Treating Adolescents

Hans Steiner, Rebecca E. Hall

• Publisher: Wiley
• Year: 2015
• ISBN:
  9781118961704
• Edition: 2
• Topic: Psychologie
• Subtopic: Psychothérapie

A unique guide to adolescent psychopathology, using a developmental approach

Treating Adolescents is a comprehensive guide to adolescent mental health care, synthesizing evidence-based practice and practice-based perspectives to give providers the best advice available. By limiting the discussion to disorders which appear during adolescence, this useful manual can delve more deeply into each to present extensive evidence and practice-based rationales for approaching a range of psychopathologies. This edition has been revised to reflect the changes in the DSM-5 and the ICD-10, with entirely new chapters on ADHD, learning and executive function, bipolar and mood disorders, sleep disorders, and suicide and self-injury. Coverage includes non-therapy interventions, such as pharmacological and environmental. The discussion of schizophrenia and psychotic disorders includes adolescent presentations of Pervasive Developmental Disorders and their relationship to classical schizophrenia.

In a developmental approach to adolescent psychopathology, different treatments are carefully integrated and matched to pathogenic processes in an effort to disrupt causal loops. This book provides in-depth guidance for providers seeking well-rounded treatment plans, with detailed explanations and expert insight.

• Understand disruptive behaviors and ADHD more deeply
• Treat anxiety, depression, and mood disorders more effectively
• Handle psychiatric traumas and related psychopathologies
• Delve into substance abuse, self-harm, eating disorders, and more

Current scholarship favors developmental approaches to psychopathology and supports an emphasis on integrated treatment packages, including environmental, biologic, and psychological interventions. With full integration of practice and research, Treating Adolescents is a comprehensive reference for constructing a complete treatment strategy.

1
General Principles

Hans Steiner, Rebecca Hall, and Julia Huemer

In the morning I want to be dead, because I can't face the day. At noon I want to live forever, because Sarah smiled at me. In the afternoon I want a red sports car, because this geek next door has one. And in the evening I want to be anywhere but home because you are fighting with Mom again about nothing. Are you serious when you ask me “What do you really want?”

—15-year-old boy, in response to his father's question in the first month of treatment

One of the great joys of psychiatry is contributing to the personal growth and development of individuals who for a variety of reasons are off-course in their lives' trajectories. Nowhere is this task more gratifying than with patients in adolescence. To intervene early and in a timely fashion with teenagers can save them years of misery and can prevent perceived wrongs from becoming a dominating influence in their lives. Such interventions are uniquely rewarding because they not only relieve suffering, but also prevent future pain.

This opening chapter is organized in three parts: First, we describe some general principles of development; then we address special problems that make working with the psychiatrically disturbed adolescent more challenging than working with adults and children; and finally we end by outlining a prototypical assessment and treatment plan that our teams utilize in our clinics at Stanford.

The treatment of adolescents is qualitatively different from that of children, a point easily understood by clinicians. Play, the major form of communication with children, is usually no longer useful with teenagers. Although verbal interchanges of adolescents resemble those of adults, communications with adolescents are certainly not identical to interchanges with adults. In particular, although the verbal and cognitive abilities of adolescents are comparable to those of adults, adolescent life experiences; interpersonal relationship patterns; stability of psychological structures, attitudes, beliefs, and behaviors; and capacities for working alliance and affiliation are not.

Basic Concepts of Adolescent Development

The clinician working with adolescents must take into account the nature of normative (i.e., appropriate for this phase of development, but not necessarily in another, in other words, fluctuations in self-esteem, planning for the future, inhibiting impulsive behavior) developmental changes when reaching a diagnosis and planning treatment. One needs to recognize that the span of adolescence and emerging adulthood (from now on we use the term adolescence for both), approximately 10 to 15 years, is not a unified stage of life and thus, behavior that is appropriate (normative) for one phase of adolescence may be indicative of psychopathology in another.

The term adolescence generally covers the second decade of life and consists of three phases, demarcated for convenience by age: early adolescence (10–13 years), mid-adolescence (14–17 years), and late adolescence (18–20 years). Emerging adulthood is a new developmental phase that encompasses ages 18 to 25. Developmental tasks to be completed are different in each of these subphases. In early adolescence, coming to terms with puberty, physical growth, and altered appearance tends to be center stage. These changes are the concrete reminder that one's relationship to the family is about to change in unprecedented ways. Middle adolescence usually brings on the realization that one's cognitive powers are equal to and even surpass some adults' abilities. This facilitates a more comprehensive look at oneself, the forging of a new identity, greater independence from the family, and an increasing reliance on peer relationships. Along with these changes comes a need for increasing privacy, which brings along new thrills and risks. Late adolescence is the stage where preparation for exit from the family of origin is central. Although this is usually not completed until the phase of emerging adulthood, there are many periods where the youth is completely independent, even responsible for others (such as younger siblings and peers). In early adulthood, there is a consolidation of independent living, extending to financial aspects as well. We also expect a consolidation of career choice and work trajectory, and partner choices become longer term, with an eye toward more balanced and binding relationships.

To some degree these tasks overlap and extend into other subphases, but there is merit for the clinician to keep an eye on how far a patient has come in resolving some of these dilemmas as they present for intervention. Very often, these tasks also are the triggers for whatever symptoms they present with. By helping the patient in resuming development after symptom control has been achieved, we can also use progress in these tasks as a measure for the resumption of maturity and continued growth.

Although there are individual differences within each phase of adolescence and gender differences, with girls proceeding through the sequence more rapidly than boys, each phase carries with it some information as to what is normative and acceptable in a given society or context. For example, in the area of heterosexual relations, in some middle-class communities boy-girl parties and school dances are acceptable in early adolescence, going out on dates is not acceptable until mid-adolescence, and sexual explorations, if acceptable at all, are condoned only at late adolescence. In other communities such as African American inner-city neighborhoods, the sequence can be earlier, with dating acceptable in early adolescence and sexual activity acceptable or at least normative in mid-adolescence. Yet in other communities, such as Mediterranean, Mormon, or Muslim neighborhoods, opposite-sex relations occur relatively later, with dating unacceptable until after high school completion. Knowledge of community norms for each phase of adolescence permits a clinician to differentiate between “on-time” age-appropriate explorations of different roles and behaviors that may have risky consequences from genuine full-blown psychopathology. The social context of behavior differentiates normative (i.e., age appropriate) from pathological. As the U.S. populations increase in diversity, these considerations become ever more important.

The developmental changes that occur during adolescence are extensive and affect virtually every domain of a teenager's functioning. Other than infancy, in no other stage in life do so many rapid changes take place. These begin with pubertal changes affecting appearance, behavior, and mood, relationships with others, and risk-taking. Our bodies go through rapid growth and development. Our muscle mass seems to increase overnight. Secondary sex characteristics appear and become the source of attention, pleasure, worry, and concern. Our appearance, which for so many years has been quite stable, becomes altered to such an extent that we sometimes have difficulty recognizing ourselves. And yet, we cannot stop looking at ourselves in the mirror. Our minds begin their steady expansion to adult scope. When teachers demand that we perform unprecedented feats of learning, we discover to our amazement that we are indeed able to deliver, even contrary to our own expectations. We note a new tone in our interactions with adults. They now sometimes treat us as equals. They respect our privacy, as they should. They even solicit and earnestly consider our opinions. And, most importantly, there is a new undercurrent in our social interactions, an added new dimension and new excitement that suddenly turns age-old playmates and acquaintances into objects of desire.

At any given time, we feel out of synchrony with ourselves, strangely off balance. When everything in us and around us is changing, it is hard to find our bearings and remain solidly grounded; yet this is precisely what our families and society expect us to do. As we prepare the final exit from the protective social structures of childhood, we need to convince others—and ourselves—that we are ready to take the big step. We need to rely increasingly on ourselves, or at least appear to, while taking on new tasks and unprecedented risks.

Adolescence is also a time of great excitement, an opening to the world and a discovery of what we stand to inherit. It is a time of growth and acquisition of new instruments, skills, and emotions. We discover that we know more and are able to do more (especially electronically) than our fathers, mothers, and grandparents—a frightening and exhilarating concept. We notice that others notice us in novel ways, and this provides a new thrill and threat at the same time, and raises questions as to how we will integrate sexuality into our lives.

What follows is just a brief synopsis of some of the details of major changes, and we direct the interested reader to a recent volume with state-of-the-art reviews of adolescent and emergent adulthood development (see the suggested reading at the end of this chapter).

Pubertal Changes

Puberty brings marked changes in a teenager's appearance, with accelerated growth, weight gain, changes in body configurations, the maturing of the reproductive organs, and the development of the secondary sex characteristics such as facial and body hair for males and body hair and breast development for girls. These changes, mostly visible and external, serve as signals both to the adolescents themselves and to others of their more mature status and their reproductive abilities. The hormonal changes that underlie these developments are implicated in the increased moodiness of teenagers, their newfound interest in the opposite sex, sexual strivings requiring some acknowledgment, and perhaps an elevated level of aggression.

There is significant variation in the age at which children enter puberty, and this variation is significant in its effect on their functioning. Early maturers in the two sexes fare differently: Girls who begin menstruation early and show the expected bodily changes are usually more at risk for teasing, inappropriate remarks, and associating with older peers and its attendant risk-taking (smoking, drinking, using drugs, and engaging in early sexual activity). Just at the time that early maturing girls are experiencing more conflict and feeling somewhat more distant from their parents, their bodies provide a strong and mostly unwanted attraction for attention from the opposite sex. To deal with this multitude of changes is a challenge at any age, but it particularly stresses the younger, inexperienced adolescent whose psychological structures are relatively weak. Not surprisingly, there is some evidence that early maturing females—that is, those who start their menses a year or two ahead of their peers—tend to have a higher rate of psychopathology (especially internalizing pathology such as anxiety disorders, anorexia nervosa, or depression) than their “on-time” classmates. In contrast, early maturing boys seem to be at some psychological advantage in that they are given more leadership experience; are judged more attractive by girls; are at a competitive advantage in sports, which gives them status in the peer group; are generally popular with peers; and date more. This advantage, however, can come at a price: these early maturing boys are more prone to taking risks and exposing themselves to risky situations.

For boys, it is the late maturers who have more trouble in being “off-time” in their development. To lack facial hair in mid-adolescence, to be small and skinny rather than tall and muscular, to look “child-like” when others look “adult-like” makes for a difficult transition. Late maturing boys often seek attention by becoming bossy or unduly talkative, or taking the part of the classroom “clown.” The unintended result of these behaviors is generally to make the late maturer less popular with both same-sex and opposite-sex peers.

Cognitive Changes

Pervasive changes in cognitive functioning permit adolescents to deal with abstractions; project thought into the future; examine previously unquestioned attitudes, behaviors, and values; and to take themselves as the object of their own thought. David Elkind claims these changes precipitate a form of egocentrism in which adolescents act as if they are on st...