Adolescent Psychiatry - Volume 4, Issue 3, 2014

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.

Background: Adolescents who have autistic features, such as social communication deficits, as well as disorganized thinking and bizarre behavior, present diagnostic challenges for clinicians as well as for researchers. Autism and schizophrenia are both neurodevelopmental disorders; they have an interconnected history that has diverged diagnostically, but retains many shared characteristics. Once conceptualized as a type of schizophrenia, autism has separated into a distinct disorder, yet similarities are evident between the two. Recent research has called into question the complete dichotomous separation of these two disorders. Methods: This review covers the history, as well as the shared phenotypic and genotypic characteristics of the disorders, including genetics, imaging, language development, and social functioning. We present possible theoretical constructs to frame the nature and extent of the overlap given the available research. Results: Adolescents who have childhood histories consistent with autistic spectrum disorders can present with psychotic symptoms in adolescence. Conversely, adolescents who appear to have childhood or adolescent onset schizophrenia may also show autistic features. Various hypotheses have been proposed to explain the overlap between these two heterogeneous conditions. Conclusions: We believe that the overlaps between autism and schizophrenia represent an important and rich area of research in order to better understand the unique characteristics of each disorder that may help to aid understand mechanisms of development, refine models of prediction and risk, as well as to understand common characteristics that may help shape entry points for future intervention.

Background: In the last twenty years interest in the clinical implications of attachment theory has greatly grown. The perspective of attachment seems to be particularly relevant with regard to the study of adolescence, insofar as the restructuring of the self that occurs during this developmental phase can lead to different outcomes in accordance with the different attachment organizations. Also the psychotherapeutic process with the adolescent can be enhanced by the understanding of the adolescent’s development with respect to attachment, and therapy can be adjusted according to the attachment models of the adolescent’s relationships. Method: In this paper I discuss the significance of this attachment- oriented approach to psychotherapy in adolescence, starting from utilizing an “attachment-based” model for the assessment of the adolescent. The administration of the Adult Attachment Interview (AAI) forms part of the assessment process. Results: Such an assessment, focusing on the dimension related to the attachment patterns of the adolescent, highlights the conversational and narrative features, the prevailing defenses and the availability of reflective functioning in order to promote individuation. This methodology implies a focus also on the way attachment patterns operate in activating, from the very beginning, specific types of unconscious responses in the therapist. Conclusion: The AAI is useful in the evaluation phase of clinical cases, before initiating therapy. In many cases the interview itself activates a process of reflection and reinterpretation of their past within the adolescent, which in turn that allows the establishing of a preliminary working alliance.

Background: Major depressive disorder is a highly prevalent disorder in adolescence that entails significant lifetime risk for repeated episodes of depression and other disorders Furthermore, it can have a negative impact on academic and psycho-social functioning with long-lasting effects. Thus, identification of the most relevant risk factors for the continuation of major depressive disorder is important. Method: Seventy one female adolescents between 10 and 18 years who were identified from a community sample as having major depressive disorder were assessed regarding stress vulnerability, stress symptoms, coping behavior and physical complaints. These variables were tested as risk factors for the persistence of major depression six months later. Results: Factors having the highest predictive power for the continuation of major depression were avoidant coping, stress vulnerability and stress related psychic symptoms. Conclusions: Stress symptoms, stress vulnerability, and a strategy of avoidant coping behavior are risk factors for the prolonged existence of major depression and should particularly be considered in prevention of major depression and intervention for depressive symptoms.

Background: Adolescent refugees face many challenges but also have the potential for resilience. The purpose of this study was to identify and characterize the protective agents, resources, and mechanisms that promote their psychosocial well-being. Methods: Participants included a purposively sampled group of 73 Burundian and Liberian refugee adolescents and their families who had recently resettled in Boston and Chicago. The adolescents, families, and their service providers participated in a two-year longitudinal study using ethnographic methods and grounded theory analysis with Atlas/ti software. A grounded theory model was developed which describes those persons or entities who act to protect adolescents (Protective Agents), their capacities for doing so (Protective Resources), and how they do it (Protective Mechanisms). Protective agents are the individuals, groups, organizations, and systems that can contribute either directly or indirectly to promoting adolescent refugees’ psychosocial well-being. Protective resources are the family and community capacities that can promote psychosocial well-being in adolescent refugees. Protective mechanisms are the processes fostering adolescent refugees’ competencies and behaviors that can promote their psychosocial well-being. Results: Eight protective resources were identified that appeared to promote psychosocial well-being in the adolescent refugees. These included 1) finances for necessities; 2) English proficiency; 3) social support networks; 4) engaged parenting; 5) family cohesion; 6) cultural adherence and guidance; 7) educational support; and 8) faith and religious involvement. Nine protective agents were identified. These included: 1) friends and peers; 2) parents; 3) older siblings; 4) extended family members; 5) school teachers, staff, and coaches; 6) church staff and congregants; 7) resettlement agency caseworkers and activity leaders; 8) volunteers, and 9) health and mental health providers. Conclusions: To further promote the psychosocial well-being of adolescent refugees, targeted prevention focused policies and programs are needed to enhance the identified protective agents, resources, and mechanisms. Because resilience works through protective mechanisms, greater attention should be paid to understanding how to enhance them through new programs and practices, especially informational and developmental protective mechanisms.

Objective: High and low body mass index (BMI) values and inaccurate body weight perceptions (BWP) (i.e.: mismatch between BMI and BWP) are known risk factors for depression/suicide. However, the relationships between BMI, BWP and depression are still insufficiently understood in adolescents, and data are lacking concerning the entire range of BMI in either gender. This study aimed to investigate how BMI and BWP are related to depression in adolescents, exploring the entire range of BMI in both genders. Method: Observational cross-sectional survey of a representative sample adolescents aged 17 from metropolitan France. A total of 39,542 subjects responded to a self-administered questionnaire between March 15th and March 31st 2008. They were classified according to their BMI (WHO thresholds: underweight/normal/overweight or obese), their BWP (five response choices from "too thin" to "too fat") and their depression levels (measured with the Adolescent Depression Rating Scale). Depression scores were calculated for each group defined by crossing the 4 classes of BMI and the 5 categories of BWP. The interaction between BMI, BWP and depression was investigated using variance analysis. Results were secondarily adjusted to control for home environment and socioeconomic status. Analyses were performed separately for boys and girls. Results: An interaction was observed between BMI, BWP and depression. Irrespective of BMI and gender, adolescents who felt they were almost the right weight had low depression scores. The greater the discrepancy between BMI and BWP, the more likely were adolescents to show high depression scores. Conclusions: From a clinical perspective, asking adolescents about their BWP could help to better identify those at risk for depression.

Background: Bullying among adolescents has increasingly been recognized as a highly prevalent problem that has long lasting consequences for both bullies and victims. Numerous school-wide interventions have been developed but there is a need for interventions that can be implemented by clinicians working with individual clients and patients who bully others. Methods: This manuscript describes a safety plan for youth who bully others which aims to prevent future bullying/ cyberbullying behavior. The ultimate goal of the Bullying Prevention Plan (BPP) is to stop bullying before it starts. Results: The (BPP) is a written plan of action created by the clinician and the youth involved in bullying that essentially charts the course of what the youth should do if he/she begins to experience bullying urges or even starts to bully others. The plan includes hierarchical steps including the identification of warning signs for bullying behavior, use of internal coping strategies, use of external coping strategies, involvement of an adult or professional provider etc. The plan should be periodically reviewed, discussed and possibly revised by the clinician and youth. It is recommended that the youth learn new skills and therefore the bullying prevention plan should be expanded. Conclusions: The bullying prevention plan offers a promising intervention that is directed toward youth who engage in bullying behaviors. Further research should study its efficacy in a systematic way.

Background: Schools serve as an important context for the prevention of behavioral and mental health problems. There is growing interest among educators in the application of a three-tiered public health prevention model to prevent a range of behavioral and mental health concerns, and in turn, improve academic and social-emotional outcomes for students. One such multi-tiered system of supports framework used by schools is called Positive Behavioral Interventions and Supports (PBIS). This model has been widely disseminated in over 20,000 schools across the U.S., with the goal of improving social, emotional, and behavioral outcomes among youth. Yet, most of the implementation efforts and research on PBIS have focused on elementary schools. Method: This paper describes a collaborative state-wide effort, called Maryland Safe and Supportive Schools, to disseminate this model in high schools and conduct a randomized trial to determine the impact of PBIS on adolescents. The model uses a collaborative, team-focused coaching framework and draws upon school climate data to implement a continuum of evidence-based prevention programs. The goal of this effort is to reduce behavioral, academic, and mental health problems among adolescents. This paper summarizes the design, implementation, and lessons learned through this unique school/non-profit/university partnership-based approach to implementing a comprehensive three-tiered model of support within the state of Maryland. Results: A relatively large and diverse sample of 58 schools voluntarily participated in the school-level group randomized controlled trial. Annual measures of school climate were collected via self-reports from over 25,000 students and through observations across 25 classrooms per school. Fidelity of tier 1 and 2 supports was generally high among the intervention schools. Preliminary findings from the randomized trial testing the impact of MDS3 suggest a positive impact on school climate and other safety related concerns following the first year of implementation. Conclusions: The MDS3 project promoted a framework for helping the school leadership teams develop data-based decision- making skills, generate data reports to establish need, optimize evidence-based program implementation, and use data to monitor progress toward goals and celebrate successes. Lessons learned include the importance of 1) obtaining data at the student and school levels; and communicating and sharing data with the schools in a way that makes sense to them and is consistent with the school’s mission.

Background: Somatic symptoms are common in trauma survivors, including those who have experienced sexual abuse. These symptoms sometimes continue or get worse during the course of medical investigations, provoking even more investigation, and leading to a vicious circle involving invasive medical procedures and frustrating attempts at diagnosis and care. In such cases, the symptoms may be considered fulminant. Method: This article presents a review and analysis of three cases of adolescents presenting with fulminant somatic symptoms. Results: In each case, the patient’s symptoms resolved when the focus of care shifted from investigation to support for coping. Sexual abuse history had been overlooked during the acute phase. Conclusions: In such patients, somatic investigation may evoke past trauma. Management should consider a shift in emphasis from investigation to promoting adaptation.