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512 921 - all notes

  1. 1. Adolescent Problems Developmental Issues and Treatment Approaches prepared by Dr Elizabeth Cosgrave 2007
  2. 2. Some considerations before youmake a start…
  3. 3. Engagement Nothing will work if you are not engaged with the adolescent Engagement takes time Things that might help  Explain your role clearly  What to expect from seeing you (be specific & give examples)
  4. 4. Confidentiality Explain it at the beginning of the 1st session, preferably with the parent also in the room Be specific & give examples  What you will & won’t tell parents Establish ground rules  What if your Mum rings me to ask how you’re going?  How do I contact you if you don’t turn up?
  5. 5. Language Explaining things  Needs to be simple, non-pejorative & not too jargonistic  Most adolescents won’t respond well to being asked to monitor their “dysfunctional cognitions” Age-appropriate questioning (CBT)  “what would you say to a friend who came to you with this problem?”  “If you surveyed 100 Year 9 students, would they all have reacted in the same way you did?”
  6. 6. Homework Monitoring Sheets  Tailor them to the individual if at all possible, & involve the adolescent in this process Completing Homework  Non-completion is not necessarily a poor prognostic indicator  Adolescents will often complete homework…of sorts
  7. 7. Dilemmas associated withworking with adolescents Involvement of family  Who wants this & who is likely to benefit from this? Making a diagnosis Diagnosing a personality disorder The use of medications Deciding when there is a problem  How to differentiate from normative adolescent development
  8. 8. Deciding when there is a problem - I  Is the adolescent distressed about the Sxs?  Is anyone else concerned? Who & why?  Is the problem having an impact on the adolescent’s functioning?  Do the Sx represent a change from the adolescent’s normal functioning?  Measure the frequency, intensity & duration of the problem/Sx
  9. 9. Deciding when there is a problem - II What is the potential for the adolescent (or anyone else) to be seriously harmed by the problem? Consider what is problem behaviour & what is developmentally normal experimentation  Substance use  Health risk behaviours  View of selves as omnipotent
  10. 10. Depression in Adolescence-I Incidence of depression, attempted suicide & completed suicide increases significantly in adolescence (cf. childhood) Depressive symptoms experienced by 15-40% of adolescents Evidence that early onset depression is a more serious form of the disorder
  11. 11. Depression in Adolescence-II Adolescent depression predictive of a number of negative outcomes:  Academic difficulties  Delinquency  Unemployment  Substance use  Forensic involvement
  12. 12. Adolescent Depression: the Myths “Adolescents don’t get depressed” “Depressed adolescents will just get over it” “All adolescents will become depressed at some stage because adolescence is a time of turmoil” “(S)he’s just being lazy/grumpy/difficult to live with”
  13. 13. Risk Factors forAdolescent Depression-I Previous MDE Being female Family Hx of psychopathology Stressful life events Low social support Subthreshold depressive Sx “out of sync” pubertal development
  14. 14. Risk Factors forAdolescent Depression-II Other psychopathology (current or past) Serious physical illness Previous suicide attempt “depressogenic” cognitive style (pessimistic, internal, global, stable) Poor coping skills
  15. 15. Recognising depression inadolescents-I Disturbance of mood:  May be sad or gloomy, but also very likely to be irritable  May describe mood as “angry”, “numb” or “nothing”
  16. 16. Recognising depression inadolescents-II Disturbance of thinking:  Self blame, self criticism  Negative thoughts re future  Difficulty making decisions  Time of important vocational choices  Inability to think clearly  Time when organisational & cognitive demands increase  Memory & concentration problems  Impact on schooling
  17. 17. Recognising depression inadolescents-III Disturbance of thinking (cont.):  Hypersensitive to feedback from others  Perceived as criticism  Thoughts about being hurt, hurting oneself, dying or committing suicide  Useful to think of these along a continuum  May manifest as ambivalence about living, passive death wish or overt suicidality  Need to assess for presence of other health risk behaviours
  18. 18. Recognising depression inadolescents-IV Disturbance of behaviour:  Decrease in activity levels  May no longer engage in extracurricular activities  Decrease in energy  May seem very drowsy or fall asleep in class  Tearfulness  Agitation  May manifest as difficulty attending to a task until it is completed
  19. 19. Recognising depression inadolescents-V Disturbance of behaviour (cont.):  Change in social interaction  Substance use  Change in sleep &/or appetite  Loss of sexual interest  Difficult to assess in adolescents  Somatic complaints  May manifest as frequent visits to “sick bay”
  20. 20. Gender Differences inAdolescent Depression From adolescence, females twice as likely to develop a depressive illness than males Gender differences in coping with depressed mood (Nolen-Hoeksema)  Ruminative vs. instrumental strategies Gender differences in subjective meaning of puberty Confluence of demands for adolescent females  e.g., pubertal changes, school transition
  21. 21. Treating Adolescent Depression-I Evidence for the efficacy of CBT & IPT & pharmacotherapy Adjunctive group and/or family therapy can also be useful Important to provide psycho-education for client and her/his family  May need to address beliefs that adolescent is just “lazy”
  22. 22. Treating Adolescent Depression-II Provide honest feedback to your client  Diagnosis (explain it)  Formulation Provide clear rationale for any treatment strategies you suggest  This will hopefully maximise engagement & likelihood of compliance Importance of using appropriate language Don’t be put off by the non-completion of homework Be flexible with treatment strategies
  23. 23. Suicide in Adolescence-I There has been a steady increase in the rates of youth suicide (15-24 years) in Victoria & Australia since 1960 in males, but not in females Adolescent females more likely to attempt suicide than adolescent males Gender differences in methods:  Females more likely to overdose or jump from heights or under vehicles  Males more likely to use firearms & car exhausts
  24. 24. Suicide in Adolescence-II A history of suicide attempts is a risk factor for suicide completion  ~50% of adolescents who attempt suicide will make subsequent attempts  Of those, between 0.1% & 11% will eventually complete suicide The presence of psychopathology is a risk factor for suicidality BUT:  not all adolescents who attempt suicide are depressed  not all adolescents who are depressed are also suicidal
  25. 25. Assessing for Suicide Risk inAdolescents-I There is no evidence that asking someone about suicide will make them suicidal Ideation  Be frank Plan  Realistic?  Perceived & actual lethality? Intent  How serious? Compare with plan & means
  26. 26. Assessing for Suicide Risk inAdolescents-II Means Despair & hopelessness Presence of psychopathology History of suicide attempts  Take thorough history Family history of suicide Suicide in community Significant psychosocial stressor  Consider adolescent’s perception of stressor
  27. 27. Assessing for Suicide Risk inAdolescents-III Physical health  Change in status, e.g., STD, HIV, unplanned pregnancy, onset/exacerbation of chronic illness) Coping skills  Inflexibility, impaired ability to generate possible solutions Impulsivity
  28. 28. Assessing for Suicide Risk inAdolescents-IV Trust your clinical judgment If in doubt, consult with a colleague Remember that confidentiality is not absolute
  29. 29. Deliberate Self-Harm-I DSH is defined as hurting oneself with the intention of inflicting pain, rather than to die  e.g., cutting, burning, scratching skin, punching walls, head banging Suicidality & DSH usually occur on a continuum Important to conduct risk assessment, as adolescents may not realise the potential lethality of the DSH
  30. 30. Deliberate Self-Harm-II Important to be flexible with your definition of DSH when working with adolescents  e.g., starving oneself, train surfing, substance use, risky sexual practices Difficult to establish prevalence rates, as young people don’t often seek medical advice for DSH & there is a lack of clarity about definition of DSH
  31. 31. Why Do Adolescents Engage in DSH? Expression of emotional turmoil Expression of self hatred Lack of ability to express difficult emotions (sadness, anger, guilt, shame) As a means of feeling something if “numb” Physical pain welcome relief from emotional pain Patterns of DSH can be hard to break because usually involves facing intense emotions and/or memories
  32. 32. Managing DSH-for theclinician Highly anxiety-provoking for clinician Importance of self care Labour intensive for clinician Disrespectful attitudes of some workers. Can be punitive, angry, disrespectful, not take the young person seriously or witholding of appropriate treatment
  33. 33. Managing DSH – for clients If in doubt, ask the adolescent why (s)he engages in this behaviour Conduct a cost-benefit of DSH Acknowledge that the young person is doing the best that (s)he can to manage intense emotional distress If a pattern of DSH has been established, improvement will take time
  34. 34. Managing DSH – for clients Important to encourage clients when they take small positive steps Take them seriously  Young people who engage in DSH can & do accidentally kill themselves
  35. 35. Adolescent Substance Use - I Adolescence is a peak time for the initial use of many substances, including tobacco, alcohol & illicit drugs potential for serious sequelae:  school failure  medical problems  psychiatric morbidity  fatal accidents  suicide  violent crimes
  36. 36. Adolescent Substance Use - II Future patterns of drug use often result from drug exposure and use in adolescence incidence of illicit substance use in adolescents is increasing evidence that “gateway” use (of cigarettes & alcohol) can lead to illicit substance use & SUD
  37. 37. Adolescent Substance Use - III Australian studies consistently identify 1-2% of secondary students whose pattern of alcohol, tobacco or other drug use is problematic having an initial episode of a SUD places adolescents at risk of developing subsequent episodes
  38. 38. Adolescent Alcohol Use Approximately 30% of Australian adolescents engage in problematic alcohol consumption alcohol-related deaths in young people are underestimated alcohol use is higher in young people not enrolled in schools (cf. students)
  39. 39. Adolescent Cannabis Use Cannabis is the illicit drug that is most commonly used by Australian adolescents adolescents who use cannabis are more likely to progress to using other illicit substances early cannabis use associated with escalation of use
  40. 40. Problems Associated with Use Habitual use can result in decrease in functioning social stigma associated with use  can impact on availability of services health risks associated with illicit substance use  regulation of composition
  41. 41. Assessing Problematic Substance Use in Adolescents - I Majority of adolescents do not develop problematic patterns of substance use when assessing use, should be able to categorise use according to:  initiation of use  continuation of use  maintenance & progression within class of drugs  progression across class of drugs  cessation  relapse
  42. 42. Assessing Problematic Substance Use in Adolescents - II important to assess why the young person engages in substance use:  relief from boredom  weight control  coping with stress  avoiding negative emotional states  conformity  social reasons  to avoid withdrawal
  43. 43. Assessing Problematic Substance Use in Adolescents - III Important to also assess misuse of legal substances (alcohol, inhalants) & prescribed medications  if you don’t ask, they probably won’t tell you  may need to educate yourself & client re risks associated with pattern of use principles of motivational interviewing are useful  need to understand what the adolescent thinks is good about using the substance
  44. 44. Managing Adolescent Substance Use Don’t pretend you know which drugs are which - ask the adolescent if unclear Acquaint yourself with the local drug & alcohol service, either individually or by setting up regular secondary consultation  important to inform yourself & advise client with accurate information (e.g., signs of intoxication, withdrawal, dangers of overdose, etc.)
  45. 45. Harm Minimisation Common & useful policy of youth agencies in Australia  cf. zero tolerance policy, common in US some strategies are specific to particular substances (e.g., SSRIs & ecstasy, size of bags with chroming), but others are relevant to all substances
  46. 46. Harm Minimisation Principles Don’t use alone. Try to use with friends & nominate one sober person know your limits (safe vs. unsafe intoxication) dangers of illicit substance use use a regular dealer have a “taste” first, i.e., test strength of substance (useful with heroin injection & ecstasy tabs)
  47. 47. Personality Disorders: Background Clients diagnosed with a PD have historically been perceived as untreatable. This is not necessarily the case, but reflects the lack of RCTs in the area lack of rigour associated with diagnosis of PDs  complexity (time needed)  importance of gathering information across time (many clinicians don’t do this)
  48. 48. Personality Disorders: Background Clients with PDs can evoke difficult emotions in clinicians important difference between:  Axis I (by definition episodic in nature)  Axis II (by definition pervasive & longstanding) definition of personality traits are “stable & enduring”  in PDs it is these that lead to distress or impairment
  49. 49. Personality Disorders: Background Important to assess how your client’s personality impacts upon those around her/him for Dx of PD: need evidence that the client’s way of interacting is maladaptive can be difficult to differentiate between a PD & an Axis I disorder, especially if Axis I disorder has an early onset & is stable over time  e.g., social phobia & Avoidant PD
  50. 50. Personality Disorders in Adolescence Can be difficult to identify during this time, as onset is usually in adolescence or early adulthood difficulties associated with assessing how your client’s personality impacts upon those around her/him:  nature of adolescent relationships can be intense & rapidly changing  frequent increase in conflict with parents: evidence of PD or normative?
  51. 51. Eating Disorders in Adolescence - I Symptoms usually emerge in adolescence (cf. low prevalence in childhood) Associated with extensive mortality & morbidity  20% mortality rate for AN at 20yr follow up symptoms usually stable over time
  52. 52. Eating Disorders in Adolescence - II subthreshold symptoms are prevalent in a number of cultures  13% of US adolescents report purging  predictive of full blown disorders  subthreshold symptoms associated with significant dunctional impairment dieting is a risk factor for the developments of eating disorders  60% of Australian 15yo females diet at a moderate level ( Patton et al., 1999)
  53. 53. Associated Features Depressive Symptoms (especially for BN) DSH Substance abuse Suicide attempts Poor school performance Withdrawal from peer relationships Deterioration in family relationships Physical complications *
  54. 54. Physical Complications - I Amenorrhea Starvation syndrome  Reduced metabolic rate  Bradycardia  Hypotension  Anaemia  Intolerance to cold Lanugo
  55. 55. Physical Complications - II Delayed gastric emptying Electrolyte abnormalities  Can lead to potentially fatal cardiac arrhythmia Renal problems Erosion of dental enamel Oesophageal tears Reduction in bone density
  56. 56. Management of Eating Disorders in Adolescents - I Know how to calculate a BMI Be aware that I/P treatment may be needed (especially for AN) Be ready to work in conjunction with a medical practitioner Limitations of psychological treatment if young person is physically compromised
  57. 57. Management of Eating Disorders in Adolescents - II Evidence for the efficacy of CBT & IPT in the treatment of BN  May also need to treat comorbid depressive Sx For AN literature is less clear  Treatment is rarely brief Adjunctive family therapy is often very useful Use of support groups/organisations for families  e.g., EDFV