.

PART 3 Special problems in delinquency assessment and treatment

7.6

Substance abusers Steven L. Jaffe

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7.7

Violent offenders Rusty Reeves

470

7.8

Adolescent sex offenders Roy J. O’Shaughnessy

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7.9

Juveniles and the adult criminal justice system: transfer/waiver to adult court Carl P. Malmquist

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7.10 Juveniles and the adult criminal justice system: the death penalty Richard A. Ratner

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7.11 Dependency court: the handling of abuse and neglect cases Kathi L. Grasso

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7.6 Substance abusers STEVEN L. JAFFE

INTRODUCTION There is a high incidence of substance abuse in the juvenile offender population. Teenagers may be arrested when getting drugs, using drugs, transporting drugs, or selling drugs. Many antisocial behaviors (i.e., shoplifting, stealing, or prostitution) are carried out in order to obtain money for the purchase of alcohol and/or drugs. Violent crimes often are committed in relation to drug trafficking. Specific drugs (e.g., alcohol, stimulants, and cocaine) often enhance aggressive behavior, leading to antisocial acts. An example is phenylcyclidine (PCP), which may produce a toxic psychosis with severe, aggressive behavior. In addition to these direct relationships between drugs of abuse and delinquency, offending adolescents – especially those with Conduct Disorder – frequently use, misuse, abuse and become addicted to alcohol and drugs. Each of these stages of alcohol/drug involvement will require specific treatment approaches and strategies. Halikas and colleagues (1984) were the first to attempt to define substance use disorders in adolescent populations. Using criteria of adverse consequences in multiple areas of the adolescent’s life secondary to the use of alcohol, they defined in an adolescent, juvenile court population that 19 per cent had alcohol abuse. In a more recent study, Reebye et al. (1995) demonstrated, in a population of youth with severe behavior problems at a residential facility, that 52 per cent of those with a diagnosed Conduct Disorder also had a substance use disorder. The substance use disorder was defined by DSM III-R criteria for abuse or dependency. Those adolescents who had more severe Conduct Disorder were more likely to also have a substance use disorder. In an inpatient hospital program for substance-abusing adolescents, DeMilio (1989) found

42 per cent of participants to meet diagnostic criteria for Conduct Disorder. Other studies of juvenile offenders have indicated that the prevalence of substance abuse disorders may be over 80 per cent (Milan et al. 1991; Bukstein et al. 1992). These studies indicate that delinquency and alcohol and substance use are strongly interrelated, and that any treatment program for juvenile offenders needs to include evaluation and treatment of their substance use disorders.

TREATMENT Because of the numerous areas or domains (Tarter 1990) of problems that substance-abusing teenagers involved with the juvenile justice system will have, an integrated, multi-modal, multi-system treatment approach is needed (Practice Parameters 1997). In this part, I will focus on the specific treatment approaches used for the treatment of substance use. These treatment approaches and strategies will need to be integrated with the other individual system and community treatments that are described in other parts of this book. The Substance Abuse and Mental Health Services Administration has developed a model in which alcohol and other drug abuse treatment is the focus of a diversion program for youth within the juvenile justice system. Within this model treatment, personnel and representatives of health and social service agencies function as partners in both the design and the implementation of this program. Screening, crisis intervention, and full assessment are implemented. The community, family, school, and social agencies are all involved, as well as the legal system, and a full continuum of different levels of treatment is

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available to be implemented. Assessment instruments and descriptions of program examples are included in this consensus monograph. Dembo et al. (1997, 1998a,b) have begun to report data related to an ongoing intervention project involving arrested youth. These Juvenile Assessment Centers are attempting to screen and intervene at an earlier stage in the youth’s involvement with the juvenile justice system. With regard to the stages of alcohol/drug involvement, the following model (Jaffe 1996b) relates specific treatment approaches and strategies which are appropriate to each stage of drug/alcohol involvement. For the adolescent at the experimental or casual stage 1, education and counseling are appropriate. Teenagers use drugs in direct proportion to their availability and in indirect proportion to their perceived risk of harm. Learning about the realistic dangers of drugs and alcohol is helpful in these situations. For example, although adolescents tend to view marijuana as being a benign drug, the reality is that marijuana poses a serious threat to their brain functioning as it will decrease attention span, impair short-term memory functioning, and impair complex visual motor behavior such as driving. Interestingly, the impairment in complex visual motor behavior is often not recognized by the teenager. Counseling is also needed for both the teenager and his/her parents, as the latter may need help in how to set appropriate limits with rewards and consequences. For stage 2 level of misuse, in addition to education and counseling, individual and group therapies, family treatments, and an abstinence contract may be needed. At this stage, family therapies, including strategic, structural, systemic or behavioral, will be important interventions. Behavioral family therapy involves parent management training as well as contingency contracting. Here specific, clear rules are established between the parents and adolescent such that there are negative consequences to all drug or alcohol behavior or associated types of behavior and positive reinforcement of all behaviors that avoid drug using-type activities. Thus, positive reinforcement is given for going to school, doing homework, avoidance of using peers, and developing other recreational activities. The abstinence contract or honest look contract is often very helpful. In this situation the teenager expresses a willingness to stop using drugs and alcohol as well as stopping ‘druggie’ types of behavior, and specific rewards and punishments related to this are established. Unannounced urine drug screens are also included in the contract. In this contract the teenager expresses willingness and a firm commitment to do without drugs and alcohol. Specific consequences if they are unable to abide by this abstinence contract or commitment are also specified, and these will include attending treatment at a more intense level of care. For the teenager who is at stage 3, or the stage of psychoactive substance abuse disorder, a higher level of more intense treatment is now required. Now, in addition to

the education, counseling, individual and group therapies, family treatments, and an abstinence contract used in the earlier levels, specific treatment modalities and levels of care are needed. These will include beginning to work a Twelve-Step program, teaching of specific cognitive and behavioral methods, and attendance at a partial or inpatient hospital versus an intensive outpatient program will be needed. The partial hospital program may include a day program, daily after-school and evening programs, or involve an intensive outpatient program of 4 hours every day of intensive groups. Recent studies of adult alcoholics in Project MATCH (Humphreys 1999) have empirically demonstrated the efficiency of Twelve-Step Facilitation therapy. Because twelve-step programs provide access to sponsors and a recovering peer group, they are an ideal treatment modality for juvenile offenders who have a Substance Abuse or Dependency Disorder. Twelve-Step programs have been among the most common treatment programs for substance-abusing adolescents, but there has been a paucity of adolescent research studies (Center for Substance Abuse Treatment 1999). Because many mental health professionals, and especially those who have not directly worked in the substance abuse field, do not have a comprehensive understanding of Twelve-Step programs, their application to adolescents will be described in some detail. Working a Twelve-Step program involves attending regular meetings of Alcoholics Anonymous (AA) or Narcotics Anonymous (NA), establishing a sponsor relationship within that program, beginning to work the Steps, and involving oneself with a recovering peer group who are also attending meetings and working a Twelve-Step program. It has been well recognized that the adolescent, at this stage of psychoactive substance abuse disorder, even if attempting to be abstinent, will relapse if he or she returns to contact with their alcohol- and drug-using peers. Above all, attending AA and NA meetings and the teenager’s involvement with social and recreational contact with other members who are working a good program is an essential ingredient for the adolescent to be able to stop using drugs and alcohol (Jaffe 1992, 1996a). Obtaining a sponsor involves the teenager developing a ‘Big Brother’ or ‘Big Sister’ relationship with an older member of AA or NA. The sponsor should be someone with at least one year of good abstinent recovery and who wants to work with a teenager to help him/her work their steps and deal with their life to get off alcohol and drugs. The working of the Steps is a core feature of Twelve-Step programs. Jaffe (1990) has produced a workbook that is developmentally appropriate for teenagers to help them work their steps. The First Step is the most important as it establishes the need to be off drugs and alcohol. The adolescent answers the questions in the workbook and then discusses these individually with a sponsor or a counselor. The answers are then presented at a First Step therapy group.

Substance abusers 467

The questions in the First Step involve detailed descriptions relating to drugs and alcohol and how they have put their own lives at risk, have put the lives of others at risk, have affected family, school and work relationships, and have affected self-esteem, mood and plans for the future. Looking at the severe negative consequences of using drugs and alcohol helps teenagers to recognize that their lives are a mess on drugs and alcohol and that they need to be abstinent (clean and sober). The Workbook recognizes that teenagers like to use drugs but that they need to be clean and sober to have a future. The teenagers are helped to try to do what needs to be done to make their lives better and not what they want to do, which is to go out and use drugs and alcohol. Teenagers are also helped to recognize that they could not use drugs and alcohol in moderation and reminded, again, of the need for abstinence. For teenagers, the emphasis here is placed on becoming more powerful by stopping the use of drugs and alcohol and that this is a program that enhances their power to have a life. Powerlessness occurs when they are using and sobriety gives them power. The other concept used for the teenager is that, although it may be difficult for them to recognize addiction and dependency, they perhaps can view themselves at this stage of abuse as someone who is on the way to being an addict. Writing down the answers to the First Step questions helps the adolescents to become more honest in acknowledging the extent of their use of drugs and alcohol and its effects on their lives. In addition to becoming more honest in how much they have used, presenting the details of their answers at a group often helps them to become more honest with the emotional aspects of what had happened to their life. In this situation the defense mechanism of disavowal is undone and teenagers emotionally recognize how bad their lives have become. An example of this could be the teenager who casually and readily talks about how he/she had been on the street and raped when using drugs and alcohol. This episode seems of little consequence and affect, but in verbally reviewing the details while clean and sober the individual may begin to cry and realize how terrible their life had become. The First Step is so important because it is here that the motivation to be clean and sober is developed. Teenagers do not stop using drugs and alcohol unless they come to recognize cognitively and emotionally that their lives have become a mess and that change is needed. The Second Step involves teenagers recognizing that they need to stop the insane ways they have been living in which they have repeated self-destructive behavior over and over. The other part of the Second Step involves beginning to believe in a Higher Power. This is a spiritual, but not religious process in which the teenager separates out what in his life is in his control and what in his life is not in his control. He further learns that those aspects not in his control need to be turned over to a

positive Higher Power. The Workbook’s approach is to first have the teenager look at his childhood Higher Powers, who are the people that raised him and to face the issues that these earlier Higher Powers often had neglected or abused him. Emotionally dealing with this grieving process then helps the teenager to begin to look at something positive, greater than himself, which can be the group, a positive force in the universe, nature, or love. The Third Step involves making a commitment to work a program, and the Fourth Step involves taking a detailed moral inventory of himself. The Fifth Step involves presenting the details of one’s moral inventory on one’s life to a sponsor or therapist so it can be discussed and reviewed. The first three Steps achieve the adolescent’s need and commitment to be abstinent and work a program, while the Fourth and Fifth Steps help him begin to look at all his life and share this with another person who is in the program. Important aspects of the Twelve-Step program include that the meetings are free, that groups exist in every city in the United States and most foreign countries, and these provide the teenager with an abstinent, recovering peer group which is essential for continued sobriety. In addition to Twelve-Step programs, teenagers at the substance abuse disorder stage are often helped by cognitive behavioral strategies which may be learned in individual or group sessions. These strategies involve learning specific techniques to deal with drugs and alcohol. Here, skills to refuse drugs, cope with urges, manage using thoughts, and handle emergencies and a lapse are taught and practiced with role-playing exercises. Other communication skills, problem solving, and anger and mood management, cognitive behavioral strategies, as well as relaxation training are important skills for these teenagers to learn. Cognitive behavioral skill training and beginning to work the Steps in a Twelve-Step program are often part of intensive outpatient and partial hospital day and afterschool programs. If the teenager is at the fourth stage of involvement (i.e., chemical dependency), a hospital or residential program is often needed at the beginning of treatment. As the teenager begins to make some progress in his hospital or residential program, consideration of a step down to partial hospital and intensive outpatient programs can be made. In all intensive outpatient and partial hospital programs, steps must be taken so that the teenager does not return to using peers or else he will fail at that level of care. If the teenager fails at one level of care corresponding to a specific stage of drug involvement this often indicates that a more advanced abuse or dependency stage was actually present and the treatment modalities of this more advanced stage will be needed. The pharmacological treatments for adolescents are sometimes helpful for the co-existing psychiatric disorders. In these situations where medications are used they must be carefully monitored. The specific modalities described

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previously are to help the teenager become abstinent. Along with these medications for depression (Riggs 1995), Attention Deficit Disorder, Bipolar Disorder or severe aggression may be cautiously used. Very few research data are available on specific treatment modalities with adolescent substance use disorders, and the efficacy of one treatment compared to another has not been demonstrated. Usually, combinations of these treatment strategies, along with treatment of co-existing psychiatric disorders as well as problems within the family, peer group, and school need to be addressed in a multi-modal, multisystem approach. Pickrel and Henggeler (1996) have developed and are actively studying the family preservation model of multisystem therapy. In this treatment approach, trained therapists work intensively with conduct-disordered teenagers and their families within their homes, schools and peer groups. Henggeler has demonstrated that this treatment approach is superior for severely delinquent conductdisordered youth and is presently studying its efficacy in conduct-disordered youth who also have substance use disorders. The high incidence of drug and alcohol involvement by delinquent youth makes it imperative for clinicians working with these teenagers to know and use assessment and treatment strategies for dealing with their substance use disorders. More research studies on the efficacy of treatment strategy and programs are clearly needed. Although managed care involvement in psychiatric treatment of adolescents has led to a marked decline in available services, the National Institute of Drug Abuse has recently directed increased support for training researchers and doing more treatment studies in adolescent substance abuse. A recent very positive development is the establishment of juvenile drug courts (Kimbrough 1998). Juvenile delinquents with a substance abuse problem who have not committed a violent offense and their parents commit to an intensively supervised, individualized treatment program instead of the usual juvenile court proceedings. This emphasis on treatment instead of punishment is a much-needed shift. Follow-up studies of the results of this approach will be extremely important.

REFERENCES Bukstein, O.G., Glancy, L.J., Kaminer, Y. Patterns of affective comorbidity in a clinical population of dually diagnosed adolescent substance abusers. Journal of the American Academy of Child and Adolescent Psychiatry 31: 1041–1045, 1992. Center for Substance Abuse Treatment. Treatment of Adolescents with Substance Use Disorders. Treatment Improvement Protocol (TIP) Series. Number 32 DHHS Pub. No. (SMA) 99-3345. Washington, DC: US Government Printing Office, 1999.

Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles with Justice System. US Department of Health and Human Services, Center for Substance Abuse Treatment, Rockville, MD: DHHS Publication No. (SMA) 95-3051, 1995. Dembo, R., Pacheco, K., Schmeidler, J., Fisher, L., Cooper, S. Drug use and delinquent behavior among high-risk youths. Journal of Child and Adolescent Substance Abuse 6: 1–25, 1997. Dembo, R., Pacheco, K., Schmeidler, J., Ramirez-Garmica, G., Guida, J., Rahman, A. A further study of gender differences in service needs among youths entering a juvenile assessment center. Journal of Child and Adolescent Substance Abuse 7: 49–78, 1998a. Dembo, R., Schmeidler, J., Nini-Gough, B., Sue, C.C., Border, P., Manning, D. Prediction of recidivism to a juvenile assessment center: a three year study. Journal of Child and Adolescent Substance Abuse 7: 57–77, 1998b. DeMilio, L. Psychiatric syndromes in adolescent substance abusers. American Journal of Psychiatry 146: 1212–1214, 1989. Halikas, J.A., Lyttle, M.D., Morse, C.L., Hoffmann, R.G. Proposed criteria for the diagnosis of alcohol abuse in adolescents. Comprehensive Psychiatry 25: 581–585, 1984. Humphreys, K. Professional intervention that facilitates 12-step self-help group involvement. Alcohol Research and Health 23: 93–98, 1999. Jaffe, S. The Step Workbook for Adolescent Chemical Dependency Recovery – Guide to the First Five Steps. Washington, DC: American Academy of Child and Adolescent Psychiatry and American Psychiatric Press, 1990. Jaffe, S.L. Pathways of relapse in adolescent chemical dependency recovery. Adolescent Counselor March: 42–44, 1992. Jaffe, S.L. Preventing relapse – guidelines for the psychiatrist. Adolescent substance abuse and dual disorders. In Child and Adolescent Psychiatric Clinics of North America. Volume 5. W.B. Saunders and Co., 1996, pp. 213–220. Jaffe, S.L. The substance-abusing youth. In Parmelee, D.X. (ed.), Child and Adolescent Psychiatry. St. Louis: Mosby, 1996, pp. 237–245. Kimbrough, R.J. Treating juvenile substance abuse: the promise of juvenile drug courts. Juvenile Justice V: 11–17, 1998. Milan, R., Halikas, J.A., Meller, J.E., Moorse, C. Psychopathology around substance abusing juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry 30: 569–574, 1991. Pickrel, S.G., Henggeler, S.W. Multisystemic therapy for adolescent substance abuse and dependence. Child and Adolescent Psychiatric Clinics of North America 5: 201–212, 1996. Practice Parameters for the Assessment and Treatment of Children and Adolescents with Substance Use Disorders.

Substance abusers 469 Journal of the American Academy of Child and Adolescent Psychiatry 36(10 Suppl.): 140S–156S, 1997. Reebye, P., Moretti, M.M., Lessard, J.C. Conduct disorder and substance use disorder; comorbidity in a clinical sample of preadolescents and adolescents. Canadian Journal of Psychiatry 40: 313–319, 1995.

Riggs, P.D., Baker, S., Mikulich, S.K., Young, S.E., Crowley, T.J. Depression in substance-dependent delinquents. Journal of the American Academy of Child and Adolescent Psychiatry 34: 764–771, 1995. Tarter, R.E. Evaluation and treatment of adolescent substance abuse: a decision tree method. American Journal of Drug and Alcohol Abuse 16(1,2): 1–46, 1990.

7.7 Violent offenders RUSTY REEVES

INTRODUCTION Clinicians who evaluate violent juvenile delinquents are routinely asked to estimate the juvenile’s chance of violent recidivism (the process is called ‘risk assessment’ or ‘dangerousness assessment’). The question also arises when juveniles present to the emergency room, the psychiatric hospital, and the outpatient clinic. Little research has been conducted on the ability of clinicians to predict violent recidivism in juveniles, and no actuarial tests exist (as exist for violent adults; e.g., the Violence Risk Appraisal Guide (VRAG); Quinsey et al. 1998) and adult sexual offenders (e.g., the Static-99; Hanson 1999). On the other hand, research has established a number of positive and negative correlates (i.e., ‘predictors,’ ‘risk factors,’ and ‘protective factors’ – not necessarily causal factors) of future general violence in juvenile delinquents. These risk factors (described below) serve as the basis for the risk assessment of general violence in juveniles. These risk factors are not ideally suited to the assessment of risk of targeted violence (e.g., a planned massacre at school). The assessment of the risk of targeted violence requires a different approach (Borum and Reddy 2001; Reddy et al. 2001). For the assessment of risk of targeted school violence, see Reddy et al. (2001), and the US Secret Service’s ‘Interim Report on the Prevention of Targeted Violence in Schools’ (US Secret Service 2000).

GENERAL APPROACHES TO THE ASSESSMENT OF VIOLENCE POTENTIAL Definition of violence A good operational definition of violence is offered by the Structured Assessment of Violence Risk in Youth

(SAVRY) (Borum et al. 2002): an act of battery or physical violence that is sufficiently severe to cause injury to another person or persons (i.e., cuts, bruises, broken bones, death, etc.), regardless of whether injury actually occurs; any act of sexual assault; or a threat made with a weapon in hand.

Conceptualization The conceptualization of the assessment of violence potential has shifted from a violence prediction model to a risk assessment/management model (Castel 1991; Menzies et al. 1995; Monahan 1996; Webster et al. 1997). The violence prediction model emphasized the prediction of whether or not an individual was a dangerous person. The danger resided within the individual (i.e., was not contingent upon the environment), and was not subject to change. The risk assessment/management model views dangerousness or risk as contextual, dynamic and continuous (National Research Council 1989). The evaluator determines the type and amount of risk an individual poses for specific behaviors given the environment in which the individual is expected to live.

Methods of assessment UNSTRUCTURED PROFESSIONAL JUDGMENT In this traditional but outmoded approach, the evaluator gathers general information about a person, usually by way of an unstructured interview and some basic psychological testing such as the MMPI or intelligence testing. Based upon this information, the evaluator processes the information in his or her head, and makes a prediction about whether the person is dangerous. This approach, which is not based upon empirically derived risk factors, is idiosyncratic and obscure in its reasoning,

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is unreliable, and lacks demonstrated validity for the basis of prediction as well as the prediction itself. Studies which have investigated the ability of individual clinicians using this approach to predict long-term risk of violence have overwhelmingly demonstrated the inaccuracy of this approach (Ennis and Litwack 1974; Steadman and Cocozza 1974; Cocozza and Steadman 1976; Thornberry and Jacoby 1979; Megargee 1981; Monahan 1981, 1984, 1996; Ewing 1983, 1985, 1991; Menzies and Webster 1995). Perhaps the single greatest reason for this inaccuracy is evaluators’ ignorance of base rates of violence (Monahan 1981).

STRUCTURED PROFESSIONAL JUDGMENT In this approach, the evaluator refers to a list of factors, each of which generally has coding criteria, that the scientific literature has demonstrated to be related to future violence. The evaluator then uses his or her professional judgment to weigh the individual risk factors and arrive at a summary risk rating. The advantages of this type of assessment over unstructured professional judgment are several: 1 It ensures a comprehensive identification of risk factors that are supported by research, and thus minimizes a clinician’s bias toward or oversight of particular factors (Werner et al. 1983, 1989; Cooper and Werner 1990). 2 The final judgment, though not statistical, is informed by research. 3 Studies indicate that risk ratings based on structured assessments perform better than unstructured clinical judgements, and may perform as well or better than some actuarial predictions (Dempster, 1998; Hanson 1998; Kropp et al. 1999). The disadvantage of this method of assessment is that most of the instruments using this method (including the Structured Assessment of Violence Risk in Youths (SAVRY), described below) have yet to demonstrate their inter-rater reliability and validity. The SAVRY is an evaluation tool based on the structured professional judgment model (Borum et al. 2002). The SAVRY was designed to assess risk of general violence in adolescents between the ages of twelve and eighteen years. The protocol for this instrument involves the systematic assessment of risk factors (both static and dynamic) identified by the scientific literature for violence in adolescents. (Most of the risk factors employed by the SAVRY are described below in the section ‘Risk factors’.) The SAVRY allows consideration of developmental and situational factors which, given the changes of adolescence, may be important in assessing short- and long-term risk of violence in adolescents. The SAVRY’s consideration of dynamic factors also guides efforts at risk reduction.

Two preliminary, and as yet unpublished validation studies support the validity of the SAVRY in forecasting violent recidivism (Bartel et al. 2001; McEachran 2001). In both of these studies, the SAVRY was as good as or better than the Psychopathy Checklist – Youth Version (Forth et al. in development) in the prediction of various violent behaviors. The Early Assessment Risk List for Boys (EARL-20B) and Early Assessment Risk List for Girls (EARL-21G) (Augimeri et al. 2001) are structured assessments for violence potential in youths aged under twelve years. These instruments were developed in Canada and also utilize most of the risk factors described below. There is a preliminary retrospective study on these instruments in the manual, but no published data are available on the instrument’s reliability and validity. Given both the limited number of studies on risk assessment in juveniles, and the absence of any actuarial method of risk assessment for this population, structured professional judgment represents the preferred method of risk assessment for juveniles.

ACTUARIAL This approach employs a statistically derived formula to generate a prediction (a probability of an even over a specified period of time), whether of violence (Borum 1996; Quinsey et al. 1998), or anything else. The actuarial approach is mechanistic, and largely removes clinician judgment from the assessment as it both identifies the relevant risk factors and specifies the weight accorded to each risk factor. Actuarial assessments are usually designed to predict long-term risk; thus, they tend to identify static risk factors. Conversely, static risk factors may not be as suitable for the prediction of short-term risk if that risk varies with dynamic risk factors. Actuarial tests, across a variety of decisional tasks, perform as well as or better than clinical judgments (Meehl 1970; Dawes et al. 1989; Borum et al. 1993; Garb 1994; Mossman 1994; Grove and Meehl 1996; Melton et al. 1997; Hanson and Bussiere 1998; Quinsey et al. 1998; Grove et al. 2000; Swets et al. 2000). However, researchers are divided over whether actuarial methods as they currently exist are preferred for the prediction of the likelihood of future violence. Most writers argue that actuarial methods are preferred (Faust and Ziskin 1988; Dawes et al. 1989; Grove and Meehl 1996; Harris et al. 1998; Grove et al. 2000). Nonetheless, a few writers argue that the statistical and practical limitations of the actuarial formulas as they currently exist outweigh their potential benefit as the ultimate decision-maker in individual cases (Melton et al. 1997; Otto et al. 2000). The problem with actuarial assessments of risk of violence, as they currently exist, is that they may offer a gloss of science without the substance of science. For example,

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these instruments are developed to predict violence on a specific sample population, and they are not extensively cross-validated (e.g., the VRAG (Quinsey et al. 1998); the MnSOST-R (Epperson et al. 1999); and the STATIC-99 (Hanson 1999)). Thus, the actuarial instrument may not be valid on a population substantially different from the population used to develop the instrument. Furthermore, actuarial instruments do not always provide standard errors or confidence intervals. Thus, the evaluator is unable to state the probability of an individual’s true score falling within a certain range. Finally, the inter-rater reliability of existing actuarial instruments is generally unknown, despite the frequent existence of coding criteria that require a modicum of judgment. Ultimately, however, properly constructed actuarial methods, given their statistically derived validity and reliability, and their emphasis on static risk factors, will probably prove superior to structured professional judgment in the prediction of long-term risk of violent recidivism of juveniles.

GENERAL INFORMATION ON JUVENILE DELINQUENCY By self-report, the majority of adolescent males engage in behaviors which, if they were arrested, would be charged as misdemeanors or felonies (Hirschi 1969; Elliot et al. 1983; Moffitt et al. 1994). Therefore adolescents whom we call ‘delinquent’ are not necessarily a psychological or social subset of adolescents: they are adolescents who have been caught (Grisso 1998, p. 30). Arrests per 1000 youths at a given age for general offenses increase from age twelve to eighteen years and then decline rapidly thereafter (Moffitt 1993; Howell et al. 1995). Most youth who are arrested in adolescence do not continue offending past the adolescent years (Gottfredson and Hirschi, 1990). Arrests per 1000 youths at a given age for violent offenses follow the same pattern as above and are higher in the fifteen- to twenty-year-old group than for the rest of adulthood. The pattern is the same for white and minority youths, except that the prevalence is 50 per cent higher for black males than for white males in the peak years of sixteen to nineteen years (Howell et al. 1995). Most youths who are arrested for a single violent offense do not engage in further violence (Elliott et al. 1983, 1986). Those who do engage in a second or third violent offense are at high risk of many future violent acts and arrests (Grisso 1998, p. 30). Based on selfreports, chronic violent offenders account for only about 15 per cent of all youthful offenders, but are responsible for 50–70 per cent of all violent offenses by youths (Howell et al. 1995).

RISK FACTORS Research has demonstrated consistent correlative relationships between a number of case characteristics (risk factors) and violent behavior among adolescents. These risk factors may be grouped into various categories. For the purposes of this chapter, they are grouped broadly into the adolescent’s behavior, and the adolescent’s environment. More importantly, most sources and guides (e.g., Augimeri et al. 2001; Borum et al. 2002; Grisso 1998) identify similar if not identical risk factors for adolescent violence. The risk factors listed below closely follow those identified by Borum et al. (2002) and employed in their SAVRY. These risk factors do not represent all the known risk factors for juvenile violence. However, they are the risk factors most strongly and consistently demonstrated by the scientific literature. The risk factors have been based mostly on research with males, and few research data exist on the correlates of violent behavior among female juvenile offenders. Thus, the following generalizations probably do not apply equally to males and females.

The adolescent’s behavior This category of risk may be divided into two subcategories: criminal behavior and general behavior (including attitudes and personality traits).

CRIMINAL BEHAVIOR In both adults and adolescents, past violent behavior is the single best predictor of future violent behavior, and risk for future violent behavior increases incrementally with the number of prior violent episodes (Kohlberg et al. 1972; Parker and Asher 1987; Farrington 1991; Mossman 1994; Tolan et al. 1995). Therefore, the history of violent behavior should generally be weighted most heavily in a risk assessment of future violence. There are fewer studies on the relationship of prior violence to future violence in females, and the existing evidence is less consistent (Stattin and Magnusson 1989). Consider also the following dimensions of past aggressive behavior: chronicity, frequency, and recency. Risk for future violence increases with earlier onset of juvenile offending and with greater overall frequency of juvenile offending (Megargee 1971; Lefkowitz et al. 1977; Olweus 1981; Stattin and Magnusson 1989; Farrington 1991, 1995; Elliot 1994; Thornberry et al. 1995; Tolan and Thomas 1995; Lipsey and Derzon 1998; Loeber and StouthamerLoeber 1998). In studies of self-reported delinquency, Elliot (1994) found that about five in ten youths continued their violent behavior into adulthood if their first violent acts occurred prior to age eleven years, about three in ten if

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the first violent behaviors occurred in preadolescence (ages eleven to thirteen years), and only about one in ten if their first violent behavior occurred during adolescence. In general, Elliot and colleagues (Elliott et al. 1983, 1986) found that only two or three out of ten juveniles who have committed violent behaviors by the age of eighteen years are arrested for violent acts in adulthood. Farrington (1995) observed that about 50 per cent of boys convicted of a violent offense between ten and sixteen years of age were again convicted of such an offense by early adulthood; this rate compared with one of 8 per cent for those with no conviction of violent crime as juveniles. However, given the differing observation periods, Farrington’s result cannot be directly compared with those of Elliot (1994). Moffitt (1993) also found that chronic youthful violent offenders tend more often to have early childhood disruptive and aggressive behavior problems and to engage in their first official delinquent acts prior to age twelve years. The risk of violence may also be increased in the first few years following a violent offense, and may decrease with time (White et al. 1990). Contrary perhaps to general expectation, the severity of past violence has generally not been found to be related to risk of future violence (Cormier and Markus 1980; Cornell et al. 1989). Nonviolent criminal behavior is also a strong predictor of future violence. Adolescents who have committed nonviolent criminal offenses or who have engaged in antisocial behavior (including, in males, stealing, property destruction, smoking, selling drugs, and sexual intercourse before age fourteen years) are at higher risk for future violence than those who have not (Robins 1966; Kohlberg et al. 1972; Parker and Asher 1987; Farrington 1989; Patterson and Yoerger 1993; Hawkins et al. 1998; Lipsey and Derzon 1998). This association is so strong that some evidence suggests a stronger association between a history of general offending behaviors and later violence than between a history of violence and later violent acts (Lipsey and Derzon 1998). However, as mentioned above, rates of general criminal behavior during adolescence are so high that such behavior is statistically normative. Thus, the evaluator should maintain a threshold of frequency to distinguish those who pose a greater or lesser degree of risk (Borum et al. 2002).

GENERAL BEHAVIOR Poor achievement in school beginning in the elementary grades is associated with increased risk for later violence, and this factor may be as strong or stronger for females than males (Farrington 1989, 1991; Denno 1990; Maguin and Loeber 1996). Poor commitment to school (e.g., truancy; seeing education as unimportant) may also be

associated with increased risk for violence, particularly in adolescents as opposed to younger children (Farrington 1989; Simourd et al. 1994; Maguin et al. 1995). Past supervision failures (including failure to obey court orders and failure to complete treatment) are associated with increased risk of violence in adults (Simourd et al. 1994; Webster et al. 1997; Andrews and Bonta 1998; Swanson et al. 2000), and thus may be associated with increased risk of violence in adolescents. Attitudes condoning violence, an inability to generate nonaggressive solutions to interpersonal conflicts, a tendency to perceive hostility or aggression by others, and inflated self-esteem are associated with future violence (Dodge et al. 1986; Slaby and Guerra 1988; Dodge 1991; Andrews and Bonta 1998; Maguin et al. 1995; Catalano and Hawkins 1996; Hughes et al. 1997; Hawkins et al. 1998). Impulsivity has consistently been shown to increase the risk for violence in children and adolescents as well as adults (Augimeri et al. 2001; Farrington 1989; Hawkins et al. 1998; Rutter et al. 1998). The problem with ‘impulsivity’ is that no one is able to offer a single definition of the word, but everyone claims to recognize impulsivity when ones sees it. Impulsivity is variously defined as behavioral instability, affective instability, a component of Attention Deficit Hyperactivity Disorder (ADHD), risk-taking, failure to consider the consequences of one’s behavior, or a specific behavioral tendency (e.g., responding violently to slight provocation). ADHD (and apart from impulsivity per se) predicts violence in childhood, adolescence, and adulthood (Satterfield et al. 1982; Barkley 1990; Campbell 1990, 1991; Loney et al. 1983; Hechtman et al. 1984; Sanson et al. 1993; Hawkins et al. 1998; Satterfield and Schell 1997). Juveniles who have attempted to harm themselves, whether by suicide attempt or self-injurious behavior, have been shown to be at higher risk for future violence (Inamadar et al. 1982; Battle et al. 1993; Garrison et al. 1993; Apter et al. 1995; Gretton 1999). Research consistently supports the link between substance abuse (which includes the abuse of alcohol and other illicit drugs or inhalants) and violence in youth (Loeber and Dishion 1983; Loeber and StouthamerLoeber 1987; Durkarm 1996; Loeber and Hay 1994), though the link is variable. Some adolescents may never engage in violence when they are using substances (e.g., marijuana), and therefore it cannot be assumed that an individual’s risk of violence is raised simply because that individual is using substances (Grisso 1998, p. 138). Instead, an inquiry should be made as to the association between substance use and violence in a given individual. Difficulty controlling anger, particularly an explosive temper or characterological anger, is associated with violence (Furlong and Smith 1994; Cornell et al. 1999). Psychopathy is a syndrome characterized by irresponsibility, criminal versatility, a lack of guilt, a disregard for

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the welfare of others, impulsivity, deceitfulness, selfishness, and sensation-seeking. Psychopathy differs from Conduct Disorder and Antisocial Personality Disorder in that psychological qualities (e.g., superficial charm, and failure to accept responsibility for one’s actions) are important features of psychopathy. Conduct Disorder and Antisocial Personality Disorder, on the other hand, emphasize behavior that violates the rights of others. Psychopathic traits have been associated with violent recidivism in adolescent offenders (Brandt et al. 1997; Forth and Burke 1998; Forth et al. 1990; Gretton 1999). Psychopathic traits have also been found to be among the best predictors of violent recidivism in both adolescent sex offenders and general offenders (Forth and Mailloux 2000; Gretton et al. 2001). Psychopathic traits are best assessed with the Psychopathy Checklist – Youth Version, which is a standardized rating scale (Forth et al. in development).

The adolescent’s environment The presence of parental criminality increases the risk for violent crime among children and adolescents (Cloninger et al. 1978; Baker and Mednick 1984; Farrington 1989). Although this factor is listed as an environmental influence, the effect may also be mediated via biological predisposition. Early separation from parents is associated with higher risk for future violence (Wadsworth 1978; Farrington 1989, 1991; McCord and Ensminger 1995; Henry et al. 1996; Hawkins et al. 1997). Physical abuse and neglect are associated with increased risk for violence in youth (Widom 1989; Zingraff et al. 1993; Smith and Thornberry 1995; Widom and Maxfield 1996; Gelles 1997; US Department of Health and Human Services 2001). Abuse and neglect may also be a stronger risk factor for violence among girls than among boys (Rivera and Widom 1990). Ineffective supervision and discipline by parents is related to future violence in juveniles. These behaviors include failure to set clear expectations for children’s behavior, poor parental supervision of children, low involvement in children’s lives, and excessively severe and inconsistent parental discipline of children. Whilst most of the literature associates this constellation of practices with general delinquency and substance abuse (Hawkins et al. 1998, p. 135), evidence also suggests these practices are associated with future violence (Williams 1994; Maguin et al. 1995). Family conflict and violent relationships (as opposed to direct assault or maltreatment of the involved adolescent) are associated with increased risk for violence among youth (McCord 1979; Farrington 1989; Elliott 1994; Edleson 1999). The absence of support from responsible and prosocial adults other than the youth’s parents (e.g., relatives,

teachers, coaches) may be associated with future violence (Estroff and Zimmer 1994; Stormont-Spurgin and Zentall 1995; Rodney et al. 1997; Stevenson 1998). Children who are rejected by their peers are at increased risk for delinquency and aggression (Coie et al. 1992; Ollendick et al. 1992; DeRoseir et al. 1994). Peer rejection refers to children and adolescents who are liked by few, if any, peers and who are actively disliked by most. These youth are not simply loners or persons who have few friends (Borum et al. 2002, p. 63). Examples of rejection include being teased, bullied, and ostracized. A youth’s association with delinquent peers increases that youth’s risk for delinquency and violence (Keenan et al. 1995). Gang membership further increases a youth’s risk of violence and delinquency – beyond the risk associated with delinquent peers itself (Maguin et al. 1995; Battin et al. 1998). Gang membership is also associated with more serious and violent offending (Thornberry et al. 1993), while delinquent siblings also increase the risk of violent behavior (Farrington 1989; Williams, 1994; Maguin et al. 1995). Both stressful events and poor coping have been associated with increased risk for violence (Felson 1992; Attar et al. 1994; Guerra et al. 1995). Stressful events include loss of material goods (e.g., parent’s unemployment), loss of persons (e.g., divorce; foster care), and loss of status (e.g., failure at school). Just as important as the events themselves is the youth’s response to the events. Social and community disorganization (including poverty, high crime, drug sales, gangs, and poor housing) is associated with increased rates of violence (Elliott et al. 1989; Sampson and Lauritsen 1994; Maguin et al. 1995; Thornberry et al. 1995). This finding applies to both males and females (Sommers and Baskin 1994).

PROTECTIVE FACTORS Protective factors mitigate the negative effects of risk factors, and thus diminish the probability of future violence. A protective factor is not merely the absence of a negative risk factor; rather, a protective factor is a positive factor, notable for its presence (Borum et al. 2002, p. 10). Such factors generally reflect commitment to conventional society, and include: prosocial activities and prosocial peers (Hoge et al. 1996; Caprara et al. 2001); social support from peers and adults during a crisis (Dubow and Reid 1994; Cauce et al. 1996); secure attachments to prosocial adults (Hawkins et al. 1992; Fitzpatrick 1997; Pollack 1998; Stouthamer-Loeber et al. 1993); motivation for treatment and a favorable attitude toward authority (Hoge et al. 1996); strong commitment to, and achievement in school (Hawkins et al. 1998; Herrenkohl et al. 2000); and resilient personality traits (e.g., above-average intelligence, and calm mood) (Kumpfer 1999).

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In a seminal study of adolescent protective factors among youths at high risk to commit serious delinquencies (i.e., youths from poor, abusive, transient families whose members often experienced trouble with drugs and the law), youths who did not engage in serious delinquency were: committed to school; did well in school; intended to continue their education; were well attached to parents; and were associated with conventional peers who themselves were approved of by the youth’s parents (Smith et al. 1995). A youth showing a few of these protective factors was only slightly less likely than other youths to avoid delinquency, while youths showing most of them had a much lower likelihood of serious or repeated delinquency.

CONDUCTING THE RISK ASSESSMENT Given that most violent adolescents do not continue their violence in adulthood, the clinician should begin with the hypothesis that the adolescent will not represent a risk of violence in adulthood (Grisso 1998). The clinician should reach the opposite conclusion only when risk factors in the case have proved the conclusion. The best predictor of future behavior is past behavior. Thus, the juvenile’s history of violent behavior should generally be weighted most heavily in the overall assessment. The juvenile’s criminal record is the starting point for the ascertainment of this risk factor. However, charges often do not describe the actual violence that occurred. Arrest reports offer a better description of such violence. Agency records (e.g., school disciplinary documents; discharge summaries; write-ups for institutional rules violations) are especially useful as they offer a frank report of the youth’s antisocial behavior, both violent and nonviolent, and may also identify other risk factors apart from antisocial behavior. Youths are generally not forthcoming about their violence and other antisocial behavior. Thus, at a minimum, a parent or guardian should be called. Additional helpful persons are caseworkers, probation officers, teachers, and therapists. Given that the risk for future violence is heavily dependent upon historical/static factors, the interview of the youth him- or herself may be the least valuable aspect of the assessment. However, the interview is invariably required and always produces some useful information. During it one may note gross inattention, hyperactivity, irritability, psychosis, and psychopathic personality traits. An assessment of the quality of attachments to family, friends, and the community can also be made. The clinician, preferably using a guide such as the SAVRY or EARL-20B, should systematically identify the risk factors associated with future violence, and the information for the juvenile on each risk factor. The clinician,

based upon combining these risk factors and weighing their clinical significance, then offers his or her opinion as to the juvenile’s risk of violently re-offending. The clinician should identify his or her reasoning used to combine the data to reach an opinion. An attorney or judge may then question that reasoning, but neither is likely to dismiss the report altogether as being unsubstantiated in its conclusions. The state of the science demonstrates that clinicians have a limited ability to predict violence over the longterm. Thus, the clinician should not try to predict whether a juvenile will or will not violently re-offend. Instead, the clinician should offer an estimate by stating whether the juvenile’s risk of re-offending is below average, average, or above average for a given time frame, in a given social context, for the population in which the juvenile resides. (Of course, this method assumes that the clinician knows the base-rate of violence for the population in which the juvenile resides.) The long-term risk of violence may be different from the short-term risk. Thus, the clinician may need to provide different estimates for different time periods. Furthermore, correctional and treatment interventions may alter the risk, and these contingencies should also be addressed.

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7.8 Adolescent sex offenders ROY J. O’SHAUGHNESSY

INTRODUCTION The term ‘Sexual Offender’ – like ‘Juvenile Delinquent’ – is not a psychiatric or psychological description or diagnosis, but is rather a sociolegal term defined by criminal statutes. Not all deviant sexual disorders are against the law and thus should not be labeled as ‘Sexual Offenses.’ By the same token, not all sexual offenses are associated with underlying psychiatric disorders and should not necessarily be considered to be within the arena of psychiatric treatment. It is perhaps an indication of the extent of our repugnance to sexual offenses that when an adolescent or adult with a long history of violent and other criminal behavior then commits a single sexual assault, they are suddenly labeled a ‘Sexual Offender.’ In such circumstances, a sexual offense is not dissimilar from other violent offenses committed by antisocial individuals who demonstrate criminal versatility. Arrest rates for sexual assaults indicate that nearly 20 per cent of all sexual assaults are committed by adolescents (Federal Bureau of Investigation: Uniform Crime Report 1987). Further, numerous studies of adult offenders have demonstrated that their sexual offenses first began in adolescence (Barbaree and Marshall 1988; Becker et al. 1986; Groth 1977). Abel and Becker (1985) demonstrated that deviant sexual interest and arousal antedated offending behavior, and the majority of adult paraphilics demonstrated deviant arousal in adolescence. There is general consensus that the early identification and treatment of adolescent sexual offenders may be instrumental in reducing sexually assaultive behavior.

DESCRIPTION OF ADOLESCENT OFFENDERS Descriptive studies of adolescent offenders reveal them to be a markedly heterogeneous group. The majority

of offenders are male, while the victims are female (Fehrenbach et al. 1986; Groth et al. 1982). The majority of victims are under twelve years of age (Fehrenbach et al. 1986), and threat or force is used in approximately 50 per cent of offenses. Studies of adolescent offenders indicate that the majority of offenders commit other criminal acts (Shaw et al. 1993). Nonsexual offenses are committed by 28–50 per cent of offenders (Fehrenbach et al. 1986; Becker et al. 1986), and prior sexual offenses are committed by 46–70 per cent of offenders (Awad et al. 1984; Smith 1988). The nature of the sexual assaults varied from nontouching offenses such as exhibitionism through to more injurious offenses including penetration or other physical violence. There is evidence that in some offenders there is a progression from less serious noncontact offenses to more serious sexual offenses (Longo and Groth 1983). Adolescent sexual offenders as a group demonstrate similar psychopathology to nonsexually offending delinquents (Rutter et al. 1998). High rates of family instability, parent–child separation and parental psychopathology are noted in both delinquents and sexual offenders (Awad et al. 1984; Lewis et al. 1979; Fehrenbach et al. 1986; Smith 1988). Conduct Disorder has been diagnosed in 48–54 per cent of samples, with up to 75 per cent in adolescent rapists (Becker et al. 1986; Kavoussi et al. 1988). Attention Deficit (Hyperactivity Disorder) (ADHD) has been diagnosed in 4–22 per cent of samples, with 34.5 per cent of offenders showing some evidence of ADHD (Kavoussi et al. 1988; Becker et al. 1988). Although the rate of alcohol abuse during actual offenses is low, substance abuse problems are seen in up to 10 per cent of offenders (Kavoussi et al. 1988; Fehrenbach et al. 1986) and from 20–33 per cent of their parents (Awad et al. 1984). The role of sexual victimization in the development of sexually assaultive behavior in adolescents is likely significant for at least some offenders. The data, however, are somewhat unclear as they depend primarily upon

Adolescent sex offenders 483

subjective reports. Self-reported sexual abuse has ranked from 0 to 57 per cent, with higher rates of abuse amongst child molesters than rapists (Awad et al. 1984; Dolan et al. 1996; Romano and DeLuca 1996; Ryan et al. 1996; Seghorn et al. 1987). Studies of males who were sexually abused in childhood, however, generally find high rates of anxiety, post-traumatic stress disorder (PTSD), substance abuse and impaired interpersonal relationships, but not evidence of sexually assaultive behavior (Kendall-Tackett et al. 1993). Despite the evidence that most individuals who are sexually abused in childhood will never go on to commit sexual offenses, childhood sexual abuse is likely to play a significant etiological role in the development of sexual offending behavior in at least some offenders (Worling 1995). Rates of violent abuse and neglect are similar to rates of sexual abuse (Becker et al. 1986; Smith 1988; Ryan et al. 1996), although rates do not differentiate between offenders with child versus peer-aged victims. The specific etiological role of violence in childhood is unclear and may well reflect the general family dysfunction and impaired socialization common to many serious juvenile delinquents. DSM-IV defines the paraphilias as recurrent, sexually arousing fantasies or behaviors including children or nonconsenting partners, nonhuman objects, or the infliction or receipt of pain or degradation. The individual paraphilias are diagnosed by reference to the characteristic behavior, but research has shown that many individuals will have multiple deviant interests that may change focus through the adolescent and early adult development period (Abel and Becker 1985; Haller et al. 1993). The determination of whether adolescents have a paraphilia is somewhat more complicated. It has been argued that adolescents who offend sexually are doing so primarily out of sexual experimentation or immaturity. However, research data indicate that most offenders have had previous normal sexual activity (Becker et al. 1986; Groth 1977). Furthermore, most studies indicate that juvenile sexual offenders have previously engaged in other sexual assaults (Groth 1977; Awad et al. 1991). Adolescent offenders tend to offend against prepubescent victims or use considerable force against peer-age victims in a pattern similar to that used by adult offenders (Becker et al. 1986; Fahrenbach et al. 1986; Saunders et al. 1986). As stated above, most juvenile sexual offenders meet the criteria for Conduct Disorder, though to what degree their behavior is a reflection of poor impulse control as part of their Conduct Disorder versus a recurrent deviant sexual impulse can be difficult to determine.

ASSESSMENT OF JUVENILE SEXUAL OFFENDERS The assessment of juvenile sexual offenders is hampered by the tendency for offenders to minimize or deny their

offensive behavior or the impact it has had upon the victim. Studies of adolescent offenders are similar to studies of adult offenders that demonstrate varying degrees of denial of the offensive behavior or attribution of responsibility for the assaults to the victim or to other factors (Becker et al. 1986; Barbaree and Cortoni 1993). Given that most adolescent offenders come forward for treatment only after there has been involvement with the criminal justice system, the first step in the assessment process is to compare the youth’s version of the events before, during, and after the assault with the victim’s statements, police reports, or other court or probation records. Where criminal justice involvement has not occurred and where reliable collateral information is unavailable, the examiner must always proceed with caution, as even seemingly cooperative patients may be withholding information that may be essential in formulating a treatment plan. The assessment of the adolescent sexual offender is similar to the assessment of the nonsexual offender, but with the additional focus on their sexual development and behavior (O’Shaughnessy 1992). A complete developmental, family, and social history, as well as assessment of interpersonal functioning, self-image, self-esteem, socialization and family functioning is required. The family assessment should cover developmental issues, interpersonal functioning, attitudes of the parents to the offense, history of any maltreatment, as well as a family history of any sexual or other offenses, substance abuse difficulties or psychiatric disorder. A detailed sexual history is required. This entails assessing sexual development, previous sexual experiences, fantasies, patterns of masturbation and specific thoughts and arousal associated with the offense. Although psychiatrists not accustomed to dealing with sexual offenders may view this type of inquiry as being aggressive and possibly harmful, clinical experience has shown that it is necessary to understand the offense cycle. When approached with sensitivity, such an inquiry is the first step in achieving a therapeutic relationship. When inquiring about deviant sexual arousal, it is imperative that the examiner avoid any pejorative tone and approach the issue with the same neutrality used in obtaining the developmental history. Discussions regarding past sexual abuse require the same sensitivity. It is generally not helpful to ask if the youth has been ‘abused,’ as often the youth does not perceive what occurred as ‘abuse.’ It is generally more productive to inquire about any behavior involving genital contact, witnessing sexual activity or experiences that were sexually arousing. A general estimate of sexual drive can be obtained by asking about frequency of sexual thoughts, arousal and masturbation practices, bearing in mind the likelihood of under-reporting in some patients (Hunter et al. 1994). In adult offender programs, penile tumescence studies are often used to measure deviant and normal sexual

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arousal. There is a large body of research supporting plethysmographic assessment as a reliable tool if confined to the clinical setting (Barker and Howell 1992; Simon and Schouten 1991; Travin et al. 1988). Its use, however, is limited because of lack of uniform standards for interpretation of results and the ease with which offenders may feign results. Although plethysmography is often used in juvenile offender programs, even greater caution must be exercised (Becker et al. 1989; Hunter et al. 1994). Ethical, moral or religious concerns on the part of the parents or others may result in consent being denied. Because of a lack of published studies regarding reliability and validity of the procedure in adolescents, the use of the procedure should be confined to individual treatment planning and monitoring of treatment results. It should not be used by itself to predict outcome or risk. Although no specific traits or profiles are seen when sexual offenders are psychologically tested, testing adds important information for treatment planning much as it does in the assessment of nonsexual offenders (Herkov et al. 1996). Intellectual assessment should be part of every evaluation as a significant subset of adolescent offenders has borderline to mild mental retardation. Other offenders may show evidence of poor verbal abilities, which may require alteration in subsequent cognitive-behavioral approaches to treatment.

TREATMENT OF ADOLESCENT SEXUAL OFFENDERS Although some offenders are brought into treatment by their parents or guardians, the majority are referred through the Criminal Justice System. In some jurisdictions, the therapist must be on an approved list of treatment providers that is sanctioned by the courts. This entails significant alterations in the normal patient–physician relationship that must be fully understood both by the clinician, as well as the patient. Issues of limitations in confidentiality, reporting laws and the extent the therapist may act as an agent for the Criminal Justice System differ from place to place. For example, in some jurisdictions, the therapist is required to report disclosures of past sexual offenses that emerge during the course of therapy, which may well result in further prosecution. While many psychiatrists would not wish to accept this role fusion between therapist and probation officer, in the majority of situations a close working relationship with the Criminal Justice System facilitates effective treatments. Most offenders require some form of external motivation to enter and continue therapy; for example, the threat of possible incarceration or revocation of probation. While somewhat coercive, the adolescent is given a choice between two difficult alternatives: (i) to choose therapy and have a reduction in sentence; or (ii) to reject

therapy and serve a longer period in custody. The therapist must help to inform the offender about these choices. Treatment programs operating inside and outside of residential settings seem of equal effectiveness, but residential settings may be required for high-risk youth who cannot control aggressive behavior. Treatment models for adolescent offenders have focused on addressing the issues identified in the assessment (Orr 1991; Lakey 1994; Knapp et al. 1992; Becker 1990, 1994; Barbaree and Cortini 1993; Henggeler et al. 1998). Treatment of comorbid disorders such as ADHD should be initiated early in therapy to improve the patient’s capacity to control impulses, and to maintain sufficient attention span so as to be able to benefit from subsequent treatments. Although treatment may be either individual or in a group, the latter approach is generally recommended in most programs. In well-functioning groups with an active therapist, the other group members are able to identify and challenge the cognitive distortions and rationalizations with greater impact than can be achieved in individual therapy. The membership within groups of sexual offenders needs to be planned carefully, with a view to keeping more vulnerable youth from those who are more predatory. The initial phase of any treatment program must deal not only with the development of rapport but also with the tendency to denial and minimization of the offense or the underlying problems. Treatment cannot occur unless the offender accepts responsibility for their behavior, and it is fruitless to continue without at least some acknowledgment. The motivation to remain in therapy is almost always tentative and will need reinforcement throughout the course of treatment. Most treatment programs use models of treatment borrowed from adult sex offender programs and modified to fit the developmental level of the adolescent offender. Treatment programs generally use a cognitive-behavioral approach that is aimed at offender-specific issues (Abel et al. 1984; Barbaree and Cortini 1993; Becker and Kaplan 1993; Hunter and Santos 1990). Many programs sequentially target deviant sexual arousal, cognitive distortions, and lack of empathy for the victim, as well as providing sexual education and social skills training. Behavioral treatment of deviant sexual arousal consists of covert sensitization, masturbatory satiation, or verbal satiation. Covert sensitization pairs the deviant sexual fantasy with unpleasant or aversive thoughts in a repeatedly rehearsed paradigm. Fantasies of being discovered, ridiculed by peers or incarcerated are often used as the aversive fantasy. To increase compliance, the youth can be required to make auditory tapes of the exercise and to produce them for review weekly (Abel et al. 1984). Masturbatory satiation involves masturbating to consenting sexual behavior until orgasm is reached. During the immediate post-orgasm period the offender is told to masturbate to the deviant image (Laws and Marshall

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1991; Marshall and Barbaree 1988). The experience is generally unpleasant, and it reduces the arousal to the deviant image. Most adolescents will object to this treatment, citing cultural, religious or moral grounds; Becker reports that verbal satiation achieves as much without the difficulties associated with recommending masturbation to adolescents (Becker and Kaplan 1993). Cognitive restructuring involves the identification, challenge and correction of the cognitive distortions that an offender uses to justify sexually assaultive behavior. Examples include an offender stating that the assault was actually teaching the young victim about sex, or that the rape victim wanted to have sex because of the way she dressed. Distortions facilitate offending by allowing offenders to rationalize their assaults as not being harmful. Empathy enhancement attempts to counteract the suppression of empathy for their victims that offenders often display. Cognitive restructuring and empathy enhancement can be provided through a combination of education and role playing. Sex education and social skills training are used in most programs to deal with knowledge and skill deficits. Conflict management and communication skills are taught through role playing. Such sessions often provide a welcome break from some of the more confrontive sessions. Treatment planning must also address co-morbid conditions. Some offenders have also been victims of sexual or physical abuse, while others suffer from substance abuse. Although empirical support is not established, individual psychotherapy for offenders who have been sexually abused is warranted. While most of these youth would not meet the criteria for PTSD, many describe premature eroticization and alteration of sexual identity that may rise from early victimization, and leads to difficulties in establishing mutually satisfying relationships. Psychotherapy addressing the damage from the earlier trauma may both reduce the urge to offend while also bolstering protective factors, such as improving the likelihood of establishing stable relationships. Family therapy and family support groups can be very effective additions to the program, and should be mandatory where there has been a sexual assault within the family (Henggeler et al. 1986, 1992). Relapse prevention is an approach borrowed from treatment programs for addictions (Barbaree and Cortoni 1993; Becker and Kaplan 1993). Addicts learn to identify situations that increase their risk of relapse or near-relapse and then rehearse techniques to avoid or reduce such risks. The sexual offender identifies similar situations and their accompanying thoughts and affects that make up the sequence of events leading to the offense. Situations such as being alone with a child, feeling lonely or sexually aroused, or masturbating to thoughts of children increase the risk of relapse. The offender then learns and rehearses coping strategies such as avoidance of at-risk situations, cognitive techniques such as thinking of the consequences

of further offenses and ongoing behavioral techniques such as avoiding thoughts of children when masturbating. As the urge to offend may be life-long, the emphasis is on teaching life-long coping strategies. Biological treatments have been used in adult offender populations to assist in the management of compulsive sexual behavior (Bradford 1995). Anti-androgen agents such as medroxyprogesterone (MPD) and cyproterone acetate (CPA) have been found effective in reducing sexual thoughts, fantasies and arousal associated with deviant sexual behavior, leading to reduced recidivism in sexual offenders (Bradford 1995). Unfortunately, normal sexual behavior is also suppressed, and side effects – though relatively benign – include mild feminization, especially with MPD. Transient periods of fatigue or mild depression, weight gain, nausea and vomiting and headaches are also seen. Although anti-androgens have been used for extended periods in adults, there are no published data available on their long-term use in adolescents. At this point, only intermittent use in carefully screened subjects and in specialized clinics such as our own can be recommended. Anti-androgens will affect pubertal development and should generally be avoided before the age of sixteen years. Luteinizing-hormone releasing hormone (LHRH) analogs, used in treating precocious puberty by downregulating pituitary gonadotropins), have been used with success in our clinic in youths aged less than sixteen years who have uncontrollable, deviant sexual drives. No major side effects have been observed, but long-term use has not been described, and effects on long-term development are unknown. At this point, these medications should only be used for the short-term control of aggressive sexual behavior in conjunction with other treatments. Serotonin reuptake inhibitors (SSRIs) may be promising adjunctive agents in the management of sexual offending (Bradford 1995; Kafka 1991; Kafka and Prentky 1992). The latter authors reported that fluoxetine decreased paraphilic and sexually addictive behaviors in twenty men with mood disorders. However, no studies have yet been reported of SSRI use in adolescent offenders, and further research is needed before these agents can be recommended for such use in adolescents. Although the use of anti-androgens in the treatment of adolescents is controversial and raises ethical concerns, the psychiatrist must ensure that the youth’s decision to take anti-androgens is voluntary and absent of any coercion, such as the threat of incarceration or transfer to adult court if they choose not to take the medication. Further, adequate information regarding the known affects, as well as the possible unknown long-term consequences, must be provided. Although adolescents may be competent to make their own decisions to take anti-androgens, it is our experience that the parents or guardians should be involved throughout the process of discussion of treatment alternatives and risk of re-offence. Both parents and guardians

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may clarify and support the therapeutic alliance, even when dealing with thorny issues such as the use of anti-androgens.

TREATMENT OUTCOME Only limited data are available on the outcome of treatment in adolescent offenders, and no reports have been made in which a control group has been utilized. Outcome measures have relied on changes in erectile responses to deviant cues, or to criminal record and self-report measures of recidivism (Rubinstein et al. 1993). Studies have noted normalization of phallometrically measured sexual arousal following a cognitive behavior treatment program (Becker and Kaplan 1993; Hunter and Santos 1990). In both studies, however, the authors expressed caution in generalizing the results because of the lack of normative data and absence of long-term follow-up to evaluate the stability of the changes. Based upon criminal records checks and telephone interviews with adolescent offenders treated in a model group program, one author (Bremer 1992) identified a 6 per cent conviction rate in subjects who had been in the community for between six and 102 months. The selfreported re-offense rate, however, was 11 per cent. Most studies suffer from significant treatment drop-outs and high rates of nonsexual criminal convictions but, despite their limits, they suggest that sexual recidivism after adolescent treatment programs is lower than after adult treatment programs (Borduin et al. 1990; Hagan and Cho 1996; Kahn and Chambers 1991).

REFERENCES Abel, G.G., Becker, A. Sex offenders results of assessment and recommendations for treatment. In Ben-Aron, H.H., Hucker, S.I., Webster, C.D. (eds), Clinical Criminology: Assessment and Treatment of Criminal Behavior. Toronto: M Graphics, 1985. Abel, G.G., Becker, J.V., Cunningham-Rathner, J., et al. Treatment Manual: The Treatment of Child Molesters. Tuscaloosa, Alabama: Emory University Clinic, Department of Psychiatry, 1984. Awad, G.A., Saunders, E.B. Male Adolescent sexual assaulters: clinical observations. Journal of Interpersonal Violence 6: 446–460, 1991. Awad, G.A., Saunders, E.B., Levene, J. A clinical study of male adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology 28: 105–115, 1984. Barbaree, H.E., Cortoni, F.A. Treatment of the juvenile sex offender within the criminal justice and mental health

systems. In Barbaree, H.E., Marshall, W.L., Hudson, S.M. (eds), Juvenile Sex Offender. New York: Guilford Press, 1993, pp. 243–263. Barbaree, H.E., Marshall, W.L. Deviant sexual arousal, offense history, and demographic variables as predictors of reoffense among child molesters. Journal of Behavioural Sciences and the Law 6: 267–280, 1988. Barker, J.G., Howell, R.J. The plethysmograph: a review of recent literature. Bulletin of the American Academy of Psychiatry and the Law 20: 13–26, 1992. Becker, J.V. Treating adolescent sexual offenders. Professional Psychology Research and Practice 21: 362–365, 1990. Becker, J.V. Offenders: characteristics and treatment [Review]. Future of Children 4: 176–197, 1994. Becker, J.V., Kaplan, M.S. Cognitive behavior treatment of the sexual offender. In Barbaree, H.E., Marshall, W.L., Hudson, S.M. (eds), The Juvenile Sex Offender. New York, The Guilford Press, 1993, pp. 264–277. Becker, J.V., Cunningham-Rathner, J., Kaplan, M. Adolescent sexual offenders. Journal of Interpersonal Violence 1: 431–435, 1986. Becker, J.V., Hunter, J.A., Stein, R.M., Kaplan, M.S. Factors associated with erection in adolescent sex offenders. Journal of Psychopathology and Behavioural Assessment 11: 353–362, 1989. Bourduin, C., Henggeler, S., Blaske, D. Multisystem treatment of adolescent sexual offenders. International Journal of Offender Therapy and Comparative Criminology 34: 105–113, 1990. Bradford, J.M.W. Pharmacological treatment of the paraphilias. In Review of Psychiatry, Volume 14, Chapter 29. Washington, DC: American Psychiatric Press Inc., 1995. Bremer, J.F. Serious juvenile sex offenders: treatment and long-term follow-up. Paraphilias related disorders. Psychiatric Annuals 22: 326–332, 1992. Dolan, M., Holloway, J., Bailey, S., Kroll, L. The psychosocial characteristics of juvenile sexual offenders referred to an adolescent forensic service the UK. Medicine, Science and the Law 36: 343–352, 1996. Federal Bureau of Investigation. Uniform Crime Report. Washington, DC, 1987. Fehrenbach, P., Smith, W., Monastersky, G., et al. Adolescent sexual offenders: offender and offence characteristics. American Journal of Orthopsychiatry 56: 225–233, 1986. Groth, A. The adolescent sexual offender and his prey. International Journal of Offender Therapy in Comparative Criminology 21: 249–254, 1977. Groth, A., Longo, R., McFadin, B. Undetected recidivism amongst rapists and child molesters. Crime and Delinquency 24: 450–458, 1982.

Adolescent sex offenders 487 Hagan, M.P., Cho, M.E. Comparison of treatment outcomes between adolescent rapists and child sexual offenders. International Journal of Offender Therapy and Comparative Criminology 40: 113–122, 1996. Hall, G.C., Shondrick, D.D., Hirschman, R. The role of sexual arousal in sexually aggressive behaviour: a meta-analysis. Journal of Consulting and Clinical Psychology 61: 1091–1095, 1993. Henggeler, S.W., Rodick, J., Bourduin, S., et al. Multisystemic treatment of juvenile offenders: effects on adolescent behaviour and family interaction. Developmental Psychology 27: 132–141, 1986. Henggeler, S.W., Melton, M., Smith, W., et al. Family preservation using multisystem treatment: an effective alternative to incarcerating serious juvenile offenders. Journal of Consulting and Clinical Psychology 60: 953–961, 1992. Henggeler, S.W., Schoenwald, S.K., Borduin, C.M., Rowland, M.D., Cunningham, P.B. Multisystem Treatment of Antisocial Behavior in Children and Adolescents. New York: The Guildford Press, 1998. Herkov, J.M., Gynther, M.D., Thomas, S., Myers, W.C. MMPI differences among adolescent inpatients, rapists, sodomists, and sexual abusers. Journal of Personality Assessment 66: 81–90, 1996. Hunter, J.A., Becker, J.V. The role of deviant sexual arousal in juvenile sexual offending. Criminal Justice and Behavior 21: 132–149, 1994. Hunter, J.A., Santos, D. The use of specialized cognitivebehavioural therapies in the treatment of juvenile sexual offenders. International Journal of Offender Therapy and Comparative Criminology 34: 239–248, 1990. Hunter, J.A., Goodwin, D.W., Becker, J.V. The relationship between phallometrically measured deviant sexual arousal and clinical characteristics in juvenile sexual offenders. Behaviour Research and Therapy 32: 533–538, 1994. Kafka, M.P. Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. Journal of Clinical Psychiatry 52: 60–65, 1991. Kafka, M.P., Prentky, R. Fluoxetine treatment of nonparaphilic sexual addictions and paraphilias in men. Journal of Clinical Psychiatry 53: 351–358, 1992. Kahn, T.J., Chambers, H.J. Assessing reoffense risk with juvenile sexual offenders. Journal of Child Welfare 70: 333–345, 1991. Kavoussi, R., Kaplan, M., Becker, J. Psychiatric diagnoses in adolescent sex offenders. Journal of the American Academy of Child and Adolescent Psychiatry 27: 241–243, 1988. Kendall-Tackett, K.A., Williams, L.M., Finkelhor, D. Impact of sexual abuse on children: a review and synthesis of recent empirical studies Psychological Bulletin 113: 164–180, 1993.

Knapp, F.H., Freeman-Longo, R.E., Stevenson, W.S. Nationwide Survey of Juvenile and Adult Sex Offender Treatment Programs and Models. Orwell, VT: Safer Society Press, 1992. Lakey, J.F. The profile and treatment of male adolescent sex offenders. Adolescence 29: 755–761, 1994. Laws, D.R., Marshall, W.L. Masturbatory reconditioning with sexual deviates: an evaluative review. Journal of Advances in Behaviour Research and Therapy 13: 13–25, 1991. Lewis, V.O., Shanok, S.S., Pincus, J.H. Juvenile male sexual assaulters. American Journal of Psychiatry 136: 1194–1196, 1979. Marshall, W.L., Barbaree, H.E. The long-term evaluation of a behavioural treatment program for child molesters. Journal of Behaviour Research and Therapy 26: 499–511, 1988. O’Shaughnessy, R.J. Clinical aspects of forensic assessment of juvenile offenders. Psychiatric Clinics of North America 15: 721–735, 1992. Orr, B.Y. Male adolescent sex offenders. A comparison of two treatment approaches. Special Issue: Child sexual abuse. Journal of Child and Youth Care 00: 87–101, 1991. Romano, E., DeLuca, R.V. Characteristics of perpetrators with histories of sexual abuse. International Journal of Offender Therapy and Comparative Criminology 40: 147–156, 1996. Rubinstein, M., Yeager, C.A., Goodstein, C., Lewis, D.O. Sexually assaultive male juveniles: a follow-up: American Journal of Psychiatry 150: 262–265, 1993. Rutter, M., Giller, H., Hagell, A. Antisocial Behavior by Young People. Cambridge: Cambridge University Press, 1998. Ryan, G., Miyoshi, T.J., Metzner, J.L., Krugman, R.D., Fryer, G.E. Trends in a national sample of sexually abusive youth. Journal of the American Academy of Child & Adolescent Psychiatry 35: 17–25, 1996. Saunders, E.B., Awad, G.A., White, G. Male adolescent sexual offenders: the offender and the offence. Canadian Journal of Psychiatry 31: 31–36, 1986. Seghorn, T.K., Boucher, R.J., Prentky, R.A. Childhood sexual abuse in the lives of sexually aggressive offenders. Journal of the American Academy of Child & Adolescent Psychiatry 26: 262–267, 1987. Shaw, J.A., Campo-Bowen, A.E., Applegate, B., Perez, D., Antoine, L.B., Hart, E.L., Lahey, B.B., Testa, R.J., Devaney, A. Young boys who commit serious sexual offenses: demographics, psychometrics, and phenomenology. Bulletin of the American Academy of Psychiatry and the Law 21: 399–408, 1993. Simon, W.T., Schouten, P.G. Plethysmography in the assessment and treatment of sexual deviance: an

488 Adolescent psychiatry and the law overview. Journal of Archives of Sexual Behavior 20: 75–91, 1991. Smith, W.R. Delinquency and abuse among juvenile sexual offenders. Journal of Interpersonal Violence 3: 400–413, 1988. Travin, S., Cullen, K., Melella, J.T. The use and abuse of erection measurements: a forensic perspective. Journal

of the American Academy of Psychiatry and the Law 16: 235–250, 1988. Worling, J.R. Sexual abuse histories of adolescent male sex offenders: differences on the basis of the age and gender of their victims. Journal of Abnormal Psychology 104: 610–613, 1995.

7.9 Juveniles and the adult criminal justice system: transfer/waiver to adult court CARL P. MALMQUIST

INTRODUCTION Recent years have witnessed an increase in public concern about the problem of juvenile violence. A byproduct of this concern has led to discussions, and outright advocacy at times, that more juveniles be handled in the adult criminal justice system rather than being maintained in the juvenile system. Some have viewed the juvenile court itself as an institution transformed from a nominally rehabilitative social welfare agency into a scaled-down second-class criminal court providing neither therapy nor justice (Feld 1999). Matters have gone so far that the federal Congress has entered the scene by proposing $1.5 billion in federal aid available to states if they will prosecute violent juveniles aged fifteen years and older as adults, and have prosecutors make such decisions rather than judges. Further, there is an estimate that by the year 2005, the number of adolescents aged fourteen to seventeen years will increase by 23 per cent (Fox 2000). The demographic variable of an overpopulated age group raises questions about where serious juvenile crime may go. Factors such as guns, gangs, drug use, emotional stresses, and social problems connected with unemployment, poverty, broken homes, and community deterioration guarantee a continuing unresolved problem.

SOURCES OF CONCERN A persistent question is: what has led to the current situation in communities with their increasing concern about policies dealing with juveniles who act in violent ways? Among the more controversial proposals are either shifting more juveniles into the adult criminal justice system or abolishing the juvenile court and trying minors as adults. Whether these are exaggerated responses or rather

rational proposals based on factual data which would reduce juvenile crime, are unresolved questions. Statutes dealing with juveniles in a more punitive manner have long existed, but the fact is that most juveniles are not handled either in a retributive manner by way of a punishment or by an effective rehabilitative model, whichever system is employed. The evidence is that aggregate levels of crime in the United States have either been declining or leveling off. However, this has not been so for violent crimes among juveniles or youthful offenders, which is the source of concern. A shift began occurring in 1985, since in the next seven years the rate of homicide committed by young people, the number of homicides committed by using guns, and the arrest rate of nonwhite juveniles for drug offenses all doubled (Blumstein 1996). This has been noted to correspond to an increase in drug trafficking and the diffusion of guns as part of the illicit drug trade. Drug arrests for young nonwhites increased as part of the picture of juveniles selling crack cocaine with open street transactions. Seemingly easy money, which readily fits in with gang activities, and is associated with status, provided the incentives. The predisposing factors operating were poverty, school drop-outs, single-parent homes, and a lack of comparative opportunity in their communities. By 1999, the data revealed 2.5 million arrests in the United States for those aged under eighteen years, constituting 17 per cent of all arrests. The growth of juvenile crime arrests that began in the late 1980s peaked in 1994. More specifically, juvenile murder arrests increased between 1982 and 1993 when they peaked with 3800 juvenile arrests; by 1999 such arrests had declined to 1400. Overall, by 1999 juveniles were involved in 9 per cent of murder arrests, 14 per cent of aggravated assaults, 33 per cent of burglary arrests, 25 per cent of robbery arrests, and 24 per cent of weapons arrests (Snyder 2000). The arrest rate for murder declined by 68 per cent between its

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peak in 1993 to 1999, while the juvenile arrest rate for violent crime index offenses fell by 36 per cent. Numbers data per se about juveniles can be deceiving since, with juveniles in particular, several might be charged with perpetrating a single offense. Even if each arrest involved a different juvenile – a highly unlikely situation – less than 0.5 percent of all persons aged between ten and seventeen years were arrested for violent crime. The juvenile crime arrest rates increased by 71 per cent between 1987 and 1994 and then declined by 4 per cent in 1995 to go back to the 1993 level. Keep in mind that from 1963 to 1985, the annual homicide rate for fifteen- to nineteen-year-old males was only one-third to one-half the rates for the next three higher five-year age brackets. However, between 1985 and 1991 the annual rates for the fifteen- to nineteen-year-old age group increased by 154 per cent, which placed them just behind the twenty- to twenty-four-year-olds. By then, the fifteen- to nineteenyear-old age group of males was more likely to be arrested than any other age group (Current Trends 1994). By 1991, the murder rate for white males, age fourteen to seventeen years had reached 13.6 per 100 000, while that for black males in the same age group was 111.8 per 100 000. What was puzzling was why the rates of homicide began to change by 1987 despite the population of juveniles and young adults shrinking. Historically, the rate of murder closely followed the percentage of the younger population. In the mid-1980s, teenagers had become more involved in homicide, both as perpetrators and victims. The recent decline of teenagers involved in violence does not deal with the variables of the severity of the crimes. The serious, chronic and violent juvenile group constitutes the pool from which juvenile cases are proposed for transfer to be handled in the adult criminal justice system.

APPROACHES TO TRANSFER JUVENILES TO ADULT COURTS Hidden in the processes of how juveniles may end up in the adult criminal justice system are basic questions pertaining to the justification for a separate system of juvenile justice itself. There has been an increasing disenchantment with the juvenile system, with some advocating an increased convergence between the juvenile and criminal courts (Feld 1998). If a separate system of juvenile justice is to continue, its current role needs careful scrutiny. What the juvenile system seeks are processes to ascertain which juveniles are such serious offenders that they cannot be remedied by the processes of the juvenile system; if they are in that group, the judgment is that it is best to handle them like any adult accused of a similar crime. If the juvenile system is not able to function in a manner demonstrating that it is capable of carrying out such

assessments with a reasonable degree of validity, and with its own jurisprudence, perhaps it is time to stop allowing the juvenile system to continue to be used as a target for critics who feel that some other system of justice can be more successful with juveniles. Whether this would mean a different system of justice for dealing with juveniles and a relative abandonment of rehabilitative efforts is a key unresolved question (Malmquist 1979). Some advocate an attempt to achieve both goals by trying all offenders, regardless of their age, in adult criminal courts with the same basic criminal procedural format, and then attempting different sentencing procedures based on their age and past delinquent/criminal histories. However, whether such changes would truly make for safer communities, even ignoring other more humane goals, remains an open question. It would increase procedural trial rights for juveniles, which could be a worthy goal, but it might not do anything beyond that in terms of status quo dispositional options available to the judicial system. Various terms are used for the processes when a juvenile is being considered as a candidate for the adult criminal justice system. Frequently used, the terms are ‘waived,’ ‘certified,’‘transferred,’ and ‘remanded,’ although they are not synonymous. Five basic processes which have evolved to determine whether a juvenile should remain subject to juvenile court jurisdiction, or rather be tried as an adult.

Judicial waiver Judicial waiver is the approach where the discretion of the juvenile court judge is the key variable in making a decision. In many cases, the initiation of a motion may be made by the prosecution, but the judge makes the decision. This is the most frequently used approach in state courts. Some states also allow the juvenile or parents to make a request for transfer. The statute may set limits on the waiver by the age of the juvenile, the offense in question, and the past history. Amenability to treatment as a criterion is a frequent opening for a mental health professional entering into the proceedings. A criticism of the process is that judges may rely too heavily on the recommendation of mental health personnel since there is often a high agreement between courts and such recommendation. Yet, that would not necessarily argue for a wrong decision unless one believes that only strict criminal procedures give optimal justice or community protection. Ages for waiver may vary considerably, with Georgia and Illinois allowing waiver from age thirteen years on, and Vermont from age ten years. Once the age threshold question is resolved, there is a variation among states as to whether any pending criminal offense suffices for waiver, or whether it needs to be a specific offense such as murder or a certain type of felony. Figures indicate that in 1994, 12 300 juvenile cases were transferred to criminal court by waiver, which was

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an increase of 71 per cent from 1985 (DeFrances and Strom 1997). Until 1991, property offenses were the largest number of cases waived, but since then offenses against the person have outnumbered property offenses. However, if drug cases and offenses against public disorder (disorderly conduct, weapons offenses, liquor law violations, some sex offenses) are included, the number of cases waived for other than offenses against the person still constitute the majority.

Prosecutorial discretion A second approach for transferring juveniles to adult courts is by way of prosecutorial discretion. This process leaves the decision to the prosecutor to proceed either in the juvenile or adult criminal system, since there is often concurrent jurisdiction or this option. The original jurisdiction is shared both by the juvenile and adult criminal courts until the prosecutor makes a decision as to which direction to take. There are usually some limits on discretion in terms of the age of the offender and nature of the offense. Thus, concurrent jurisdiction that leads to an either/or approach may be restricted to repetitive property offenses or acts of extreme violence. It is difficult to believe that there are no national data available on how many juveniles are prosecuted overall in adult criminal courts by this approach, but such data are lacking (Sickmund 1994). There are suggestive data that more juveniles in fact may be transferred to adult courts in this manner than by judicial waiver.

Concurrent jurisdiction This third approach to transferring juveniles, concurrent jurisdiction, is similar to prosecutorial discretion in that the approach is called between the adult and juvenile courts for certain classes of offenses. The grouping usually pertains to serious criminal felonies which have as a possible punishment the loss of life or life imprisonment. The criminal court is then seen as having exclusive jurisdiction. Since jurisdiction is in the adult court initially, cases not handled there are viewed as being ‘transferred down’ to the juvenile system. Many variations in the concurrent jurisdiction approach exist. In other states, the approach applies only to older juveniles but without regard to the nature of the offense. Some states approach the problem by the nature of the offense itself regardless of the age of the juvenile. Constitutional issues may arise if the state has conflicting statutes whereby the juvenile court is granted original jurisdiction over juveniles, yet another statute in the same state vests general jurisdiction over all offenses punishable by death or imprisonment in the adult criminal courts. The question then is which court has priority.

Legislative enactment In the fourth approach, legislative enactment, a statute simply excludes certain offenses alleged to have been committed by a juvenile from the jurisdiction of the juvenile court. A variation of this is legislation that lowers the age for adult criminal court jurisdiction. If a statute provides that the oldest age for juvenile jurisdiction is up to age sixteen years, it means that the entire group of juveniles age between sixteen and seventeen years has in effect been transferred to the adult system by such a legislative act. Connecticut, New York, and North Carolina have legislation where juvenile court jurisdiction does not extend beyond age fifteen years (Syzmanski 1994). The approach of excluding certain offenses from juvenile jurisdiction, such as murder or offenses against the person, has elicited the criticism that it is an invite to prosecutors to overcharge. Thus, they may automatically have the case lodged in adult criminal court by way of such overcharging. Further, it is an approach quite sensitive to public opinion and political advocacy for pressure to keep expanding the list of excluded offenses. For example, Illinois added to its list of excluded offenses the unlawful use of weapons on school grounds. This was challenged on due process and equal protection grounds, but the statute was upheld (People v. M.A. 1988). Another complication occurs when a juvenile is initially charged with an excluded offense, and the case is then in the adult criminal court. However, the juvenile may plead or be found guilty of a lesser offense in adult court. A typical example is a charge of murder which ends up as manslaughter. Yet, the latter offense is one in which the charge would not originally have landed the juvenile in the jurisdiction of the adult criminal court. States have different viewpoints of such occurrences, with some adhering to the position that the adult court retains jurisdiction, whereas others hold that the case must then be remanded to juvenile court if a lesser offense is the eventual resolution (Davis 1981). Again, no overall national data exist on the number of juveniles handled in adult criminal courts by way of legislative enactments.

Reverse certification In the fifth approach of reverse certification, all transfer decisions are simply under the control of a judge in the adult criminal court. Pennsylvania has utilized such an approach where the judge must certify the juvenile back to the juvenile court. This statute was challenged on grounds of violating equal protection, and a lack of adequate standards to determine when a case should be so transferred violating due process rights of the juvenile. However, the statute was upheld (Commonwealth v. Wade 1979). A criticism of reverse certification is that there is usually an underlying presumption that cases which arise

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in a particular court, such as the adult criminal court, should largely remain there and only exceptional cases ever sent to the juvenile court. The approach has also been criticized as a way of allowing prosecutors to bypass the necessity for holding a transfer hearing as the Kent case required (Kent v. U.S. 1966). Only New York and Nebraska authorize the criminal court to make all judicial transfer decisions, but at least ten other states authorize the criminal court to make some transfer decisions (Davis et al. 1997).

KEY LEGAL CASES The emphasis on the State as benevolent parent under the welfare doctrine of parens patriae has been stressed by many as the groundwork for a separate juvenile system. Yet, it was never the sole determinant. The prosecutorial adversary role with the main goal being community protection never disappeared. Other goals of the criminal law also operated, such as punishment or restraint. At least one major justification for a separate system of juvenile justice was that minors would not have to face the same penal consequences for antisocial behavior as adults. Therefore, certain disqualifications associated with being a convicted criminal would not accrue. Records were to remain confidential, which has come under increasing attack from pressures to certify and pervasive automation (Bureau of Justice Statistics 1997). Not until the Gault case (In re Gault 1967) were specific protections given to juveniles, and then only if commitment to an institution could occur. These were right to counsel, notification of charges, right to confront and cross-examine witnesses, and protection against selfincrimination. Similarly, when a finding of delinquency could result in commitment to a state institution, the proof for guilt by an evidentiary standard of reasonable doubt was not established until 1970 (In re Winship 1970). Even now, the evidentiary standard used for waiver is independent from a finding of delinquency per se, since it is based on civil standards of preponderance of the evidence. California now starts with the presumption that the juvenile is not a proper subject to be dealt with in the juvenile court unless evidence is presented to the contrary (California Welfare and Institutions Code 1996). Minnesota starts with the presumption of non-amenability to juvenile proceedings for juveniles aged sixteen years and older charged with a serious crime; the presumption must be rebutted by clear and convincing evidence (Minnesota Statutes 1994). The changes were viewed as rights being restored to juveniles because their de-facto handling approximated the adult model of criminal justice. Juveniles have still not been granted the right to a jury trial, and continued ambivalence exists towards the issue as seen in the

statement of the Supreme Court which referred to a jury trial as a right ‘… which would most likely be disruptive of the unique character of the juvenile process’ (McKeiver v. Pennsylvania 1971). Rights to receive a transcript of the legal proceedings, to bail, and to appeal diverse issues remain unclear. Since the Kent case (Kent v. U.S. 1966), waiver of juveniles without a hearing has been interpreted as unconstitutional. Although the case legally involved the interpretation of statutory language, wherein a judge was required to conduct a full investigation before effecting a waiver, the Supreme Court applied constitutional principles relating to due process and the assistance of counsel. The Court acknowledged the inconsistency of giving minors the right to a separate system of juvenile justice and then, without proper safeguards, allowing it to be undone. ‘There is no place in our system of law for reading the result of such tremendous consequences without ceremonies – that is, without hearing, without effective assistance of counsel, without a statement of reasons.’ However, after the Kent case it was remanded to the juvenile court for a hearing, the original waiver was sustained as entirely ‘appropriate and proper’ (Kent v. U.S. 1968). The reason given for the waiver is most revealing since it reveals one role that psychiatry plays. The juvenile court held that Kent should be waived since long-term facilities which could provide the type of psychiatric treatment the juvenile required did not exist. Therefore, the decision was to waive him to the adult court to stand trial as a criminal. This reasoning is truly ironic. It logically amounts to accepting a conclusion that a certain treatment approach is necessary, but if a community has not provided it, a totally contrary approach is acceptable. Such double-talk infuriates those involved in juvenile processes. A basic sense of injustice attaches when the absence of facilities or inadequate professionals leads to adult criminal handling. For juvenile cases, treatment interventions may have limited usefulness, but they are probably superior to the outcome of adult prisons unless pure incarceration is accepted as the goal. Acceptance of a civil commitment is predicated. On a review of cases, it is the need for community protection that still seems predominant over rehabilitative efforts in serious cases. Part of the problem is connected with what different courts at a waiver hearing interpret and accept as adequate and relevant behavioral data to help them in reaching a decision. A skeptic may say that such data are not useful or that it is irrelevant to focus on the act and not the actor. In practice, decisions are based more on correctional data with a heavy emphasis on past delinquency records and contact with correctional facilities. Hence, data from police departments, sheriffs’ offices, and FBI arrest records along with mental health records are compiled as a basis for determining amenability to juvenile handling. The quality of probation reports varies widely,

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depending on the experience and quality of the probation officer. These types of reports can either aid or hinder the direction of waiver, depending on the data. They are admitted, even though some is hearsay, since the hearing is viewed as a transfer hearing and not an adjudicatory one, which can lead directly to confinement or punishment. Many waiver hearings lack any psychiatric evaluations, and those that have them often lack adequate data. If any mental health personnel are involved, it is most likely not psychiatrists. This may be no worse than what occurs in the criminal justice system, but due to a greater lack of those with adequate training and expertise with adolescents, the discrepancy is more glaring. The result is either inadequate clinical data or a complete lack of it. Games may be played where reference is made to clinical material. In common practice, people who work in correctional facilities testify as experts on the issue of treatability. Their opinions regarding treatment are heard as expert testimony with respect to clinical assessment and prediction. Personnel testifying for a waiver may be employed at the same institution where the juvenile will be sent if waiver is denied. Therefore, the people working at an institution help decide whether the juvenile is someone who they wish to have at their institution or not. Their testimony is not binding on a court, but a close working relationship often develops among people who work together in the system. As in many other areas of court work, testimony by experts is often conclusory and unelaborated. At juvenile hearings, despite the serious consequences that may ensue, great latitude exists regarding those who are permitted to give opinions. As indicated, the absence of treatment facilities often means that treatment needs get bypassed. Again, it seems ironic that while more procedural protections, such as the right to a hearing before waiver, as in the Kent case (along with the assistance of legal counsel), have occurred, there is at the same time a laxity of standards as to testimony by experts on key behavioral questions. Unless the standard devolves to waiver simply being contingent upon a certain type of charge as determined statutorily, there is a great need for clinical expertise at these hearings. Nor should legal counsel’s failure to demand a high level of psychiatric expertise in their witnesses at these hearings be ignored. In part, this reflects a lack of knowledge in many of the parties as to what constitutes the training of an expert and an adequate clinical evaluation of an adolescent. Much testimony does not do justice to the complex legal, psychiatric, and personal significance of waiver. It is the last and only time that a minor can assert his status as a minor relating to the charges.

SUMMARY Although no state has yet abolished the juvenile court, the pressure to move in this direction has come both

from retributionists, who feel the juvenile court has gone too far in its attempts to rescue children (Platt 1969), and from those who believe that the constitutional rights of juveniles have still not been fully implemented. While acknowledging the shortcomings of the juvenile system, Rosenberg (1993) has argued that in the end it is worth preserving. Ongoing studies are comparing outcomes in jurisdictions where juveniles are transferred to adult court with those in which similar teens are retained (Snyder 2000; Redding 2000). Results have shown less recidivism in those retained and handled in juvenile courts after two years, although there was no difference between the groups after six years among the transferred youth when property crimes were excluded (Winner et al. 1997). Despite daunting methodological problems in carrying out such objective research, when clear findings are available they will carry more weight with policymakers in the future than relying on ideological predisposition. An alternative to expanding transfers into the adult criminal justice system that has emerged in some states is by way of expanding the punishment power of the juvenile court. Extending the age of legal adulthood so that the juvenile court retains jurisdiction does this. Such a strategy is referred to as ‘blended jurisdiction’ since it blends features of the juvenile and adult court systems. Various types of juvenile court blended sentencing frameworks have evolved:

• • •

A first approach whereby the juvenile court can impose either a juvenile or adult sentence. A second approach where the juvenile court imposes both a juvenile and an adult sentence, with the adult sentence being held in abeyance if certain conditions continue to be met. A third approach where the juvenile court imposes a sentence past its normal outer jurisdictional limits, and bring juveniles (later of adult age) back into court up to a certain age to decide whether they need to serve the entire sentence (Zimring 1988). The idea is that the blended sentence will provide for longer and more punitive sentencing for juveniles, but without subjecting them to an adult criminal court.

REFERENCES Blumstein, A. Violence by young people: why the deadly nexus? In Sullivan, J.J., Victor, J.L. (eds), Criminal Justice 96/97. Guilford, CT: Dushkin Publishing Group, 1996, pp. 158–164. Bureau of Justice Statistics. Privacy and juvenile justice records: a mid-decade status report. Washington, DC: U.S. Department of Justice, 1997. California Welfare and Institutions Code, §707(c) 1996. Commonwealth v. Wade, 485 Pa 453, 402A2d 1360 (1979).

494 Adolescent psychiatry and the law Current trends. Morbidity and Mortality Weekly Report. Atlanta, Department of Health and Human Services, Public Health Services. Morbidity and Mortality Weekly Report 43: 725–727, 1994. Davis, S.M. The efficacy of a probable cause requirement in juvenile proceedings. North Carolina Law Review 59: 723–757, 1981. Davis, S.M., Scott, E.S., Wadlington, W., Whitebread, C.H. Children in the Legal System, 2nd edition. Westbury, NY: The Foundation Press, Inc., 1997, pp. 861–872. Feld, B.C. Juvenile and criminal justice systems’ responses to youth violence. In Crime and Justice, 24. Chicago, IL: University of Chicago Press, 1998, pp. 189–261. Feld, B.C. The honest politicians guide to juvenile justice in the twenty-first century. Annals of the American Academy of Political and Social Science 564: 10–27, 1999. DeFrances, C.J., Strom, K.J. Juveniles prosecuted in state criminal courts. Bureau of Justice Statistics/Selected Findings. Washington, DC: United States Department of Justice, Office of Justice Programs, March, 1997. Fox, J.A. Demographics and U.S. homicide. In Blumstein, A., Wallman, J. (eds), The Crime Drop in America. New York: Cambridge University Press, 2000. In re Gault, 387 U.S. 1, 87 Sct 1428 (1967). In re Winship, 397 U.S. 358, 905 Ct 1068 (1970). Kent v. U.S., 383 U.S. 541 (1966). Kent v. U.S., D.C. Cir 401 F2d 408 (1968). Malmquist, C.P. Adolescents in the adult criminal justice system. In Feinstein, S., Giovacchini, P.L. (eds), Adolescent Psychiatry, Volume 7. Chicago: University of Chicago Press, 1979, pp. 444–456. McKeiver v. Pennsylvania, 403 U.S. 528, 915 Ct 1976 (1971). Minnesota Statutes Annotated §260.125(2a) 1994. People v. M.A., 124 III 135, 529 NE2d 492 (1988). Platt, A.M. The Child Savers: The Invention of Delinquency. Chicago: University of Chicago Press, 1969. Redding, R.E. Recidivism Rates in Juvenile versus Criminal Court. Charlottesville: Juvenile Forensic Evaluation Resource Center of the Institute of Law, Psychiatry and Social Policy, University of Virginia,

2000. Available on the Internet at: http://ness.sys.virginia.edu/juv/RecidRates.html Rosenberg, I.M. Leaving bad enough alone: a response to the juvenile court abolitionists. Wisconsin Law Review 1993: 163–185, 1993. Sickmund, M. How juveniles get to criminal court (OJJDP Update on Statistics). Washington, DC: U.S. Department of Justice, Juvenile Justice Bulletin, October 1994. Snyder, H.N. Juvenile arrests 1999 (OJJDP). Washington, DC: U.S. Department of Justice, Juvenile Justice Bulletin, December 2000. Szymanski, L. Upper age of juvenile court jurisdiction statutes analyses. Pittsburgh: National Center for Juvenile Justice, 1994. Winner, L., Lanza-Kaduce, L., Bishop, D.M., Frazier, C.E. The transfer of juveniles to criminal court: reexamining recidivism over the long term. Crime and Delinquency 43: 548–563, 1997. Zimring, F.E. American Youth Violence. New York: Oxford University Press, 1998.

Suggested reading Bishop, D., Frazier, C. Consequences of transfer. In Fagan, J., Zimring, F.E. (eds), The Changing Borders of Juvenile Justice: Transfer of Adolescents to the Criminal Court. Chicago: University of Chicago Press, 2000, pp. 261–264. Piquero, A. Testing Moffitt’s neuropsychological variation hypothesis for the prediction of life course persistent offending. Psychology, Crime and the Law 7: 193–215, 2001. Snyder, H. Serious, violent, and chronic juvenile offenders: An assessment of the extent of and trends in officially-recognized serious criminal behaviour in a delinquent population. In Loeber, R., Farrington, D. (eds), Serious and Violent Juvenile Offenders: Risk Factors and Successful Interventions. Thousand Oaks, CA: Sage, 1998, pp. 4278–444. Suffredini, N. Note, Juvenile gunslingers: a place for punitive philosophy in rehabilitative juvenile justice. Boston College Law Review 35: 885–901, 1994.

7.10 Juveniles and the adult criminal justice system: the death penalty RICHARD A. RATNER

INTRODUCTION In those jurisdictions where capital punishment exists, if one is tried as an adult for a so-called capital crime, conviction can result in the penalty of death. In recent years, changing legislation has resulted in greater and greater numbers of adolescents being tried as adults. Inevitably, increasing numbers of adolescents below the age of eighteen years who are accused of capital crimes will be eligible for capital punishment. Juvenile offenders have been put to death on over 350 occasions throughout the history of this country, twentyone of which executions have occurred since 1973 (Streib 2003). An additional 203 have been condemned to death since 1973, but of these, 123 have had their convictions reversed or commuted. Eighty remain on death row while their cases are being appealed. Half of death sentences have been imposed by three states: Texas, Florida, and Alabama, while almost two-thirds of actual executions having taken place in one jurisdiction, Texas.

POST FURMAN: 1973–1987 The modern era of death penalty legislation began in 1972, when the Supreme Court (in Furman v. Georgia) threw out all existing death penalty statutes as unconstitutional. Rather than stating, as critics of the death penalty had hoped, that capital punishment itself constituted a form of cruel and unusual punishment that violated the Eighth Amendment to the Constitution and thus outlawing it for all crimes in all jurisdictions, the Court invalidated Furman’s conviction on procedural grounds. A majority of the Court indicated that the death penalty was not cruel and unusual in every circumstance but in this case felt

that it had been administered in a capricious or discriminatory manner (Furman was black, mentally impaired, and the shooting leading to death was probably accidental). Taking their cues from this decision, many states rewrote their capital punishment laws to be in compliance with the standards suggested by the opinions in this case. This process took time, and as a result, for several years after 1972 nobody was executed anywhere in the United States. In some jurisdictions, such as the District of Columbia, the absence of a death penalty remains in place. However, in states that have reinstituted capital punishment for adults, the potential for juveniles being tried as adults and actually being given a death sentence has once again become a possibility.

THOMPSON, STANFORD AND WILKINS: 1988–1990 Despite their loss (in Furman) on the larger issue of the death penalty, advocates for a rehabilitative, rather than a punitive, approach to adolescent offenders had another opportunity to sway the Court’s thinking in 1987, when the case of Thompson v. Oklahoma (1988) was accepted for hearing. When he was aged fifteen years, Thompson had participated in the murder of his former brother-in-law with three other men. The others were tried and sentenced to death for the especially brutal crime, and Thompson was given a transfer (or waiver) hearing before the juvenile court. Because he was found not likely to be amenable to treatment and rehabilitation he was transferred to adult court to be tried. There, he too was sentenced to death. Because of Thompson’s age at the time of the crime, death penalty opponents again petitioned the Supreme Court to hear the case. Even if capital punishment per se did not violate the Eighth Amendment, it was suggested

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that the execution of a minor that young did, particularly in light of the concept of ‘evolving standards of decency,’ under which the Court had long ago decided to interpret the Eighth Amendment. In preparation for arguments in this case an amicus curiae brief was filed by the American Society for Adolescent Psychiatry and the American Orthopsychiatric Association stating that the death penalty is inherently cruel and unusual by virtue of being excessive and disproportionate and contrary to evolving standards of decency. The major arguments consisted of a developmental one: that adolescence is a transitional state in which juveniles have not yet fully developed the ‘cognitive ability, judgment and fully formed identity or character of adults’ (McLaughlin et al. 1987); and the assumption that juveniles on death row suffer from ‘serious psychological and family disturbances which exacerbate the already existing vulnerabilities of youth.’ The latter argument was based primarily on a study conducted of fourteen juveniles on death row (Lewis et al. 1979), including Thompson himself. For both of these reasons, it was argued that capital punishment was excessive and that it served no legitimate penological purpose with respect to adolescents. While these arguments seemed cogent to many, if not all, mental health professionals, their weakness was that they could be applied with equal justice to individuals over the age of eighteen years. Death penalty proponents saw these arguments as the opening wedge of a policy that might in time lead to the total banning of capital punishment. In the end, however, the Court made its decision upon very different grounds. It performed a survey of all states and found that of all the states which had death penalty laws (thirty-seven at the time) setting minimum ages for execution, eighteen had set the minimum age at sixteen years. In other words, if a juvenile aged younger than sixteen years committed a capital crime in those states, he or she could not be executed. A majority of the court added these eighteen states to the fourteen states that prohibit capital punishment altogether and came up with a majority of states – thirty-two – that considered anyone aged younger than sixteen years to be too young for capital punishment. In essence, these justices used ‘community standards’ as set forth in state laws as evidence of a ‘national consensus’ in favor of sixteen years as the minimum age at which a perpetrator could be eligible for the death penalty. Shortly after this case was decided, however, the Court agreed to hear two other cases regarding the minimum age for the death penalty. Kevin Stanford was seventeen years and four months old when he committed a crime for which he was convicted and sentenced to death in Kentucky. Heath Wilkins was aged sixteen years and six months when he committed a capital murder in Missouri. Both cases were accepted for review by the Supreme Court to decide on the permissibility of capital punishment for adolescents who commit such crimes between the ages of sixteen and eighteen years of age.

In this pair of cases (Stanford v. Kentucky; Wilkins v. Missouri, 1989) the same organizations filed nearly identical friend-of-the-court briefs (McLaughlin et al. 1988) making most of the same arguments. However, the Supreme Court followed the lead of its most conservative member and found that there was no constitutional bar to the death penalty in teenagers committing a capital crime on or after their sixteenth birthday. The same analysis of existing state laws that resulted in the national consensus against capital punishment for children aged younger than sixteen years did not hold true for sixteenyear-olds and older. For a somewhat more detailed discussion of these decisions and the reasoning of the court, see Ratner (1999). One troublesome aspect of this decision is that it appears to have relied upon the juvenile court to retain those young people in the juvenile court system who have committed capital crimes but are amenable to rehabilitation and treatment. The usual proceeding where such decisions – whether to retain a juvenile or transfer him or her to adult court – are made is the transfer (or waiver) hearing. Were every teenager being considered for transfer to adult court permitted such a hearing in juvenile court, this safeguard would be meaningful. However, in recent years juveniles have more and more often been transferred to adult court without such a hearing – victims of various automatic forms of waiver based upon the nature of the crime or prosecutorial discretion (see Chapter 7.9). In such cases, one of the major safeguards relied upon by the Court in Stanford is not present.

RECENT HISTORY: 1990–2000 Attempts to protect underage criminals from the death penalty continued. In one recent Georgia case (see Garrett 2000), a youth suffering schizoaffective disorder who had committed a capital crime at age seventeen years was given the death sentence. In an amicus brief filed by such organizations as the Children’s Defense Fund, NAMI, and the National Mental Health Association (Garrett 2000), both issues of age and of mental illness were noted as reasons for the governor to commute the death penalty. In addition, the brief argued once again that the death sentence should be unconstitutional as a violation of the ‘due process’ clause of the Constitution and because it flies in the face of ‘evolving standards of decency.’ In this case, while the briefs were successful in persuading the governor, the defendant, Williams, later committed suicide in prison. This brief also raised one of the various ethical issues that often arise uniquely in forensic settings. Since one must, as for all other legal processes, be competent to be executed, the use of involuntarily administered psychotropic medication solely to render an individual competent for execution poses an ethical dilemma for the physician, whose duty is to save life and ‘do no harm.’

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Consequently, such ‘treatment’ is considered unethical behavior by both the American Psychiatric Association (1998) and the American Medical Association (2000). During the past three years there have been a number of encouraging developments for those who believe that juvenile offenders ought not to be subjected to capital punishment. In tandem with advocacy in the states around this issue, there has also been a continuing campaign to abolish capital punishment for mentally retarded offenders. In this regard, advocates have been exceptionally successful in various states, which have banned capital punishment for the mentally retarded. This effort climaxed when the Supreme Court, in Atkins v. Virginia (2002) ruled execution of the mentally retarded unconstitutional. In addition, the death penalty defense bar has continued to push for the elimination of capital punishment altogether. While an outright ban on capital punishment would have the effect of removing us from the company of such nations as Iran and Yemen, it would also resolve the difficulties inherent in determining either how young is young enough, or how mentally retarded is ‘enough’ to avoid being considered fully responsible for one’s actions. Yet in the absence of an end to capital punishment in general, advocates have been forced to attempt to achieve victories in a piecemeal fashion. However, arguments that attempt to shelter youth under a particular age from capital punishment are difficult to justify once a youth reaches his mid-teenage years. The notion that one crosses the line into psychological maturity over 24 hours as one attains any arbitrary age is absurd, and while younger youths clearly seem less than fully mature and responsible, late teenagers may typically seem to be as responsible as adults for their crimes. Grisso (1996) predicted with some frustration that no progress would likely be made with the public until further research became available into how adolescents make risky choices and particularly in the ‘interpersonal and situational contexts in which adolescents’ homicides and other violent acts occur.’ As if in response to this challenge, however, very new studies of brain development in adolescents have begun to highlight significant differences in the adolescent brain. In particular, functional MRI techniques have indicated both a pruning of gray matter and a late myelination of regions of the frontal cortex and striatum that are essential for such functions as ‘response inhibition, emotional regulation, planning and organization.’ (Sowell et al. 1999). These findings have been embraced by advocates against the death penalty for minors as hard evidence that juveniles should not be held as responsible as adults for their acts.

MOST RECENTLY Despite the fact that the death penalty remains available for teenage offenders, advocates for these juveniles have

had enough recent successes to have become cautiously optimistic that this sanction will soon become a thing of the past. In addition to the decision in Atkins noted above prohibiting further executions of the mentally retarded, individual states choosing to ban capital punishment for teenage offenders are increasing in number. In March of 2002, for example, the state of Indiana became the sixteenth state to bar the death penalty for juveniles, and the governor of the State of Kentucky is supporting a ban on these practices in his state. Interestingly, Kevin Stanford – the individual whose capital punishment was allowed to stand by the Supreme Court, is still alive as of this writing – and various organizations and friends of the court (including the American Society for Adolescent Psychiatry) have submitted briefs arguing that his penalty should be commuted. While the Court declined to hear the appeal, in its aftermath and that of a failed appeal to the Supreme Court by a Texas youth, Toronto Patterson, and his subsequent execution, four Justices of the Court issued a statement recommending that the Court review its decisions regarding the death penalty for minors. While these Justices’ personal senses of decency are clearly offended by the continued lawfulness of these executions, they are clearly watching developments in the states in the timing of their remarks. At the rate things are changing, a majority of the states are likely to have prohibited these executions by the time the next case of this type comes before the Court. Since, as noted above, the basis for the Court’s decisions regarding evolving standards of decency lies in their review of the laws in the states, when the majority no longer permits the execution of juveniles, it is highly likely that, when given an opportunity to review the situation again, it will conclude that matters have evolved to a point where these executions have finally become cruel and unusual punishment. Perhaps the most encouraging news, however, is growing opposition to the death penalty altogether. This reached national prominence when the governor of Illinois, a Republican, placed a temporary ban on all capital punishment in his state after a noteworthy case in which the newly emerging technology of DNA identification was used to clear an individual mistakenly condemned to death. A commission established by the governor to study the death penalty concluded in May of 2002 that the justice system was simply unable to determine with 100 per cent accuracy which individuals were guilty of crimes. It recommended that with the uncertainty involved, the death penalty would be inappropriate and recommended it be abolished. Numerous other cases, some of which have been documented by the nonprofit Innocence Project (www.innocenceproject.org), have resulted in setting free some who have been on death row for many years, further illustrating the wisdom of this conclusion. Most recently in January of 2003, Governor Ryan concluded his term in office by commuting the sentences of all the inmates held on death row in the state of Illinois.

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Despite the current climate regarding the treatment of criminals remaining retributive rather than rehabilitative, such developments as these seem to be changing people’s perspectives on a form of punishment that, once levied, cannot be revoked. As is so often the case when decisions are made in the political realm, the importance of momentum cannot be underestimated. Despite the horrors recently inflicted upon the American people on September 11 2001, the so-called ‘standards of decency’ may indeed be evolving in a more humane direction.

RESOURCES Finally, it is by now prosaic to point out that the Internet has revolutionized the acquisition of information for anyone able to log on to it. No less than in other fields of endeavor, professionally managed websites devoted to the death penalty in both adults and juveniles can be found through the use of any search engine. Excellent places to start include the Death Penalty Information Center’s home page (www.deathpenaltyinfo.org) where, among many other things, a review article on the death penalty by Streib (2000) can be found. Another excellent source of information is the website of the American Bar Association’s Juvenile Justice Center (www.abanet.org/ crimjust/juvjus/home.html), as well as that of Professor James Vanderhoof at (www.uncp.edu/home/vanderhoof/ heath.html). At the time of this writing, another organization – The Justice Project – has also established a website concentrating on the death penalty www.thejustice project.org). The ultimate source of information on crime in general and juvenile justice in particular is the website of the National Criminal Justice Reference Service (NCJRS): www.ncjrs.org, where one may also find all on-line offerings of the Office of Juvenile Justice and Delinquency Prevention (OJJDP).

REFERENCES American Bar Association’s Juvenile Justice Center: www.abanet.org/crimjust/juvjus/home.html American Medical Association. Current opinions of the council on ethical and judicial affairs. Policy E-2.06: Capital Punishment. Updated 2000. Available at www.ama-assn.org (accessed January 18, 2003).

American Psychiatric Association. Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. Washington DC: American Psychiatric Association, 1998. Atkins v. Virginia: 122 S.CT. 2242 (2002) or 536 US. 304 (June 20, 2002). Death Penalty Information Center: www.deathpenaltyinfo.org (2002). Furman v. Georgia: 408 U.S. 238 (1972). Garrett, M.C. Amicus Brief in Support of Petitioner, Alexander Williams IV. Garrett & Gilliard attorneys, Augusta, GA, 2000. Grisso, T. Society’s retributive response to juvenile violence: a developmental perspective. Law and Human Behavior 20: 229–247, 1996. The Innocence Project: www.theinnocenceproject.org (2002). The Justice Project: www.thejusticeproject.org (2002). Lewis, D., Shanok, S., Pincus, J., Glaser, G. Violent juvenile delinquents: psychiatric, neurological, psychological, and abuse factors. Journal of the American Academy of Child Psychiatry 18: 307–319, 1979. McLaughlin, J., Epstein, J., Weisburg, H., et al. Brief of the American Society for Adolescent Psychiatry and the American Orthopsychiatric Association as Amici Curiae in Support of the Petitioner (Thompson v. Oklahoma). New York, Counsel Press, 1987. McLaughlin, J., Epstein, J., Weisburg, H., et al. Brief of the American Society for Adolescent Psychiatry and the American Orthopsychiatric Association as Amici Curiae in Support of the Petitioners (High v. Zant, Wilkins v. Missouri ). New York, Counsel Press, 1988. National Criminal Justice Reference Service: www.ncjrs.org. (2000). Ratner, R. Juvenile justice: an update. In Esman, A. (ed.), Adolescent Psychiatry, Developmental and Clinical Studies, Volume 24. Hillside, NJ: The Analytic Press, 1999, pp. 143–158. Sowell, E.R., Thompson, P.M., Holmes, C.J., Jernigan, T.L., Toga, A.W. In vivo evidence for post-adolescent brain maturation in frontal and striatal regions. Nature Neuroscience 2: 859–861, 1999. Stanford v. Kentucky; Wilkins v. Missouri: 109 S.CT. 2969 (1989). Streib, V.L. The Juvenile Death Penalty Today: Death Sentences and Executions for Juvenile Crimes, January 1, 1973–June 30, 2000. Available at: www.law.onu.edu/ faculty/streib/juvdeath.htm (accessed January 13, 2003). Thompson v. Oklahoma: 487 U.S. 815, 108 S. CT. 2687 (1988).

7.11 Dependency court: the handling of abuse and neglect cases KATHI L. GRASSO

INTRODUCTION Those working in the family, juvenile or dependency court system look regularly to psychiatrists and other mental health professionals for guidance when making life-affecting decisions regarding families coming under the court’s auspices. Judges, lawyers, and parties may ask psychiatrists to assess parental fitness, a child’s mental health status, and treatment options. As part of these evaluations, they may request mental health experts to make recommendations relevant to the development of case plans, including whether a child should be reunited with a parent, adopted, or placed in long-term foster care. Although judges are ultimately responsible for issuing the final orders in cases, psychiatric opinion can have an enormous influence on an order’s nature and scope. Specifically, when dealing with adolescents involved in the child welfare system, psychiatrists are likely to address issues such as:

• • • • •

in the environment of managed care, access to timely and comprehensive mental health services provided by mental health professionals with the requisite expertise to provide services to adolescents; the appropriateness of in-patient psychiatric hospitalization for evaluation or treatment purposes; the appropriateness of long-term placement in a residential treatment facility, possibly out-of-state, versus a less restrictive alternative, such as therapeutic foster care; the prescription of psychotropic medications and the monitoring of their use; and teenagers’ access to independent living services which include a mental health component.

Based on reporting from forty-five states, the District of Columbia and Puerto Rico, available data indicate that as of September 30, 1999, approximately 568 000 children were placed in the nation’s foster care system. Older children and adolescents (aged 11–19⫹ years) comprised 46 per cent of these jurisdictions’ foster care populations (US Department of Health and Human Services, AFCARS 2000). Studies reveal that a significant percentage of children in foster care have serious physical and mental health problems. A sampling of findings of selected foster care populations indicate that:

•

•

•

•

Some 22 per cent of children aged three to six years, 63 per cent of children aged seven to twelve years, and 77 per cent of teenagers were found to be in need of a mental health referral; almost 75 per cent were at risk due to a family history of mental illness and/or drug or alcohol abuse; 18 per cent had been sexually abused or were suspected to be victims of such abuse (Chernoff et al. 1994). For foster children in California, 75 per cent of mental health services billed under Medi-Cal were for treatment of adjustment disorders (28.6%), conduct disorders (20.5%), anxiety disorders (13.8%), or emotional disorders (11.9%) (Halfon et al. 1992). Of the 77 per cent of eligible children screened, 15 per cent had indicated either a previous attempted suicide or were suspect for suicidal ideation, and 7 per cent admitted to, or were suspect for homicidal ideation (Chernoff et al. 1994). Of those four- to eighteen-year-olds in foster care, 48.7 per cent showed evidence of psychological disorders; this population was from two to over thirtytwo times at higher risk for psychological disorders,

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than children raised in their own homes (McIntyre and Keesler 1986). Given the significant mental health needs of youth in our nation’s child welfare system, it is imperative that psychiatrists and other mental health professionals understand the court process so that they will be better able to ensure that these young people obtain access to appropriate mental health services. This section will briefly highlight the stages of dependency court proceedings with special emphasis on adolescent concerns. Though laws and procedures relevant to civil child protection proceedings may vary from state to state, the court processes described below are typical of those in most states. Practitioners should keep in mind that if they have any questions about the legal process, they should consult with a knowledgeable attorney who can advise them about the reporting of child abuse and neglect, their role in the legal process, and state-specific concerns.

THE DEPENDENCY COURT PROCESS

The federal AACWA made a significant difference in the lives of thousands of children. Many children were protected from the trauma associated with the unnecessary severance of parental, sibling and other familial ties, and benefited from dependency courts being more attentive to permanency planning considerations. However, despite the ACCWA, many children continued to languish in foster care for a variety of reasons, including a dramatic increase in the number and complexity of cases since 1980 and systems ill-equipped to deal with those numbers. With these concerns in mind, President William Clinton signed P.L. 105-89, the ‘Adoption and Safe Families Act’ of 1997 (ASFA), into law on November 19, 1997. This law modified provisions of the AACWA to expedite court decision making in foster care cases and better ensure that children’s safety is paramount when determinations are made as to reunification with family. On January 25, 2000, the United States Department of Health and Human Resources published final regulations implementing ASFA. 65 Fed. Reg. 4020 (2000) (codified at 45 C.F.R. §§1355, 1356 & 1357). When relevant, specific provisions of these federal laws will be noted below.

Legal authority to intervene

Pre-court involvement

Dependency courts – which are also referred to as juvenile or family courts – are authorized by state law to rule on cases involving the abuse and neglect of children. State statutes will usually provide that such courts have jurisdiction over children alleged or found to be abused and neglected from the date of their births until the age of eighteen. Some states provide that the court’s jurisdiction continues until a youth is aged twenty-one years. Assuming jurisdiction over a family allows the court to make rulings on whether abuse and neglect has occurred, children’s placement in out-of-home care, and the provision of services, including mental health services, to children and families. In addition to state laws governing court processes, federal laws impact on legal proceedings. In 1980, the United States Congress enacted the Adoption Assistance and Child Welfare Act (AACWA), P.L. 96-272, 42 U.S.C. §§620-627, 670-679, to combat the harm that children experience when left ‘adrift’ in the child welfare system. The Act was expected to be instrumental in reforming the nation’s handling of child abuse and neglect cases to ensure that children were not unnecessarily separated from their families when appropriate services could keep them together, and that if removed, they would be afforded the opportunity to have permanency, stability and adult nurturance in their lives. The Act was the impetus for the passage of numerous state statutes incorporating the requirements of the federal act, including provisions related to family reunification, permanency planning, and independent living services.

All states have laws that govern the state and private citizen’s role when intervening in cases in which child abuse and neglect is suspected. The statutes delineate the following:

• • • • •

what constitutes abuse and neglect; professionals and others who must report suspected abuse or neglect; procedures for reporting suspected abuse or neglect to local child protection service (CPS) and/or law enforcement agencies; immunity for reporters; and penalties for failure to report.

Psychiatrists and most other mental health professionals are required under law to report their suspicions of child abuse and neglect to their local CPS or law enforcement agency. Adolescents suspected of being abused or neglected are encompassed under these statutes. The penalties (i.e., criminal sanctions, fines, license revocation) for failure to report will differ to some degree from state to state. Health professionals may also be subject to civil medical malpractice actions for breaching a statutory duty to report. Upon receiving a report of abuse or neglect, the CPS or law enforcement agency has the legal obligation to immediately investigate and determine whether the child should be removed from his or her family to protect that child from harm or risk of harm. Should the child be removed from his or her parents or other custodian, the local CPS agency will file a petition with the court seeking

Dependency court: the handling of abuse and neglect cases 501

the continued removal of the child from the home or the return of the child to the home with services. If a mental health professional believes that the designated state agency is not responding as it should to a report of abuse or neglect, that individual should consider voicing his or her concerns to those in charge at the CPS or law enforcement office, the attorney or legal agency that represents the CPS or law enforcement agency, his or her own attorney, the local child advocacy office, and/or the state children’s ombudsman office, if available. In some states, persons who disagree with a CPS decision not to investigate or follow up on a case of abuse and neglect have the option of filing their own legal petition seeking the court’s intervention. It should be remembered that teenagers are just as entitled to protection from abuse and neglect as younger children. On occasion, reports of abuse perpetrated against teenagers may be viewed by those with the obligation to investigate as merely reflective of a less serious parent–child conflict. The case may be perceived as one in which the youth is deserving of the parent’s wrath or is capable of taking care of him or herself. This is a case that still needs to be investigated to determine whether the underlying reasons for conflict are of a serious enough nature to warrant state intervention.

Preliminary/shelter/removal hearing Once a child has been removed from his or her legal custodian, the court must be notified and holds an emergency hearing to determine whether removal is necessary. The court will typically schedule an emergency hearing, usually within 24–72 hours of the removal, depending on state law. Parties to the proceedings should be notified of the hearing and requested to appear. The local child welfare agency should (but does not always) attempt to identify both the mother and father of the children who are the subject of the petition. The child welfare agency files its petition alleging abuse and neglect around the time of the emergency hearing. In accordance with most state statutes, each party is entitled to legal representation by independent counsel at all stages of court proceedings. Immediately prior to or at the time of the emergency hearing, an attorney or guardian ad litem will be appointed to advocate for the child. If a parent is indigent, an attorney will be provided to the parent at no cost. Unfortunately, in many jurisdictions children do not have access to competent, independent legal representation. In some states, indigent parents may only be entitled to counsel at certain stages of the proceedings or if they are actively seeking custody of their children. At the emergency hearing, the parties, usually through their attorneys, will present oral argument or evidence regarding the allegations of abuse and neglect. As required

by federal law and the law of most states, the court must make a finding that continued placement in the child’s home is ‘contrary to the welfare of the child’ [45 C.F.R. §1356.21(c)]. This finding must be ‘detailed’, giving reasons why removal is appropriate [45 C.F.R. §1356.21(d)]. (It should be noted that in order to receive federal money for foster care services, states must agree to comply with federal law, including modifying their state laws to bring them in compliance with the mandates of federal law.) Further, within sixty days of removal, the court must make a finding as to whether the state has made ‘reasonable efforts’ to prevent the child’s removal [45 C.F.R. §1356.21(b)]. This determination can be made at the shelter care hearing or at a subsequent hearing within the sixty-day period. The court will inquire as to whether services should have been provided to keep the child in the home or whether services can now be provided to enable the child to be reunited with his or her family. These services can include home visitation by a qualified social worker, parenting skills training, or housing with support services. In the most egregious cases, in which child maltreatment has been especially severe, the court can decide that no efforts need to be made to preserve or reunify the family. In these cases, the child welfare agency should rapidly develop and implement a permanent placement plan for the child. Besides addressing the issue of removal at the emergency hearing, the court may consider the appropriateness of visitation between parents and their children, the need for psychiatric or psychological evaluations, and the child’s placement pending the next hearing. For adolescents, placement issues can be compounded by the fact that in many jurisdictions, foster homes for teenagers are limited. Lawyers and other professionals working with youth involved in dependency proceedings should ensure that the placement selected is the ‘least restrictive’ one necessary to accommodate the youth’s needs. Because of a shortage of teenage foster care or group home placements, teenagers may find themselves inappropriately placed in residential treatment facilities and state and private mental hospitals.

The adjudicatory hearing The adjudicatory hearing – also known as the trial on the merits – will ideally be scheduled within thirty days of the removal hearing. At this hearing, evidence is presented to support or rebut the allegations of abuse and/or neglect stated in the original petition. In many states, the state must prove its case ‘by a preponderance of the evidence’ (sometimes thought of as a ‘51%’ level of certainty) which is a lesser standard of proof than ‘clear and convincing’ (75%) or ‘beyond a reasonable doubt’ (90% plus). In other states, clear and convincing evidence is required.

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In the great majority of states, a judge determines the case findings rather than a jury. The hearing may be contested or it may settle. Experts, including mental health professionals, may be called upon to testify. Expert opinion might be sought on the alleged psychological or physical maltreatment of a child. For instance, in a case involving Munchausen syndrome by proxy, a psychiatrist might testify as to whether the evidence presented in the case supported a finding that the child was a victim of the syndrome. Additionally, when a psychiatrist has been treating the child or family prior to the report of abuse, he or she, keeping confidentiality concerns in mind, might provide the court with insight into the family constellation prior to the report of abuse and/or neglect. If the court finds that the evidence supports a finding that a child has been abused or neglected or, more generally, is in need of the court’s assistance, a dispositional hearing will be scheduled, often to immediately follow adjudication, or within thirty to sixty days. Pending this hearing, the court may require the parties to undergo evaluations to assess parental fitness and/or the special needs of the child, make further orders as to the child’s placement, and ensure that the child welfare agency develops a case plan for the court’s review.

Dispositional hearing When the court finds that facts exist to support its continued supervision of a case, the court must rule on the appropriateness of case planning for the child. At the dispositional hearing, a judge must decide on a more permanent placement for the child and the services needed to implement that plan. The court will review permanency and case plans that the child welfare agency should have been developing since the child’s entry into state care. In accordance with 45 C.F.R. §1355.20, permanency plan options are:

• • • • •

reunification with biological parents or original legal custodian; parental rights termination/adoption; legal guardianship to an appropriate individual ‘intended to be permanent and self-sustaining’; permanent placement with a ‘fit and willing’ relative; and placement in ‘another planned permanent living arrangement’ (but only in cases in which the state documents to the court a compelling reason that another plan is not in the best interests of the child).

As with the adjudicatory hearing, the dispositional hearing can either be contested or settled. Experts will often be called to testify or produce their findings and recommendations in a written report for submission to the court. In a case involving an adolescent, an expert witness frequently presents evidence on the appropriateness

of proposed placements, including residential treatment or group home settings, as well as a youth’s need for outpatient mental health services. The parties, in particular the child’s attorney, can ask the court to frame its orders to ensure the provision of services.

Foster care review/permanency hearing The federal laws cited above, as well as state laws, require courts to hold periodic reviews of the cases of children in foster care and other out-of-home placements. Under ASFA, there is a special type of foster care review hearing known as a permanency hearing. The primary purpose of the permanency hearing is to ensure that progress is being made in implementing one of the above-stated permanency plans. The underlying premise is that children and youth should not languish for years in state care, never knowing stability and nurturance in their lives. Judges must review these cases in a timely and expeditious manner. Even for the older adolescent, adoption may be the most appropriate plan (Elstein 1999). In addition to examining adolescents’ permanency planning options, courts must also assess the sufficiency of services offered the adolescent transitioning to adulthood. Too often, foster care youth – especially those with mental health problems – are pushed out of the child welfare system and not offered services (i.e., housing, work skills training, mental health counseling) that would allow them to more easily transition to adulthood. Under federal law, in cases involving youth aged sixteen years or over, courts are required to make a finding regarding the specific services needed for youth to transition from foster care to independent living. [42 U.S.C. §675(5)(C)]. Moreover, in December 1999, President Clinton signed the Foster Care Independence Act of 1999 into law [Pub. L. No. 106-169, 113 Stat. 1822 (codified at 42 U.S.C. §677)]. The Act has the potential to enhance significantly the provision of transitional living services, including health care benefits, to the estimated 20 000 young people aged between eighteen and twenty-one years who exit foster care each year (US Government Accounting Office 1999). It increases annual appropriations to the states and gives states the option of expanding Medicaid coverage to this population of young adults (English and Grasso 2000; Allen and Nixon 2000).

Parental rights termination/adoption If a child’s permanency plan is adoption, the court must first terminate parental rights. Termination of parental rights is more than a transfer of the child’s legal custody to another person. It is the severance of all ties the parents might have with the child, including the right to visit the child and make decisions about his or her care.

Dependency court: the handling of abuse and neglect cases 503

Because the loss to the parent is so great, the United States Supreme Court has ruled that the party moving to terminate parental rights has a heavy burden of proof and must prove by ‘clear and convincing evidence’ the stated legal grounds for termination [Santosky v. Kramer, 455 U.S. 745, 102 S.Ct. 1388, 71 L.Ed.2d 599 (1982)]. In most states, parents have the statutory right to be represented by an attorney in a parental rights termination proceeding. Both fathers and mothers generally have a right to be notified of these legal proceedings so that they can challenge the action if they so wish. Psychiatric and other expert testimony in these types of cases can be pivotal, especially as it relates to parental fitness and whether termination is in the child’s best interests. In ruling on whether to terminate a parent’s rights, the court is guided by state law that requires the court to make specific findings relevant to the parents’ ability to care for the child, as well as children’s ties to current custodians and community. Judges find that these decisions are among the hardest that they make. Once the court terminates parental rights, the child is free to be adopted. The adoption requires a distinct legal proceeding in which the court evaluates home studies and evidence relevant to the prospective adoptive parents’ ability to care for the child. In some states, the court must also inquire as to whether an older child legally ‘consents’ to the adoption. In addition, in some states, the court may have the option of ordering an ‘open’ adoption, which allows a child’s biological parents to have limited specified contact with him or her. Usually, a plan of ‘open’ adoption is proposed only if the prospective adoptive parents are in agreement. Mental health professionals should be aware that children with disabilities, including those with mental health problems, can be adopted if child welfare agencies identify prospective adoptive families and inform them of the possibilities of a ‘subsidized’ adoption. Such an adoption can ensure that adoptive parents receive some state financial support and medical assistance after the adoption has taken place.

ACKNOWLEDGMENTS This chapter was completed by the author under grant no. 5 U93 MC 00106-04 to the American Bar Association Center on Children and the Law from the U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Adolescent Health, Partners in Program Planning for Adolescent Health.

REFERENCES Allen, M., Nixon, R. The foster care independence act and John H. Chafee foster care independence program: new catalysts for reform for young people aging out of foster care. Clearinghouse Review 34: 197, 2000. Chernoff, R., Combs-Orme, T., Risley-Curtiss, C., Heisler, A. Assessing the health status of children entering foster care. Pediatrics 93: 594–601, 1994. Elstein, S. Teenagers are adoptable: strategies for success. ABA Child Law Practice 18: 49, 1999. English, A., Grasso, K. The foster care independence act of 1999: enhancing youth access to health care. Clearinghouse Review 34: 217, 2000. Halfon, N., Berkowitz, G., Klee, L. Mental health service utilization by children in foster care in California. Pediatrics 89: 1238–1244, 1992. McIntyre, A., Keesler, T. Psychological disorders among foster children. Journal of Clinical Child Psychology 15: 297–303, 1986. US Department of Health and Human Services. Adoption and Foster Care Analysis and Reporting Systems (AFCARS), The AFCARS Report 1 (Current Estimates as of October 2000) (visited May 15, 2001) . US Government Accounting Office. Foster Care: Effectiveness of Independent Living Services Unknown (GAO/HEHS-00-13) 4 (1999).

Index

AA see Alcoholics Anonymous AACAP see American Academy of Child and Adolescent Psychiatry AACP see American Academy of Child Psychiatry AAFS see American Academy of Forensic Sciences AAPCC see Association of Psychiatric Clinics for Children AAPL see American Academy of Psychiatry and the Law ABAP see American Board of Adolescent Psychiatry abduction 432 Abeloff, Jennifer 112–24 ABMS see American Board of Medical Specialties abortion 85, 425 ABPN see American Board of Psychiatry and Neurology abstinence 148, 466 abuse cases see also physical abuse; sex offenders; sexual abuse; substance abuse dependency court 499–503 access to services 218, 406 Accreditation Councils Fellowships in Adolescent Psychiatry (ACFAP) 76, 77, 78 Fellowships in Forensic Psychiatry 78–80 Graduate Medical Education (ACGME) 75, 76, 77–8 acculturation 33–4, 166–7, 238 ACFAP see Accreditation Council on Fellowships in Adolescent Psychiatry ACGME see Accreditation Council for Graduate Medical Education Ackerman, Nathan 209–10, 383–4 action-oriented interventions 358 activity therapy groups 391 actuarial assessment 471–2 adaptations 125–31, 398, 400 Adaptive Behavior scales 234 ADD see Attention Deficit Disorder ADHD see Attention Deficit Hyperactivity Disorder adjudicatory hearings 501–2 Adler, A. 390 adolescence concept 4, 68, 149, 155–6 adolescent turmoil 6–7, 27–8, 36, 69–70, 93, 343 adoption 500, 502–3 adult cognition 178

adult criminal justice system 453, 489–98 see also waivers adulthood 4–5 affect 288, 330–1 affective disorders 229, 377 African-Americans adolescents 33 HIV rates 96, 147 Major Depression 284 psychotherapy 240 values orientation 168 violence exposure 113 aggression see also Conduct Disorder; violent behavior aggressive patients 353 childhood 104 Cognitive Behavioral Therapy 362 drugs 465 passive-aggressive personality disorder 305 pharmacotherapy 318 psychopharmacology 378, 379 racism 32 Aichhorn, August 390, 391, 444, 457 AIDS 85, 90, 145, 146 see also HIV alcohol see also substance abuse abuse 101–3, 284, 328–9, 331, 465 alcoholism 103–4, 317, 329, 334, 466, 467 dependency 332 Alcoholics Anonymous (AA) 466 Alessi, Norman 397–8 alienation 6, 32–4, 104, 438 alliances 211, 312 see also therapeutic alliance AMA see American Medical Association amenorrhea 54, 299 American Academy of Child and Adolescent Psychiatry (AACAP) 13, 16, 71, 74, 77, 435 American Academy of Child Psychiatry (AACP) 70, 71 American Academy of Forensic Sciences (AAFS) 16–17, 419–20 American Academy of Pediatrics 12, 13 American Academy of Pediatrics v. Lungren (1977) 13

Index 505

American Academy of Psychiatry and the Law (AAPL) 11, 16, 419–20 American Board of Adolescent Psychiatry (ABAP) 71, 74–5, 76–7 American Board of Medical Specialties (ABMS) 73, 74, 75 American Board of Ophthalmology 73 American Board of Psychiatry and Neurology (ABPN) 71, 73, 74, 76–7, 419, 420 American Medical Association (AMA) 16, 19, 108, 496–7 American Orthopsychiatric Association (Ortho) 69, 70, 496 American Psychiatric Association (APA) see also Diagnostic and Statistical Manual of Mental Disorders conservatism 69 Continuing Medical Education 77 ethical guidelines 16, 19 forensic evaluation 435, 496–7 Model Law 10 Opinions 19 testing the physically impaired 235 American Society for Adolescent Psychiatry (ASAP) 16, 70–2, 76, 77, 496 amicus curiae brief 496 Anderson, Martin M. 51–67 Anderson, Tanya R. 237–42 anomic suicide 9 anomie 6, 7, 8 anorexia nervosa 7–9, 98, 295–7, 299 see also eating disorders anti-androgens 485–6 anticonvulsants 291–2 antidepressants 272, 281, 289–90, 318, 321–2 tricyclic 290, 321–2, 375 antipsychotics 344, 375, 378 Antisocial Personality Disorder 307, 315, 317 anxiety disorders 278–83 ADHD 321 group therapy 394 juvenile offenders 456 psychopharmacology 377, 378, 380 substance abuse 105–6, 331 APA see American Psychiatric Association Aries, Philippe 4, 68 Armed Services Vocational Aptitude Battery 245 arrest rates 446, 489–90 Asian adolescents 33 Asperger’s disorder 258, 259, 261 aspiration disorders 9 aspirational ethics 12 assent see informed consent assessment adolescent pregnancy and parenting 139–40 biological 226–30 clinical interviews 201–6

Cognitive Behavioral Therapy 362–3 criminal competency 451 cultural 237–42 eating disorders 298–9 educational 243–7 family 207–14 homosexuality issues 159–60 introduction 200 juvenile offenders 456, 483–4 juvenile sexual offenders 483–4 medical 221–5 moral development 189 personality functioning 232, 233 Pervasive Developmental Disorders 259–60 psychological 231–6 psychosocial 215–20 psychotic disorders 343–4 risk behaviors 97 sexual offenders 483–4 substance abuse 331–2 treatment planning 248–54 violence risk 470–81 assimilation 167, 172, 238 Association of Psychiatric Clinics for Children (AAPCC) 7077 asymptomatic STIs 57–8 Atkins v. Virginia (2002) 497 attachment 312 attachment theory 459 Attention Deficit Disorder (ADD) 20, 97 Attention Deficit Hyperactivity Disorder (ADHD) 320–3 anxiety disorders 278, 280 Bipolar Disorder 285 brain imaging research 228–9 Cognitive Behavioral Therapy 360, 362 Conduct Disorder 316 disruptive disorders 315 juvenile offenders 456 managed care 20 Oppositional Defiant Disorder 319 pharmacotherapy 271, 272 post-traumatic stress disorder 41 psychopharmacology 374–6 sexual offenders 482, 484 substance abuse 105, 331 Teacher and Parent Rating Scales 246 tic disorders 266, 271 violence risk 473 authentic educational assessments 244–5 authority 185, 500–3 autism 228, 257, 259, 260, 266 see also Pervasive Developmental Disorders autonomous justice 181 autonomy 20, 32–3, 89, 134, 319 avoidance 40 Avoidant Disorder of Childhood 278

506 Index

Axis diagnoses see diagnosis, Axis… Azima, F.J.C. 393–4 Baker, D.G. 94 Bandura, A. 180, 358 Barkley, R. 360 BASC see Behavioral Assessment System for Children Bates, Marsha E. 328–40 Bateson, G. 384 Beavers family model 207 Beck, A.T. 278, 357, 358 Beck Depression Scale 97, 287 Becker, J.V. 485 Beer, Douglas A. 265–77 Beers, Clifford 69 behavior modification 148–50, 457–8 Behavioral Assessment System for Children (BASC) 202, 246 behavioral disorders 307, 378–80 behavioral therapy 268–9, 299–300, 310–11, 388 beneficence principle 20 benzodiazepines 281–2 Berkeley study 28 Berman, Sidney 70 Bernfield, S.S. 8 beta-blockers 379 bi-cultural socialization 167 Billick, Stephen 180–92 Binder, A. 443 binging 102, 295–6 bioethics 12, 20 biologic psychiatry 71–2 biological assessment 226–30, 298–9 factors 94, 157, 287–8, 316, 329 treatments 298–9, 330, 333, 485 Bion, W.R. 391 biopsychosocial perspective 94 bipolar disorders 285, 316, 321, 341–2, 456 bisexuality 156 blended jurisdiction 447, 493 Blos, P. 4, 6, 390 Blumenthal, S.J. 29 body appearance 88–9 see also eating disorders Bond, M. 353 boot camps 118, 460 borderline patients, therapeutic alliance 353 Borderline Personality Disorder 47, 127, 304, 305, 307, 456 Bowen, M. 385 boys 86–7, 88, 316, 446 see also males Boys and Girls Club 108 brain 185, 320, 341 imaging 175–6, 227–9, 233–4, 278–9, 342 see also individual techniques

Bravo, M. 239 Breed v. Jones (1975) 445 Brent, D.A. 39 Brigance Inventory of Essential Skills 244 Brown, Larry K. 132–44 Brown, Murray 384 Brown and Ponton Risk Assessment 97 Bruch, Hilde 297, 300 bulimia nervosa 8, 295–6, 299, 331 Buros Institute of Mental Measurements 247 California Achievement Test (CAT) 244 Canino, G. 239 Canino, Ian A. 165–70 CAPA see Child and Adolescent Psychiatric Assessment cardiac evaluation 224 cardiovascular complications, eating disorders 53 care continuity of 308 morality of 184 see also treatment Carnegie Council on Adolescent Development 76 case history taking, cultural assessment 237 CAT see California Achievement Test; Children’s Apperception Test CBT see Cognitive Behavioral Therapy CD see Conduct Disorder chancroid 59 Chatlos, J.C. 103 chest pain 61 Chicago, Illinois delinquents study 68–9 Child and Adolescent Mobile Team 404–5 Child and Adolescent Psychiatric Assessment (CAPA) 201 Child Behavior Checklist 202, 204, 234, 317 Child Guidance Movement 69, 70, 71, 383, 443–4 child psychiatry 70–1, 150 child-snatching 432 Childhood Disintegrative Disorder 257–8, 259, 260, 261, 262 children aggression 104 authority responses 185 childhood concept 4, 68 Conduct Disorder onset 315 dependency court 499–503 depression diagnosis 287 ethnic orientation 166 family assessment participation 210 fathers 196 in foster care 499–500, 502 as moral philosophers 182–3 mothers 135, 137, 195–6 in need of supervision 447 neglect laws 426 Obsessive–Compulsive Disorder 266 physical abuse 115

Index 507

sexual abuse 125, 126–9 sexual development 85–6 suicide 287 welfare system 499–503 Children’s Apperception Test (CAT) 233 Children’s Depression Inventory 287 CHINS see children in need of supervision chlamydia 58, 146 chronic fatigue 62, 64 Church, J. 68 civil commitment 13–14, 425–6, 451 Clawson, Lance D. 403–9 clinical interviews 201–6, 332 cultural assessment 239 clinical notes 49 clinical presentations 257–64, 265–6 closing 205–6, 212–13 Codes of conduct 16–17 see also ethical guidelines cognition Conduct Disorder 316 deficiencies 358 development 69, 134, 171–9, 181 distortions 357–8 emotional disorders 357 insanity defense 452–3 re-attributions 360 restructuring 360–1, 485 cognitive approaches, juvenile offender treatment 458 cognitive behavioral approaches 71 anxiety disorders 278, 282 Conduct Disorder 317 family therapy 388 group therapy 394 sexual offenders 484 Twelve-Step programs 467 Cognitive Behavioral Therapy (CBT) 268–9, 292, 299–300, 334, 357–65 Cohen, P.R. 106 collateral information 202–3, 238 coming out 158, 195 commitment, civil 13–14, 425–6 Committee on Bioethics of the American Academy of Pediatrics 12 communication assessments 210, 222 autism 257 barriers 204–5 clarification 385 double bind 342, 384 community death penalty eligibility 496 factors 115–16, 168, 238, 496 sanctioned violence 120 community-based treatment 403–9 homosexuality resources 161 juvenile delinquency 446, 447, 458

multisystemic therapy 415, 458 personality disorder 311 pervasive developmental disorders 261 psychosocial assessment 215–16 substance abuse prevention 107–8 violent behavior 115–16, 117 competence 171 competency for trial 445, 450–2, 496–7 compliance 65, 240 Comprehensive Test of Nonverbal intelligence 233 compulsive behavior 379 computed tomography (CT) 227, 233, 260 computer use 217 concrete operations stage 173, 174, 175, 176, 181 concurrent jurisdiction 491 condom use 95, 146, 148, 150 Conduct Disorder (CD) 315–16 juvenile offenders 456, 457, 465 personality disorders 304 psychopharmacology 376 sexual offenders 482, 483 substance abuse 105, 331 confidentiality see also disclosure child abuse 14 clinical interviews 204 court records 445, 446, 492 ethical issues 10–11 legal issues 426–8 legal rights 424 limits 204 managed care 23 medical assessment 223 medical records 427 multimodal dynamic psychotherapy 413 psychoanalytically informed psychotherapy 368–9 substance abuse treatment 332 therapeutic alliance 351, 353 Conners, C.K. 317, 321 Conners Rating Scales 97, 234, 246, 321 conscience 181, 185–6, 187–8 consent see informed consent; parental consent; treatment consent consequentialist ethics 12 conservation principle 174 consolidation stage 351–2 consultant-liaison psychiatry 45–50 contraception 54–7, 58, 64, 95, 133 contracts 183, 349, 466 control, personality disorder treatment 308, 313 control theories, violence 114 conventional morality stage 182, 184 conventionality, substance abuse 104 costs see financial restraints court records 492 covert techniques 361 criminal behavior, violence assessment 472–3

508 Index

criminal responsibility 443, 451, 452–3 criminalization of juvenile courts 444 crisis stabilization 398, 399, 401 criterion-referenced educational tests 243 crowds 194–5 CT see computed tomography cultural assessment 237–42 cultural factors adolescent development 31–5 adolescent mothers 134–5 diagnosis 40, 240, 241 psychological assessment 234–5 STD/HIV epidemic 147–8 substance abuse 331 treatment effects 31–5 cultural psychology 187 culture-bound syndromes 240 Cummings, S.R. 26–30 curricula 79, 420 custody (post-divorce) 430, 431–2, 436–8 dangerousness 470 Darwin, Charles 68, 278 dating 193, 195 Dattilio, F. 388 De Bellis, M.D. 39 death 49 penalty 15–16, 495–9 see also homicide decalage 174 decentration stage 173–4 defenses, tickling the 210 deficiencies, cognitive 358 degenerative diseases 62 deinstitutionalization 446, 447, 457 delinquency see juvenile delinquency; juvenile justice system dementia infantilis 257–8, 259, 260, 261, 262 deontological ethics 12 Department of Justice 420 Department of Juvenile Justice 404 dependency court system 499–503 dependent youth 423–4 Depo-Provera 54, 133 depression ADHD 321 adolescent parents 136, 137 Cognitive Behavioral Therapy 362 Conduct Disorder 316 contraception 56–7 group cognitive behavioral approach 394 Major Depressive Disorder 284–94, 331 post-partum 136–7 post-traumatic stress disorder 40–1 research 27 sexual abuse 129 substance abuse 105

suicide 7, 46 violence 115 Depression Inventory 405 desipramine 322 detention, secure 446 Deutsch, Helene 297 development see normal development; sexual development Development Language Disorders 259 Development Test of Visual-Motor Integration 234 developmental disorders 228, 376 developmental history 226 developmental perspective, psychopharmacology 373 Dewey, John 243 diagnosis see also Diagnostic and Statistical Manual of Mental Disorders; differential diagnosis Attention Deficit Hyperactivity Disorder 320 Axis I 249, 250, 251–2 Axis II 249, 250, 252 Axis III 221, 249, 250, 252 Axis IV 218, 249, 250, 252 Axis V 218, 250 Conduct Disorder 315–16 cultural assessment 240 depression 287 differential 40–1, 63, 259–61, 288 multimodal dynamic psychotherapy 411 personality disorders 304–5 post-traumatic stress disorder 39–42 psychological assessment 232 psychotic disorders 343–4 treatment planning 249–50 Diagnostic Interview for Children and Adolescents (DICA) 201 Diagnostic Interview Schedule for Children (DISC) 201, 319 diagnostic interviews 201, 209–10, 319 Diagnostic and Statistical Manual of Mental Disorders (DSM-III) 304, 305, 465 Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) see also diagnosis, Axis I–V alcohol dependence 332 anorexia nervosa 295 anxiety disorders 278 Asperger’s disorder 258 Attention Deficit Hyperactivity Disorder 320 binge eating 295–6 bipolar disorders 285 borderline Personality Disorder 305 bulimia nervosa 295 Childhood Disintegrative Disorder 258 Conduct Disorder 105, 315 cultural assessment 240, 241 culture-bound syndromes 240 depressive disorders 285 disruptive behavior disorders 315

Index 509

ethnic considerations 240 general medical condition 221 Generalized Anxiety Disorder 279 Major Depressive Disorder 285–6 Mathematics Disorder 244 mood disorders 285 observation and report basis 231 Obsessive–Compulsive Disorder 265 Oppositional Defiant Disorder 318 Panic Disorder 279 paraphilia 483 personality disorders 304–5, 307 Pervasive Developmental Disorder 257 post-traumatic stress disorder 36, 39–40 psychological assessment 232, 234 psychosocial factors in diagnosis 218 Reading Disorder diagnosis 244 Rett’s disorder 258 schizophrenia 341 Separation Anxiety Disorder 279 Social and Occupational Functioning Assessment Scale 218 Social Phobia 280 Specific Phobia 280 substance abuse 102–3 Tourette’s Syndrome 265 treatment planning 248, 249–50 Dialectical Behavior Therapy 360 DICA see Diagnostic Interview for Children and Adolescents DiClemente, Ralph J. 93–100, 101–11, 145–54 Didactic Core Curriculum 79 diet 320, 322 dieting 296, 300 differential diagnoses 40–1, 63, 259–61, 288 directives 387–8 disagreement management 211–12 disasters 38 DISC see Diagnostic Interview Schedule for Children disclosure 22, 126, 158, 160, 427–8 see also confidentiality discretion, prosecutorial 491 discrimination 20, 238 see also racism disordered eating 295–302 disorders of aspiration 9 dispositions 444, 446, 460, 501–2 disruptive behavior disorders 315–27 distortions, cognitive 357–8 divorce, legal issues 430–9 DNA evidence 497–8 doctor-patient relationship 23–4, 49 Doctors, Shelley R. 366–72 domain theory 184–5 dopamine 270, 271 double bind communication 342, 384 double jeopardy 445

Drug Abuse Resistance Education 335 Drug Use Inventory – Revised 106 drugs see also substance abuse abuse 7, 415, 446, 466 drug courts 460, 468 interactions of medical 64 legal 329 risk behavior 95 trafficking 465, 489 use 104, 106, 328 DSM-III see Diagnostic and Statistical Manual of Mental Disorders (DSM-III) DSM-IV see Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) due process 444–5, 447 Dulit, Everett P. 45–50 Durkheim, Émile 6, 7, 8, 9 Dusky v. United States (1960) 445, 450, 451, 452 dyad, therapist–patient 367 dying 49 dysfunction, sexual 89–90, 380 Early Assessment Risk Lists 471 eating disorders 52–3, 295–302 anorexia nervosa 7, 8, 9, 98, 295–7, 299 binge eating 295–6 bulimia nervosa 8, 295–6, 299, 331 prevention programs 96 sexual abuse 127 sexual development 89 sports involvement 217 ecological model of behavior 404 ecologies, cultural 31 economic conditions see socio-economic factors ECT see electroshock therapy education see also schools in adolescent psychiatry 76–81 assessment 243–7 depressive disorders treatment 288–9 moral development 180 normal development 159, 168–9 psychoeducational family therapy 388 sex education 88, 89, 96, 485 sexual abuse prevention 129–30 sexual offenders 485 substance abuse 334, 466 testing 243–4, 247 violent behavior prevention 116–17 Education of all Handicapped Children Act 245 Education Resource Information Center 247 Educational Testing Service 247 educators as resources 246 EEG see electroencephalographic monitoring efficacy research 26–7 ego ideal 186–7

510 Index

ego psychology 187, 383, 391 ego-dystonic symptoms 384 ego-syntonic symptoms 384, 398 egocentrism 174, 177 ejaculation 86, 89 electroencephalographic (EEG) monitoring 175–6, 226–7, 233, 260 electrolytes 53 electroshock therapy (ECT) 426 Elkind, D. 177 Elliot, D. 472–3 Elliott, Alan S. 231–6 Elliott, Glen R. 373–82 Ellis, A. 357–8 emancipation statutes 424 emotional autonomy 89 emotions 184, 186, 342, 388, 401 enculturation process 166–7 endocrine system 53 engagement 308, 312 English, Abigail 423–9 environmental factors 157, 330, 342 environmental interventions 119–20, 322 epidemiology adolescent turmoil 28 alcohol and substance abuse 101–2 anxiety disorders 279 autism 259 depressive disorders 284 eating disorders 296–7 Obsessive–Compulsive Disorder 267 Oppositional Defiant Disorder 319 personality disorder 303–4 post-traumatic stress disorder 36–7 risk-taking 94–6 STDs 146–7 substance abuse 328–9 theory-free 7 Tourette’s Syndrome 267 violence 113–14 epoch-dependent syndromes 7 Epstein, Nathan 207 equilibrium 28, 93, 172 erectile dysfunction 89 Erikson, Erik 4, 6, 69, 167, 390 eroticism 87–8, 89–90 ethics 10–18, 19–25 see also confidentiality; moral development; morality forensic psychiatry 419, 496–7 universal 183 violent patients 119 ethnic groups alienation 32–4 development 166–7 diagnosis considerations 240 educational success 168 ethnic identity 166–7

family support 168 mental health service utilization 34 motherhood and pregnancy 132, 133, 134–5 sexual intercourse 156 socialization 168 substance use 107, 328 violent behavior 115–16 etiology anxiety disorders 278 Attention Deficit Hyperactivity Disorder 320–1 autism 260 Conduct Disorder 316 homosexuality 157 mood disorders 286–7 Obsessive–Compulsive Disorder 267–8 Oppositional Defiant Disorder 319 post-traumatic stress disorder 37–9 substance abuse 103–4, 329 Tourette’s Syndrome 267–8 evaluations clinical in juvenile justice system 450–5 forensic 11, 15–16, 435, 450–5 laboratory 224–5, 332, 344 evolutionary psychology 187 exclusive parenting time 432 execution (death penalty) 15–16, 496–7 expectancy, substance abuse 330–1 expectations 8 experience clinical training 77, 79 cognitive development 171, 181 experiential family therapy 385 expert witness 419, 454 exposure with response prevention treatment 268–9 expressed emotion 342, 388, 401 fact witnesses 419 fairness 180 false self 307 family see also parent… addiction liability 103–4 adolescent mothers support 134–5 alliances and coalitions 211 assessment 207–14, 223 clinical interview involvement 203–4, 205–6 Cognitive Behavioral Therapy 362 Conduct Disorder 316–17 Conner’s Rating Scales 234 criminality 474 depression 292 developmental life cycle 208 discipline and violence risk 474 dynamics 223 ethnic socialization support 168 function models 207–8 high-risk 117

Index 511

histories 212, 226, 237–8 homosexuality support 158, 159, 160–1 immigration history 237–8 inpatient treatment 399, 400–1 medical assessment 223 moral development 183, 187–8 multimodal dynamic psychotherapy 412–14 normal development 168 paradigm model 208 parent relations 193–4 personality disorder 309 psychoanalytically informed psychotherapy 368 role assignment 212 sexual development 86, 89–90 styles 386 substance abuse 103–4, 107, 331, 384 therapeutic alliance 351, 354–5 violence 113–14, 115, 117, 119–20 family therapy 71, 383–9 ADHD 322 anxiety disorders 282 Conduct Disorder 317 eating disorders 300 juvenile offenders 459 Oppositional Defiant Disorder 319 personality disorders 310 risk behaviors 98 sexual offenders 485 substance abuse 107, 333, 466 fatherhood 135–6, 137–8, 196, 431–3 fatigue 62, 63, 64 fear 89, 278 feet 62 Feinstein, Sherman F. 70, 71, 353 females see also sexual abuse depressive illness 284 HIV trends 96 juvenile offenders 446, 460 moral development 183–4 post-traumatic stress disorder 38 sexual development 87, 88, 89 Ferenczi, S. 392 financial constraints 17, 22–3, 72, 390, 397 firearms availability 95 gun laws 116, 120 homicide 113, 115, 489 suicide method 284 Fitch, W.L. 447 Flaherty, Lois T. 341–5 focal assessment techniques 231 folk medicine see traditional medicine forensic psychiatry 418 criminal competency assessment 451 death penalty evaluations 15–16 ethics 419

post-divorce 434–6 slippage 11 training 419–20 formal operations stage 173, 174–5, 176–7 foster care 499–500, 502 Fountain, G. 178 Fragile-X syndrome 260, 261, 321 Freud, Anna adolescent turmoil 28, 69, 70, 93, 343 delinquency treatment 457 discovery of adolescence 4 parent involvement 369 treatment of adolescents 367, 457 Freud, Sigmund anxiety 278 delinquency treatment influence 443, 444 Dora 367 medicopsychology 6 Oedipus complex 181, 186 superego 181, 183 The Individual Delinquent 69 Three Essays on the Theory of Sexuality 4 Friedman, R. 403 friendship 194 Furman v. Georgia (1972) 495 GAF see global assessment of functioning Galatzer-Levy, R. 367, 436 Gallagher, Richard 248–54 gangs 117 GAP see Group for the Advancement of Psychiatry Garcia Preto, N. 208 Gardner, G. 28 Gardner, H.M. 299–300 Gardner, R.A. 438 Garfinkel, P.E. 8 Garner, D.M. 8 gastrointestinal complications 53 Gateway Theory 104 gays see homosexuality Geller, B. 281 gender 88, 156 General Systems Theory (GST) 391 general violence 470 Generalized Anxiety Disorder 278, 279–80, 281 genetic diseases 62 genetic factors ADHD 322 autism 260–1 biological assessment 226 Conduct Disorder 316 Major Depression Disorder 287 mood disorders 292–3 Obsessive–Compulsive Disorder 267 psychotic disorders 342 risk behavior 94 substance abuse 103, 329

512 Index

genitals 58, 59, 88, 224 genograms 211, 213 Ghuman, Harinder S. 257–64, 403–9 Ghuman, Jaswinder K. 257–64 Giles, H. 166 Gilligan, C. 89, 183, 184 Giovacchini, Peter 71 girls see females Gitelson, Maxwell 69 global assessment of functioning (GAF) 250, 252 Godenne, Ghislaine D. 349–56, 413 Goldberg, A.A. 367 gonorrhea 57–8, 95, 146 Gonsiorek, J.C. 158 Gonzalez, Nilda M. 165–70 Gosselin, Gary J. 200, 201–6, 215–20 Governor of Illinois 497 granuloma inguinale 59 Green, A.H. 125, 127 Greenbaum, P.E. 105 Grisso, T. 497 Group for the Advancement of Psychiatry (GAP) 69 group homes, juvenile offenders 460 group therapy anxiety disorders 282 Cognitive Behavioral Therapy 362 delinquency treatment 444 multimodal dynamic psychotherapy 414–15 personality disorders 309 post-traumatic stress disorder 41 professional organizations 71 psychotherapy 309, 390–6, 414–15 sexual offenders 484 substance abuse 333–4 group-administered standardized educational tests 244 groups, specialty 392–3 growth and development 51–2, 224 GST see General Systems Theory guidelines, family assessment 208–9 Gular, Enrique 231–6 guns see firearms Gurman, A.S. 383 Hague Conference on Private International Law 432 Hague Convention on the Civil Aspects of International Child Abduction 432 Halamandaris, Phill V. 237–42 Haley, Jay 384, 387 Halikas, J.A. 465 Hall, G. Stanley 4, 27, 68, 93 Haller, Lee 456–62 hallucinogens 95, 101, 102 Hanson, Graeme 125–31 harm, risk of 398, 427–8 Harper, G. 401 Harrington, Martin J. 193–8 Hawaii 447

Hawthorne, Nathaniel 446 head and neck medical review 224 headaches 59–61 Health Insurance Portability and Accountability Act 427 Health Maintenance Organizations (HMOs) 19 Healy, William 68–9, 443–4 Hegel, Georg Wilhelm Friedrich 6 Heilbrun, K. 451 Heinz dilemma 182 Heller, T. 257–8 hematology, eating disorders 53 Hendren, Robert L. 315–27, 328–40 Henggeler, S.W. 458, 468 heritability, anxiety disorders 279 herpes simplex II 58 heteronomous morality 181, 182 Hippocrates 19, 20 Hirsch, Glenn S. 248–54 Hispanic Americans 33, 134–5 history of adolescent psychiatry 68–72 HIV 59, 95, 96, 133, 145–54 HMOs see Health Maintenance Organizations Hoffman, M.L. 186 Hofmann, A.D. 156 Hoge, S.K. 451 Hoggart, Richard 4–5 Holmes, W.D. 27 home layout description 211 homicide arrests 489–90 by girls 460 firearms 113, 115, 489 increase 95 mass murder 446 homosexuality 155–62, 195, 297 honest look contract 466 Horowitz, M.J. 39 Horowitz model of post-traumatic stress disorder 39 hospitalization 46, 298, 398, 399–401, 426 see also inpatient treatment Howard, K.I. 26 Hulley, S.B. 26 human ecologies 31 human immunodeficiency virus see HIV hyperarousal 40 hyperventilation 61 identity adolescent mothers 134 confusion 392 crisis vs. diffusion 167 dating 195 disorder 304 educational assessments 246 ethnic 166–7 formation 391

Index 513

gender 156 homosexual 156, 157 risk-taking 93 role identity 392 secure 6 sexual 4, 156, 157 IEP see Individualized Education Program Igra, V. 94 immigrant groups 33–4, 237–8 see also ethnic groups implied consent 424 impulsivity 359, 452, 473 in camera proceedings 434 in limine orders 434 In Re Causey 445 In Re C.W.M., District of Columbia 445 In Re Gault 15, 444–5, 492 In Re Roger S. 14 In Re Winburn 445 In Re Winship 445, 492 incarceration 446 incest 125, 126, 127, 129 see also sexual abuse indications brain imaging 227–8 family therapy 384 group psychotherapy 393 psychoanalysis 367–8 The Individual Delinquent 69 Individualized Education Program (IEP) 245 Individuals with Disabilities Education Act 245 induction 187, 188 information-processing theories 171, 175–8 informed consent 12–13, 20–1, 47–8, 424 see also parental consent; treatment consent inhalant use 95, 328 initiation rites 5 injuries, sports 61–2 Innocence Project 497 inpatient treatment 397–402 see also hospitalization eating disorders 298 legal issues 423–9 personality disorders 298, 309 substance abuse 333 insanity defense 16, 445, 450, 452–3 insight-oriented family therapy 385–6 instrumental relativist orientation 182 insurance 26, 248, 427 integration and commitment model 156 intellectual functioning assessment 232–3 intelligence scales 232, 233, 240, 257 intent 452 interference, managed care 23–4 intergenerational cultural issues 238 international custody and access (post-divorce) 432 International Society for Adolescent Psychiatry 71

Internet 420, 498 interpersonal concordance 182 problem-solving 361 relationships 193–8 sphere 412 interpersonal psychotherapy for depressed adolescents (ITP-A) 292 interpersonal therapy (ITP) 299–300 interpretation 231 interventions see also school-based interventions action-oriented 358 eating disorders 300 legal authority 500–3 moral development 189 multimodal dynamic psychotherapy 412–13 parenting 137–8 pregnancy 96, 137–8, 140 sexual abuse 129 sexual behavior modification 148–50 violent behavior 112, 117, 118–20 interviews 201–6, 209–10, 319 intimacy 89, 195 intrapsychic sphere 412 intrusive phenomena 40, 41 investigational treatment 272–3 irresistible impulse 452 Irwin, C.E. 93, 94 Island Youth Program 458 ITP see interpersonal therapy ITP-A see interpersonal psychotherapy for depressed adolescents Jackson, D.D. 384 Jackson v. Indiana (1972) 451 Jaffe, Steven L. 465–9 Jani, Sushma 278–83 Japanese-Americans 168 Jessor, R. 94 Johns Hopkins Depression checklist for children 287 Johnson, P. 166 joining process 386 Joint Commission on the Accreditation of Healthcare Organizations 248 joint custody 431–2 Jones, Ernest 69, 93 Joshi, Paramjit T. 284–94 Judge Baker Foundation 69 jurisdiction 491, 493 jury trial 492 ‘Just Say No’ campaign 94 justice concept 20, 180, 181, 183, 184 Justice Project 498 Juvenile Assessment Centers 466 Juvenile Court Act (1899) 443

514 Index

juvenile delinquency 20th century concept 68–9 Conduct Disorder 316 violence assessment 470–81 Juvenile Justice and Delinquency Prevention Act (1974) 446, 447 juvenile justice system 418–19, 443–9 dependency courts 499–503 insanity defense 452–3 justification questions 490 juvenile courts 415, 443–7, 460, 468 juvenile drug courts 460, 468 multimodal dynamic psychotherapy 415 psychiatrist involvement 450–5 sexual offenders treatment 482–8 state custody 423–4 status offenders 424, 446, 447, 449 treatment of offenders 404, 456–62 Kagan, J. 186, 279 Kaggwa, Esther 112–24 Kalafat, J. 29 Kalogerakis, Michael G. 348, 410–16 Kandel, D.B. 103 Kanner, L. 257 Kaplan, H.I. 349 Karitani, Mai 265–77 Kauai Longitudinal Study 159 Kaufman Test 244 Kazdin, A.E. 393 Kelly, George 357 Kendall, P.C. 280 Keniston, K. 68 Kent v. United States (1966) 444, 445, 492, 493 Kernberg, O.F. 305, 306, 309 Key Math test 244 Kiddie Schedule for Affective Disorders and Schizophrenia 287 Klein, R. 304, 307 Kleinman, A. 239 Klerman, G. 7 knowledge units 175 Kochanska, G. 188 Kohlberg, L. 182–3, 184, 186, 188 Kohut, Heinz 305, 306–7 Kovacs, M. 287, 316 Kratochvil, Christopher J. 193–8 Krupnick, J.L. 349 Kuder Interest Inventories 245 Kupfer, D.J. 29 Kymiss, Paul 390–6 laboratory evaluations 224–5, 332, 344 Lambda Youth Network 160, 161 language 32–3, 173, 238 Latino Americans 167 law and order orientation 182

Lazarus, Jeremy A. 19–25 learning theory 39, 388 Leff, J. 388 legal authority to intervene, dependency court 500–3 legal drug use 329 legal issues, inpatient/outpatient treatment 423–9 legal proceedings involvement, patients 218, 249 legal rights of minors 424 legal status of adolescents 423–4 legislation adolescent psychiatrists 11–12 child abuse 14–15 child neglect 426 informed consent 12–13 introduction to adolescents and the law 418–20 substance abuse prevention 108 legislative enactment, transfer of juveniles to adult courts 491 leisure activities 217, 224 Leiter International Performance Scale (LIPS) 233 Leonard, Henrietta L. 265–77 Leong, Gregory B. 10–18, 31–5 lesbians see homosexuality Levy, R.J. 436, 437 Levy-Warren, M. 367, 369 Lewis, O. 413 liabilities to addiction 103–4 life cycle, family developmental 208 life skills training 116 lifestyles, risk behavior 94 Linehan, M. 360 LIPS see Leiter International Performance Scale literature, 19th century 5–6 Lithium 291, 318 Lock, J. 297 locus of control 168 Loevinger, J. 187 Lorand, Sandor 349 Lourie, Kevin J. 132–44 love withdrawal 187, 188 LSD use 95 Lubit, Roy 180–92 Lucas, A.F. 296–7 Lucas, A.R. 297 Luria, A.R. 358 lymphogranuloma venereum 59 MacArthur Foundation 451 McCracken, J.T. 286 McIver v. Pennsylvania (1971) 445 McMaster family model 207 Madanes, Cloe 384, 387 magnetic resonance imaging (MRI) biological assessment 227 cognitive development 175–6 competence for death penalty 497 eating disorders 298

Index 515

pervasive development disorders 260 psychological assessment 233 Social Phobia 278–9 magnetic resonance spectroscopy 175–6 Mainzer, Edward A. 243–7 Major Depressive Disorder (MDD) 284–94, 331 see also depression majority, age of 13 males boys 86–7, 88, 316, 446 eating disorders 297 moral development 183–4 protracted adolescence 8 sexual abuse 129 sexual development changes 88–9 suicide trends 284 malingering 453–4 Malmquist, Carl P. 489–94 malpractice, medical 419 man-made disasters 38 managed care 19–25, 72 mandatory disclosure 428 Manhattan cocktail 432 mania 285 manic-depressive illness 341 manualized treatments 391, 392 marijuana 95, 101, 102, 104 marital wrong 431 Marohn, R. 367–8, 370–1 marriage see also divorce teenage mothers 132–3 Marx, Karl 6 mass media 116, 217, 335 mass murder 446 Massachusetts Youth Screening Instrument 457 Masterson, James F. 69–70, 304, 307, 349 masturbation 86, 87–8, 258, 484–5 MAT see Metropolitan Achievement Test Mathematics Disorder 244 mature minors doctrine 424–5 MDD see Major Depressive Disorder medication see also pharmacology; psychopharmacology anxiety disorders 281–2 commonly used 374, 375 competence for execution 496–7 post-traumatic stress disorder 41 psychotic disorders 47, 344 medicine assessment 221–5 emancipation statutes 424 ethics 11–12 expertise 49 informed consent 13 malpractice suits 419 medical history taking 222–3

medical records confidentiality 427 principles of adolescent 51–67 privacy regulations 427 specialties 73 subspecialties 73–4 Meeks, John E. 355 Meichenbaum, D. 358, 359 Meissner, Donald 112–24 melancholy 7 menarche 87 menstruation 54, 87 mental health foster care children 499–500 services 24–5, 34, 403, 404, 406–8 see also community-based treatment mental illness 97–8, 238, 451, 452–3, 496 Mental Measurement Yearbooks 247 mental retardation 497 Metropolitan Achievement Test (MAT) 244 Mexican-Americans 31–2, 33, 166, 168 migraine 60, 61, 321 Miller, Arthur 71 Millon Adolescent Personality Inventory (MAPI) 453 Minnesota Multiphasic Personality Inventory (MMPI) 233, 453–4, 470 minority groups see ethnic groups minors legal status 423–4 treatment consent 424–5, 426 Minuchin, Salvador 384, 386 Mirtazapine 290 MMPI see Minnesota Multiphasic Personality Inventory M’Naghten insanity defense 16 model curriculum, forensic 420 modification of behavior 148–50, 457–8 Modified Overt Aggression Scale 317 modifying factors, post-traumatic stress disorder 37–8 Monitoring the Future Survey 101, 328 monoamines 260, 290 mood disorders 284–94 mood disturbance treatment plan 252 mood stabilizers 291–2, 375, 379 Moore, J. 447 moral development 180–92 moral domain 184 morality 181, 182, 183, 184, 431 Moreno, J. 390 Moretti, M.M. 459 Morris, R. 51–67 mortality 93, 145 Mossman, D. 94 mothers see also parenthood; pregnancy adolescent 132–7, 195–6, 431 motoric hyperactivity 378, 379 MPPI see Millon Adolescent Personality Inventory MRI see magnetic resonance imaging

516 Index

MST see Multi-Systemic Therapy Mullen, David 315–27 multi-system treatment program, substance abusing offenders 465 Multi-Systemic Interventions (MSI) 117, 118–19 Multi-Systemic Therapy (MST) 403–4, 415, 457–8, 468 multimodal dynamic psychotherapy 410–16 multiple agency problems 11–12 murder see also homicide mass 446 Myers, Wade C. 443–9, 456 NA see Narcotics Anonymous Naidu, S. 258 Nair, Mohan 36–44 Narcissistic Personality Disorder 304, 305, 306–7 Narcotics Anonymous (NA) 466 Nass, G. 195 National Assembly on School-Based Health Care 406, 407 National Center for Health Statistics 28–9 National Center for Juvenile Justice 446 National Committee for Mental Hygiene 69 National Criminal Justice Reference Service 498 Native Americans 32, 168, 331 natural disasters 38 neck and head 224 Nefazodone 290 neglect cases, dependency court 499–503 Neigher, W.D. 29 neonatal sequelae 133 network therapy 414 neuroleptics 270–1 neurologic examination 53, 224 neuropeptides 260 neuropsychology 233–4, 329–30 neurotic adolescents 367 neutrality 309, 313 Ng, Yiu Kee 201–6, 215–20 Nietzsche, Friedrich 6 night cramps 61 Noller, P. 193 noncompliance 65 non-maleficence principle 20 noncustodial parents 209, 432–3, 435, 438–9 nonverbal techniques 361 norm-referenced educational tests 243 normal development cognitive 134, 171–9, 181 cultural variation 31–2 interpersonal relationships 193–8 moral development 180–92 physical 51–2 sexual 85–92, 159 sexual abuse effects 125–31 sociocultural issues 165–70

normative crises 69 ‘not criminally responsible’ 452 ‘not guilty by reason of insanity’ 452 notes 49, 253 novels 5–6 numbing 40 Nutbeam, D. 94 Nye, Sandra G. 430–9 Oberfield, Richard A. 207–14, 383–9 obesity 296 object relations theory 306, 307 observations, family assessment 210–12 obsessional behavior 378, 379 Obsessive–Compulsive Disorder (OCD) 259, 265–77, 305 brain imaging research 228 psychopharmacology 377 psychotic disorder 343 obstetrics 133 ODD see Oppositional Defiant Disorder Odd/Eccentric Personality disorders 307 Oedipus complex 181, 186–7 offense-based dispositions 446 Offer, Daniel 6–7, 26–30, 70, 93, 412 Offer, J.B. 412 Office of Juvenile Justice and Delinquency Prevention (OJJDP) 420, 446, 447, 457, 498 Olson circumplex family model 207–8 operational structure of cognition 172 ophthalmology 73 Opinions of the American Psychiatric Association Ethics Committee 19 Oppositional Defiant Disorder (ODD) 280, 315, 318–19, 376 oppositionality psychopharmacology 378, 380 oral sex 88 orgasm 88, 89 Ortho see American Orthopsychiatric Association orthopedics 61–2 Osgood–Schlatter’s disease 61 O’Shaughnessy, Roy J. 482–8 Osipow, S.H. 168 outpatient treatment 333, 423–9 Overanxious Disorder 278 overlap model 29 Pachuco argot 33 pain 46 PAM see Peer Advocacy Models PANDAS see Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection Panic Disorder 279 Paoletti, D. 101–11 Paolino, T.J. 349 paradoxical directives 387–8

Index 517

paraphilia 483 parens patriae principle 443, 445, 492 Parent Management Training 458 parental alienation syndrome 438 consent 424, 425, 426 responsibility 432 rights 502–3 Parental Kidnapping Prevention Act 432 parenthood during adolescence 132–44 exclusive parenting time 432 intervention programs 117, 137–8 parents, noncustodial 209, 432–3, 435, 438–9 Parham v. J.R. (1979) 13, 425, 426 parity, mental and medical illness 19–20, 26 passive–aggressive personality disorder 305 pathogenesis 103–4, 297, 329 patients see also therapeutic alliance aggressive 353 borderline 353 concept of adolescent 3–9 doctor-patient relationship 23–4, 49 psychotic 343 STD/HIV risk 147–8 suicide 284 therapist–patient relation 367, 370–1 violent 117–18, 119 Patterson, Toronto 497 Pearson, Glen T. 303–14 Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infection (PANDAS) 268, 272, 273 Peer Advocacy Models (PAM) 150 peers adolescent mothers 134–5 Cognitive Behavioral Therapy 362 Conduct Disorder 317–18 counseling programs 116 friendship research 194 homosexuality 159 mediation programs 116 moral development 188 multimodal dynamic psychotherapy groups 414–15 normal development 167–8 peer courts 460 pressure 167 psychosocial assessment 216 rejection by 474 relationships 159, 167–8, 194–5, 216, 317–18 substance abuse factor 104 support 134–5 violent behavior 115, 116, 474 pelvic inflammatory disease (PID) 58 People v. M.A. (1988) 491 perceived environment 94

performance and competence 171 permanency hearings 502 permissive disclosure 428 personal construct theory 357 Personal Experience Questionnaire (PESQ) 332 personality disorders 303–14 Axis II traits 249 functioning assessment 232, 233 inventories 233 juvenile offenders 447, 456 risk behavior factors 94 Severe Personality Disorder 47 sexual abuse 127 substance abuse factors 330, 331 therapeutic alliance 353 treatment planning factors 249 persons in need of supervision (PINS) 447 Pervasive Developmental Disorders 257–64, 266 PESQ see Personal Experience Questionnaire PET see positron emission tomography Petit Mal 321 pharmacotherapy see also psychopharmacotherapy aggression 318 Conduct Disorder 318 depressive disorders 289 inpatient 400 juvenile offenders 467–8 Obsessive–Compulsive Disorder 269–70 personality disorders 310 Pervasive Developmental Disorders 261–2 substance abuse 333, 467–8 theory-free 7 tic disorders 270 phenomena, intrusive 40, 41 physical abuse 38–9, 115, 224, 428, 474, 483 appearance concern 88–9 examination 224 growth and development 51–2 health 249 impairment assessment 234–5 Physician Hospital Organizations (PHOs) 19 physicians, historical 73 Piaget, Jean cognitive development theory 69, 171–6 formal stage of reasoning 16 Kohlberg comparison 182, 183 moral development 181–2, 184, 186, 188 Pickrel, S.G. 468 PID see pelvic inflammatory disease Pine, D.S. 280 PINS see persons in need of supervision plethysmography 483–4 PMS see premenstrual syndrome policy effects, psychosocial assessment 218 Pollock, M. 316

518 Index

Ponton, Lynn E. 93–100, 159, 295–302 pornography 125 portfolio educational assessments 244–5 POSIT see Problem Oriented Screening Instrument for Teenagers positive connotation approach 387 positive transference 349 positron emission tomography (PET) 175–6, 227 post-conventional morality 183, 184 post-traumatic stress disorder (PTSD) 36–44 ADHD 321 juvenile offenders 456 sexual abuse 127, 129 substance abuse 106 violence exposure 113 Postponing Sexual Involvement program 138 poverty 94, 133, 216 power 187, 188, 360, 361 pre-conventional morality 182, 184 Pre-Operational Stage 173–4, 181 Preferred Provider Organizations (PPOs) 19 pregnancy 85, 96, 132–3, 137–8, 140 see also parenthood preliminary hearing, dependency court 501 premature ejaculation 89 premenstrual syndrome (PMS) 54 prescribing for adolescents 373–4 presentation issues 246, 251, 253, 454 prevalence Attention Deficit Hyperactivity Disorder 320 eating disorders 296–7 homosexuality 156–7 mood disorders 284 pervasive development disorders 259 post-traumatic stress disorder 37 prevention eating disorders 300–1 OCD 268–9 risk behavior 96–7 sexual abuse 129–30 sexually transmitted diseases/HIV 148–51 substance abuse 101–11, 335 suicide 29, 292 violent behavior 124 Principles of Medical Ethics, American Medical Association 16, 19 private institutions, inpatient admission 426 problem list construction, treatment planning 250 Problem Oriented Screening Instrument for Teenagers (POSIT) 332 problem-solving skills training see skills training problems in clinical interviews 205 process, expert witness testimony 419 professional judgment 470, 471 professional organizations 70–2 Program in Assertive Community Treatment 404 progress notes 253

progressive learning 97 prohibitions 187 projective identification 385 projective techniques 233 promiscuity 129 proof, burden of 445 prosecutorial discretion 491 protective risk factors 94, 113, 474–5 provoking agents, depression 286 pseudomutuality 384 PSUD see psychoactive substance use disordered adolescents psychiatric conditions, juvenile offenders 456 psychiatric profiles, adolescent parents 136–7 psychiatric subspecialties 73–5 psychiatrists child 150 roles 11–12, 221–2, 434–5, 450–5 psychoactive substance use disorder (PSUD) 330, 331, 333, 334, 335 psychoanalysis 7 anxiety disorders 278, 282 delinquency 444, 457 discovery of adolescence 4 Judge Baker Foundation 69 object relations theory 306, 307 post-World War II 26 self-psychological theory 306–7 superego development theory 186–7 psychoanalytically informed psychotherapy 366–72 psychodiagnostics 233 psychodynamic therapy 282, 312, 412 psychoeducation 388 psychogenic disease 47 psychological assessment 231–6 development of adolescent mothers 134 factors in Conduct Disorder 316–17 man 6 pregnancy sequelae 133 reports 232 tests 231 treatments 299–300, 457–9 psychopathologies 93–8, 129, 306, 331, 482–3 psychopathy and violence 473–4 psychopharmacology 117–18, 223, 240–1, 373–82, 459 psychosis 343, 377–8, 452 psychosocial factors assessment 215–20 functioning spheres 411–12 parenthood outcomes 136–7 post-traumatic stress disorder 39 psychotic disorders treatment 344 STD/HIV epidemic 147–8 support systems 398 tic disorders treatment 270 treatment planning 249

Index 519

psychosomatic symptoms 62–4 psychostimulants 318, 321 psychosurgery refusal 426 psychotherapy African-Americans 240 Attention Deficit Hyperactivity Disorder 322 cost cutting consequences 72 cultural assessment 240–1 depression 292 eating disorders 300 group 390–6 multimodal dynamic 410–16 Oppositional Defiant Disorder 319 personality disorders 309–11 psychoanalytically informed 366–72 psychopharmacology relation 380 psychotherapeutic psychiatry 72 psychotic disorders 344 sexual offenders 485 psychotic disorders 341–5 patients 46–7, 343 thinking 380 psychotropics 299, 426 PTSD see post-traumatic stress disorder puberty 51–2, 86–7, 88–9, 373 Public Law 94-142 245 Puerto Rican Americans 240 punishment 115 purging/vomiting 53 Pynoos, R.S. 39 Quintana, Humberto 171–9 racism 32, 168 RADSO see Reynolds Adolescent Depression Scale Rakoff, Vivian M. 3–9 Rank, Otto 278 rap groups 41 rape 36–7, 445 RAPI see Rutgers Alcohol Problem Index rapport 209, 351 rating scales Attention Deficit Hyperactivity Disorder 246, 321 Conners 97, 234, 246, 321 disruptive behavior disorders 317 psychological assessment 234 suicidal ideation 287 teachers 234, 246 Rational Emotive Therapy 357–8 Ratner, Richard A. 418–20, 450–5, 495–8 Raven’s Progressive Matrices 232–3 Ravitz, Alan 397–402 re-attributions, cognitive 360 re-enactment 40, 41 Reading Disorder 244

reading lists see suggested reading Real Economy System for Teens (REST) 319 Real Self 307 reality sphere 411–12 reasoned action theory 114 recidivism 470 Reeves, Gloria 278–83 Reeves, Rusty 470–81 refeeding 52 referral 203–4, 232, 350 refusal of treatment 426 Regier, Michael 112–24 regression and reconstruction 308 rehabilitation 245–6, 444, 490 reinforcement 175, 180, 358 Reiss, D.J. 208 Reister, A. 391 relapse prevention, sexual offenders 485 relationships doctor–patient 2–4, 49 interpersonal 193–8 peers 159, 167–8, 194–5, 216, 317–18 symbiotic 384 religion 7–8, 104, 107, 216–17, 426 relocation (post-divorce) 430, 433, 438–9 removal hearings 501 renal stones 74 reports expert witness 454 psychological 232 self-reports 204, 205, 234, 405 res judicata 437 research 13, 26–30, 80, 187, 393–4 residence (home) 215 residencies (training) 76–8, 80 residential care 118, 307–8, 309, 333 resistance 343, 398 Resource Mothers Program 138 resources see also financial constraints allocation 20 educators as 246 responsibility criminal 443, 451, 452–3 parental 432 restraints, refusal of physical 426 retributive justice 446 Rett, Andreas 258 Rett’s Disorder 258, 259, 260, 261 reverse certification 491–2 reverse waiver procedure 450 review of systems, psychosocial 411 Reynolds Adolescent Depression Scale (RADS0) 27 Rickel, A. 136 Rickler, Kenneth C. 265–77 Riester, A. 392 rights 424, 502–3

520 Index

risk-taking and risk behavior 93–100 see also pregnancy assessment 249–50, 470, 475 cognitive development 176 domains overlap model 29 eating disorders 300 factors 94, 115–16, 330, 332, 472, 475 gay/lesbian adolescents 158–9 of harm 398, 427–8 juvenile delinquency 470 management model 470 medical review 224 motor vehicles 218 psychopathology relation 93–4, 96, 97, 98 psychosocial assessment 215–16 research participation effect 13 sexual abuse effect 129 sexual behavior 145–54 substance abuse 330, 332 treatment planning 249–50 violence 115–16, 470, 472, 475 roles assignment 212 identity 392 psychiatrists 11–12, 221–2, 434–5, 450–5 therapeutic alliance 352–3 Rorschach test 233, 287 Roscoe, B. 195 Rosner, Richard 76–81 Rousseau, Jean-Jacques 180 rubella 260 Russell, Diana 126 Rutgers Alcohol Problem Index (RAPI) 332 Rutter, M. 258–9, 456 Ryan, Governor of Illinois 497 Sadock, B.J. 349 safe sex 89, 159 safety measures, suicidality 292 St. Louis Missouri, adolescent violence study 113–14 Salpekar, Jay A. 284–94 Santosky v. Kramer (1982) 503 SAP see Society for Adolescent Psychiatry satiation, masturbatory 484–5 Savin-Williams, R.C. 195 SAVRY see Structured Assessment of Violence Risk in Youths ‘scared straight’ programs 460 Schiffer, M. 391 Schizoid Personality Disorder 259 schizophrenia 341 ADHD 321 brain imaging 228, 342 Conduct Disorder 316 cultural uniformity 6 neurodevelopmental abnormalities 342 onset age 342

Pervasive Developmental Disorders 259 spectrum disorders 342–3, 456 substance abuse 331 school see also education; school-based interventions decreased performance treatment goal 252 minority adolescents 34 refusal 97 School Phobia 281 sexual abuse effects 127 targeted violence 470 violent behavior 115 school-based interventions Conduct Disorder 317–18 eating disorders 300 life skills training 116 mental health services 404, 406–8 multimodal dynamic psychotherapy 414 personality disorder treatment 309 pregnancy and parenting 137–8 psychosocial assessment 215 referral process 203 substance abuse prevention 107 screening questions 201–2 seating dynamics 209 secondary prevention, substance abuse 107 Section 504, Rehabilitation Act 245–6 secure detention 446 selective serotonin reuptake inhibitors (SSRIs) ADHD 376 anxiety disorders 281 Conduct Disorder 318 depressive disorders 289, 290 Obsessive–Compulsive Disorder 269–70, 272 post-traumatic stress disorder 41 sexual dysfunction effects 380 sexual offenders treatment 485 substance abuse 333 tic disorders 272 self 306–7 self-concept 87 self-defense, criminal responsibility 452 self-determination 6 Self-Directed Search 245 self-efficacy theory 358 self-esteem 88–9 Self-Instructional Training models 358 self-perceptions 166, 167 self-psychological theory 306–7 self-talk 358, 360 Selvini-Palozzoli, M. 387 semenarche 86 semiotic function 173 sensitization model 157 sensory motor stage 172, 173, 181 sentences, blended 447 Separation Anxiety Disorder 279, 281

Index 521

serotonin reuptake inhibitors (SRIs) 269 service organizations, psychosocial assessment 218 Serzone 290 Severe Personality Disorder 47 sex education 88, 89, 96, 485 fear of 89 masturbation 86, 87–8, 258, 484–5 offenders 482–8 orgasm 88–9 pleasure 85, 87–8 sexual development 85–92, 159 dysfunction 89–90, 380 high-risk behavior 145–54 history 224, 483 identity 4, 156, 157 intercourse 146–7, 156 maturity ratings (SMRs) 51 orientation 129, 156 victimization 482–3 sexual abuse 125–31 see also sexual offenders erotic development 90 ethical issues 14–15 group psychotherapy 392–3, 394 mandatory disclosure 428 medical review 224 post-traumatic stress disorder 37, 38–9 prevention programs 85 sexuality, homosexual 155–62 sexually active 86, 88, 95, 195 sexually transmissible infections (STIs) 57–9 sexually transmitted diseases (STDs) high-risk sexual behavior 145–54 HIV 59, 95, 96, 133, 145–54 normative data 156 post-partum 133 sexual abuse 129 Sgroi, S. 125 Shapiro, E.R. 311, 312 shelter hearings 501 Sheppard, M.A. 193 siblings 188, 208, 260–1 sickle cell 46 Silva, J. Arturo 10–18, 31–5 Simmond’s disease 297 single photon emission computed tomography (SPECT) 227 skills training Conduct Disorder treatment 317 juvenile offenders 458 life skills 116 problem-solving 359, 361, 399, 458 sexual offenders 485 social 322, 485 skin 53–4, 224

Skipper, J.K. 195 Slaff, Bertram 68–72 Slavson, S. 390, 391 sleep 40–1, 62, 223, 287 slippage, forensic evaluations 11 Slovenko, R. 446 Smith, C. 475 Smith, E.D. 327 smoking 101–2, 104, 133 SMRs see sexual maturity ratings Social Anxiety Disorder 280 social class 5–6, 88, 168, 317 Social Cognitive Theory 114, 149, 150 social development model 115 social disorganization theory 114 social factors see also psychosocial factors; socio-economic factors adolescent development 215 Conduct Disorder 317 eating disorders 301 risk behavior 94 social family therapy 388 social influence programs 335 social learning theory 96, 114, 180–1 Social and Occupational Functioning Assessment Scale (SOFAS) 218 Social Phobia 106, 279, 280 social skills training 322, 485 social support, adolescent mothers 134–5 social systems involvement, personality disorder treatment 309 social treatments, juvenile offenders 457–9 social-contract legalistic orientation 183 socialization 167 Society for Adolescent Psychiatry (SAP) 70 socioeconomic factors 94, 133, 216, 284, 328 sociocultural issues, normal development 165–70 SOFAS see Social and Occupational Functioning Assessment Scale special education assessment 245–6 special populations juvenile offenders 465–9 psychological assessment 234–5 specialty groups 392–3 specialties, adolescent psychiatry 79–80 Specific Phobia 280 SPECT see single photon emission computed tomography spectrum disorders 342–3 Spencer, Elizabeth Kay 221–5 sports involvement 217, 224 sports medicine 61–2 SRIs see serotonin reuptake inhibitors SSRIs see selective serotonin reuptake inhibitors stabilization, inpatient treatment 398, 399, 401 Stacy, A.W. 331

522 Index

standardization educational tests 243–4 research measures 27 standards, Accreditation Council on Fellowships in Forensic Psychiatry 78–80 Stanford v. Kentucky (1989) 16, 496, 497 Stanford–Binet Intelligence Scale 232 starvation 53, 298–9 state custody 423–4 status offenders 424, 446, 447, 449 Stay SMART program 108 Stein, D.B. 319 Steiner, H. 297 steroid medication 288 Stewart, D.C. 156 Stewart, K.E. 101–11 Stiffman, Arlene Rubin 112–24 Stilwell, Barbara 185–6 stimulants 101, 271, 375 Stoller, Caryn 26–30 Stone, L. 68 Stranger Danger 90 strategic family therapy 384, 387–8 Streib, V.L. 498 Stress Inoculation Training 359 stressors 37–8, 218, 474 Strong Interest Inventory 245 Stroul, B.A. 403 structural family therapy 384, 386–7 Structured Assessment of Violence Risk in Youths (SAVRY) 470, 471, 475 Stuart, R.B. 388 subjectivity 6 substance abuse 7, 101–11, 328–40 family 384 juvenile offenders 465–9 medical review 223 multimodal dynamic psychotherapy 415 psychotic disorders 343 violence 115, 456 Substance Abuse and Mental Health Services Administration 465–6 substances abusers 465–8 substance dependence 102 Substance-induced mood disorders 285 Sugar, M. 392, 394, 414 suggested reading biological assessment 230 clinical interviews 206 cognitive development 179 community-based treatment 409 cultural assessment 241–2 custody, visitation and relocation 439 depression 293 educational assessment 247 family assessment 213–14

family therapy 389 juvenile delinquency 449 medical review 225 Obsessive–Compulsive Disorder 277 Pervasive Developmental Disorders 264 psychological assessment 236 psychosocial assessment 220 psychotic disorders 345 status offenders 449 suicide 293 Tourette’s Syndrome 277 transfer to adult criminal justice system 494 treatment planning 253–4 suicide 284–94 adolescent mothers risk 136 anomic 9 homosexuality 159 mandatory disclosure 428 post-suicide attempters 46 rates 7–8, 95 research 28–9 sexual abuse 129 statistics 28–9 substance abuse 331 suicidal ideation 284, 287, 288 suicidality 115, 288, 292, 353, 428 therapeutic alliance 353 violence 115 Sullivan, Harry Stack 383 superego 69, 181, 186–7 supervision children in need of 447 of training 77, 355 support systems 134–5, 158–61, 168, 398 supportive therapy for depression 292 surgeons (historical) 73 Swanson, Donald 164 Swedo, Susan E. 265–77 Sydenham’s Chorea 272 symbiotic relationships 384 symbolic activity stage 173 symptom-formation factors, depression 286 symptomatology, therapeutic alliance and patient’s 353 symptoms, psychotic 341 syndromes, epoch-dependent 7 syphilis 58–9, 74, 95–6, 146 systems medical review of 223 psychosocial 411 support 134–5, 158–61, 168, 398 theory 71, 384, 391 tampons 87 targeted violence 470 Tarrasoff vs. Regents of University of California 119 TASI see Teen Addiction Severity Index

Index 523

TAT see Thematic Apperception Test teachers rating scales 234, 246 see also schools teaching, training in 80 team model, community-based treatment 404–5 technical aspects personality disorder 311–12 psychoanalytically informed psychotherapy 370 technical neutrality 309, 313 techniques Cognitive Behavioral Therapy 358–61 group psychotherapy 392 learning theory 388 Teen Addiction Severity Index (TASI) 106 teenagers, 1950s 4–5 television 217, 335 tender years doctrine 431, 432 termination of parental rights 502–3 psychoanalytically informed psychotherapy 369 therapeutic alliance 355 see also closure testosterone 86–7 Tests in Print 247 textbooks for training 77 Thematic Apperception Test (TAT) 233, 287 therapeutic alliance 349–56, 386, 413 therapeutic contract 349 therapeutic treatments, violent behavior 118 therapists commitment 308 patients relation 367, 370–1 therapeutic alliance role 352–3 Thomas, E. 136 Thompson v. Oklahoma (1988) 15–16, 495–6 threats of violence 428 Three Essays on the Theory of Sexuality 4 tic disorders 270–3, 376–7 tickling the defenses 210 Tillitski, C.J. 390, 394 tobacco see smoking tolerance in substance dependence 103 Tourette’s syndrome 228, 265–77, 316, 321 traditional medicine 34, 238, 239, 240 training 76–81 see also skills training forensic psychiatry 419–20 group therapy leadership 393 medical subspecialties 74 professional organizations 70–1 Tramonata, M.G. 393 transductive reasoning 174 transfer to adult court see waivers transference 313, 349, 353, 385, 415 transport use 218

trauma see post-traumatic stress disorder treatment anorexia nervosa 98 anxiety disorders 281–2 Attention Deficit Hyperactivity Disorder 321–2 biological 298–9, 330, 333, 485 Cognitive Behavioral Therapy 362 competence for execution 496–7 Conduct Disorder 317–18 consent 424, 425 cultural assessment 240–1 cultural factors 31–5 depressive disorders 288–92 eating disorders 298–300 family assessment 213 HIV 59 homosexuality 159–60 hospitalization 399–40 inpatient 397–402 introduction 348 investigational 272–3 juvenile offenders 404, 456–62 language sensitivity 33 manualized 391, 392 masturbatory satiation 484–5 Obsessive–Compulsive Disorder 268–70, 272–3 Oppositional Defiant Disorder 319 personality disorder 307–11 Pervasive Developmental Disorders 261–2 pharmacological 7, 269–70, 400, 467–8 planning 213, 248–54, 332–4, 485 psychoanalytically informed psychotherapy 368–9 psychotic disorders 344 refusal 426 research history 26–7 risk-taking 97–8 sex offenders 482–8 STD/HIV 150–1 substance abuse 106–7, 108, 331–5 tic disorders 270–3 violent behavior 117–19 trial by jury 492 tricyclic antidepressants 290, 321–2, 375 Trileptal 291–2 trust 205 Turiel, E. 184–5 turmoil see adolescent turmoil Twelve-Step therapy 466, 467 typical day description 211 unconscious 370, 412 Uniform Child Custody Jurisdiction Act 432 United States Supreme Court, civil commitment 13–14 universal ethical principles 183 urgency continuum 222

524 Index

utilization of mental health services 34, 403 Utilization Review Organizations 19 values 32, 148–9, 168 Vanderhoof, James 498 Vaughn, C. 388 verbal communications confidentiality 427 verbal problem-solving skills 359, 399 victimization 158, 482–3 Vietnam war 36, 38 Vietnamese Americans 33 Vineland Adaptive Behavior Scale 234, 246 violence 112–24 assessment 217, 470–81 crime 465 deaths by 95 drug trafficking 465 exposure 38, 113–14, 217, 456 minority groups 34 offences 446 of patients 117–18, 119, 353 psychosocial assessment 217 risk factors 115–16, 472, 473–4, 475 substance abuse 456 threats 428 violent offenders 470–5 visitation (post-divorce) 430, 432–3, 438 vital signs medical review 224 vocational assessment 245 vocational influences, normal development 168–9 volitional prong, insanity defense 452–3 Volkmar, F.R. 262 Volproic Acid 291 vomiting 53, 300 vulnerability factors, depression 286 Vygotsky, L. 358 Wagner, K.D. 27 waivers 446–7, 450, 453, 490–3, 495–6 warts, genital 59 Watzlawick, P. 387

websites 420 Wechsler Adult Intelligence Scale 232 Wechsler Intelligence Scale for Children 232, 240 Weiner, I. 68 Weinstock, Robert 10–18, 31–5 Weintrob, Alex 430–9 Weissman, Kathy 73–5 Weissman, Sharon 73–5 Weissman, Sidney 73–5 Weist, Mark D. 403–9 Weisz, J.R. 393 well-being 223 Wexler, David B. 357–65 Whitaker, Carl 385 Wide Range Achievement Test-3 (WRAT-3) 244 Wide Range Assessment of Memory and Learning (WRAML) 234 Wilkins v. Missouri (1989) 16, 496 Wilson, J.Q. 186 Winn, Catherine 112–24 withdrawal, substance use 103 Womack, William M. 155–62 Woodcock–Johnson Psychoeducational Battery 244 working-class 5 workplace 217 WRAML see Wide Range Assessment of Memory and Learning wrap-around services 403, 408 WRAT-3 see Wide Range Achievement Test-3 YABCL see Young Adult Behavior Checklist Yalom, I.D. 391 YAPA see Young Adult Psychiatric Assessment YASR see Young Adult Self-Repot Yates, A. 85–92 Young Adult Behavior Checklist (YABCL) 234 Young Adult Psychiatric Assessment (YAPA) 201 Young Adult Self-Report (YASR) 234 youth gangs 117 youth groups 107–8 Youth Self-Report (YSR) 204, 205, 234, 405