oa Editorial: From Research to Clinical Practice in Adolescent Psychiatry

As I looked for a unifying theme in the articles published in this issue, it occurred to me that all of the articles deal with bridging the gap between research and clinical practice. As Camille Wilson and colleagues point out in the lead article in this issue, there has been a longstanding debate over the relationship between autism spectrum disorders and schizophrenia. Both of these disorders are now understood to be neurodevelopmental in origin. They have overlapping features—both involve difficulties in social interactions and information processing. Both have demonstrable brain abnormalities that are distinct in some ways but similar in others. Whether these disorders are in fact variants of the same condition or two separate disorders has clinical implications, especially in terms of early intervention. Wilson and colleagues have carefully reviewed the history of thinking about these disorders and have summarized recent research and hypotheses. Conversely, adolescents who appear to have childhood or adolescent onset schizophrenia may also show autistic features. They point out that clinicians may miss signs of autism in adolescents with psychotic symptoms, or fail to detect the onset of schizophrenia in teenagers with autistic features. Beginning in 1970s with the work of British psychoanalyst John Bowlby, attachment research has steadily progressed and led to a substantial body of knowledge that has bridged the gap between theory and empirically based knowledge. Originally focusing on infant studies, attachment research was subsequently extended to adults, and finally, to adolescents. Enrico de Vito, a psychoanalyst who has carried out research on attachment in adolescents in Italy, describes how he began to incorporate a systematic approach to assessing attachment in his clinical work with adolescents. In their article, “Stress-related Risk Factors for the Maintenance of Major Depression in Adolescent Girls” Ulrike Schmidt- Gies and Reinhold Laessle present the results of their research in Trier, Germany on a community sample of adolescent girls with major depressive disorder. They found avoidant coping, stress vulnerability and stress related psychic symptoms to be correlated with the presence of symptoms of major depression 6 months later. Their results have implications in terms of intervention, especially school-based interventions¸ which might target coping with stress as a way of improving resilience. In another study that deals with coping with stress, Weine and colleagues describe their work with Burundian and Liberian refugee adolescents who resettled in the US. They identified several factors that appeared to promote psychosocial well-being in the adolescent refugees. Some were straightforward, such as financial resources and English language proficiency, while others involved social support, especially that of the family. Religious and faith institutions also played an important role. Taken as a whole, the results point in the direction of efficacious interventions for this population. A large scale study of French adolescents by Huas and colleagues investigated the relationship between the adolescents’ perceptions of their body weight, their actual weight as reflected in BMI, and depression. Feeling they were either too thin too fat, even when their BMI was within normal range was associated with depression; adolescents who felt they were almost the right weight had low depression scores. The greater the discrepancy between BMI and BWP, the more likely the adolescents were to have high depression scores. The authors suggest that it is important for clinicians to inquire about adolescents’ perceptions of their body weight, even when they are not overweight or underweight, as these perceptions, reflective of distorted body image, may be risk factors for depression and/or eating disorders. Two articles present promising approaches that await systematic evaluation in controlled studies. Much of the work on bullying has focused on helping victims, and addressing the problem of bullying from a systemic perspective. However, interventions for bullies that can be delivered in an office setting on a one-to-one basis have not been developed. In their article, “The Bullying Prevention Plan: An Approach to Youth who Bully Others” Anat Brunstein Klomek, and colleagues outline an approach to these youngsters. Their approach is based on a suicide prevention approach developed by Brent and colleagues, with the rationale that both suicidal behavior and bullying are characterized by impulsivity, problems in emotion regulation, difficulties in adaptive problem solving and deficits in interpersonal communication, as well as being associated with depression. Their approach focuses on improving emotion regulation and—in the case of those whose bullying is a result of impulsive acts—impulse control. It involves a “chain analysis” of bullying incidents, and a written plan with coping strategies. In another article that describes an intervention plan, this time on a school-wide basis, Bradshaw and colleagues review The Maryland Safe and Supportive Schools Project. This project involves implementing a program called Positive Behavioral Interventions and Supports (PBIS) in high schools in Maryland. PBIS is “a set of intervention practices and organizational systems for establishing the social culture and intensive individual behavior supports needed to achieve academic and social success for all students” (Sugai, Horner, & Lewis, 2009, p. 4). It involves implementation of interventions designed to reduce disruptive behavior and support desirable behavior, along with rigorous collection of data and monitoring and evaluation of outcomes. It utilizes a three-tiered approach that is drawn from public health, with intervention conceptualized as primary, secondary and tertiary. PBIS has been widely used in the US, but mostly in elementary schools, and has been found to be efficacious in randomized controlled trials. Attempts to implement it in high schools have proven more problematic. Bradshaw and colleagues describe the necessary steps to implementing this school wide intervention in high schools, including most importantly “buyin” by the school leadership. Impressively, the authors were able to obtain support for the project from a large number of public high schools in Maryland. Preliminary results have demonstrated a variety of very positive outcomes ranging from improved school climate to reductions in school violence and substance abuse. Finally, in the clinical perspectives section, Gordon Harper and Oommen Mammen remind us that there is still a role for developing treatment recommendations based on clinical observation. They introduce the term “fulminant somatization,” and illustrate it using three cases of adolescents hospitalized in a tertiary care center with unexplained somatic symptoms. (It is noteworthy that the term somatization was dropped in DSM-5 in favor of “somatic symptom disorder,” but the authors feel that it is still useful in describing some patients). The adolescents whose cases are presented underwent extensive and repeated medical investigations in the hospital, with recurrences and exacerbations of their symptoms as the medical staff became ever more determined to discover the cause of their mysterious illness. All of the patients had experienced sexual abuse in the past, a known risk factor for somatic symptom disorder. The symptoms abated once the focus of treatment shifted away from continued diagnostic evaluation and in the direction of addressing problematic psychosocial issues. The authors discuss how the past sexual abuse places these patients at risk for both somatic symptoms and re-traumatization in the form of invasive medical procedures. They offer specific recommendations for clinicians who are faced with such cases. The state of research in adolescent psychiatry was summarized in a 2008 report as follows: While there are clearly limitations in our understanding of adolescent mental health, we know enough to act. The challenge is to translate emerging research findings in these diverse areas—such as context, positive function, resilience, culture and special populations—into indicators that can be monitored over time and used to guide policy and program development (Knopf, Park, & Mulye, 2008). The articles in this issue of Adolescent Psychiatry represent steps in meeting this challenge.