Indentifying co-occurring disorders in adolescent population

A structured diagnostic interview (Practical Adolescent Diagnostic Interview) designed to gather basic information about substance use disorders, other mental health conditions, and related experiences was used in a variety of clinical settings. Anonymous data from 279 adolescents interviewed as part of routine clinical assessments in a variety of clinical programs were analyzed to assess the ability of the questions to identify potential problem areas and to provide a preliminary exploration of interrelationships between those problems. Results demonstrated that the vast majority of individuals manifested indications of multiple problems. For a given diagnostic condition, the trend is for those meeting at least the minimal DSM-IV criteria to exhibit substantially more than the minimum number of symptoms. Internal consistencies for item groups defining the various conditions range from more than .700 to over .900 indicating adequate to excellent internal consistency and reliability. Utility of the instrument for routine clinical use is also discussed.

EINAQ -- a European educational initiative on Attention-Deficit Hyperactivity Disorder and associated problems

BACKGROUND

Continuing Medical Education (CME) plays an important role in quality management, especially as quality assurance, for the improvement of healthcare in child and adolescent psychiatry. This requires responsibility regarding quality standards of clinical practice throughout Europe as outlined by the European Union of Medical Specialists (UEMS).

OBJECTIVE

Therefore, steps should be undertaken to improve specialists' medical care and harmonize it in Europe. Attention-Deficit Hyperactivity Disorder (ADHD) with its many co-existing developmental disorders/problems is the central healthcare problem in child and adolescent psychiatry with high impact on society. Therefore, it was chosen as the target.

METHOD

A European Interdisciplinary Network for ADHD Quality Assurance (EINAQ) was founded, didactic material was developed and a faculty of experts from several European countries established to offer all over Europe harmonized courses on ADHD and associated problems.

RESULTS

Pilot courses were given in Germany in 2003/2004 and were highly appreciated by the participants. Further courses in Germany and other European countries will take place in 2004.

CONCLUSION

EINAQ seems to be on the right track to be part of CME and specialized networks for healthcare in ADHD to improve the provision for mental health problems in children and adolescents in Europe. Cooperative projects with official European bodies like the UEMS -- Section on Child and Adolescent Psychiatry/Psychotherapy and the European Society of Child and Adolescent Psychiatry could strengthen the impact of EINAQ.

A Group Adaptation of Interpersonal Psychotherapy for Depressed Adolescents

This paper presents an overview of the adaptation of Interpersonal Psychotherapy for depressed adolescents (IPT-A) to be delivered in a group format (IPT-AG) for the treatment of depressed, nonbipolar outpatient adolescents. The model has been modified to address the challenges of working with several adolescents in a group context. It takes advantage of the group as a laboratory environment for experimenting with new ways of communicating and interacting with others. The IPT-AG manual, described in this paper, provides guidelines for working with multiple interpersonal issues and keeping the group discussion relevant to the group as a whole. These adaptations are discussed in the context of the interpersonal framework with respect to each phase of treatment. Preliminary data about the feasibility and acceptability of conducting IPT-AG are discussed.

Testimonial psychotherapy for adolescent refugees: a case series

Adolescent refugees are a traumatized, vulnerable group of arrivals to America who lack experience with or interest in psychiatric care. Testimonial psychotherapy's unique focus on transcribing personal, traumatic events for the altruistic purpose of education and advocacy make it an acceptable interaction by which to bridge the cultural gap that prevents young refugees from seeking psychiatric care. The theoretical basis for testimony is discussed. Testimonial psychotherapy has been used with adult refugees, but not with adolescents. This article describes the testimonial process with three Sudanese adolescents (the so-called 'Lost Boys'), which appeared feasible and safe. An efficacy study is underway.

Child and adolescent inpatient restraint reduction: a state initiative to promote strength-based care

OBJECTIVE

To reduce the use of restraint and seclusion with children and adolescents in psychiatric inpatient units by promoting a preventive, strength-based model of care.

METHOD

The State Mental Health Authority used data analysis, quality improvement strategies, regulatory oversight, and technical assistance to develop and implement system change over a 22-month period. No changes in regulation or policy were undertaken.

RESULTS

Comparative data collected before and after the interventions demonstrated substantial reductions in the use of restraint and seclusion. Child units (age 5-12) decreased from 84.03 to 22.78 episodes per 1,000 patient days (72.9%), adolescent units from 72.22 to 37.99 episodes (47.4%), and mixed child/adolescent units from 73.37 to 30.08 episodes (59%).

CONCLUSIONS

The use of restraint and seclusion in child and adolescent inpatient settings can be reduced through a systems approach, which may have applicability to other settings and systems.

Using music as a therapy tool to motivate troubled adolescents

Children and adolescents with emotional disorders may often be characterized by having problems in peer and adult relations and in display of inappropriate behaviours. These include suicide attempts, anger, withdrawal from family, social isolation from peers, aggression, school failure, running away, and alcohol and/or drug abuse. A lack of self-concept and self-esteem is often central to these difficulties. Traditional treatment methods with young people usually includes cognitive- behavioural approaches with psychotherapy. Unfortunately these children often lack a solid communication base, creating a block to successful treatment. In my private clinical practice, I have endeavoured to break through these communication barriers by using music as a therapy tool. This paper describes and discusses my use of music as a therapy tool with troubled adolescents. Pre- and post-testing of the effectiveness of this intervention technique by using the Psychosocial Functioning Inventory for Primary School Children (PFI-PSC) has yielded positive initial results, lending support to its continued use. Music has often been successful in helping these adolescents engage in the therapeutic process with minimised resistance as they relate to the music and the therapist becomes a safe and trusted adult. Various techniques such as song discussion, listening, writing lyrics, composing music, and performing music.

Quantitative Documentation of the Therapeutic Efficacy of Adolescent Telepsychiatry

The following is a case report of a 15-year-old adolescent who was evaluated and treated via telepsychiatry as part of an ongoing project at the University of Michigan Health System and the Hiawatha Community Mental Health Center in Michigan. In addition to clinical information, prospective quantitative data was collected at baseline, 6 weeks, and 3 months. Measures included the Youth Self Report (YSR), Child Behavior Checklist (CBCL), Suicide Probability Scale (SPS), Reynold's Adolescent Depression Scale (RADS), Connor's Global Index-Parent Version (CGI-P), and the Children's Global Assessment Scale (CGAS). Prior to the telepsychiatry intervention, the patient was diagnosed as having bipolar disorder with psychosis. During the telepsychiatry intervention, the diagnosis was altered to a posttraumatic stress disorder; medications were discontinued and the patient improved. All scales showed reductions in severity of symptoms after the telepsychiatry interventions. This case represents the first application of adolescent telepsychiatry for the diagnosis, treatment, and tracking of clinical symptoms.

[Planning and implementation of evaluation studies in child and adolescent psychiatry]

An introduction into planning and implementing evaluation studies in child and adolescent psychiatry is presented. After the presentation of theoretical aspects of evaluation studies, the necessity of these studies is elucidated. Further, a conceptualisation of the dimensions of a treatment programme and some criteria for the selection of outcome criteria are offered. In addition to symptomatology, other criteria such as family functioning and quality of life are proposed in this context. Furthermore, it is recommended to ascertain data already at the time of the patient's registration. The influence of drop-out rate on the study result makes it necessary to closely consider any missing data. These and other problems lead to the conclusion that a sophisticated and complex evaluation methodology is required to assess the performance of a child and adolescent treatment programme validly. Finally, the design of the Hamburg evaluation study is presented, which is suitable for the implementation of some of the mentioned aspects.

Clinical application of the gender role strain paradigm: Group treatment for adolescent boys

The aim of this article is to demonstrate the clinical application of the gender role strain paradigm with a group of adolescent boys. Adolescent boys experience overwhelming pressure to adhere to gender norms. As they attempt to conform to the expectations associated with the male role, boys suffer from gender role strain. We illustrate how the protective environment of the group enables boys to engage and discuss problems with male role norms. The shift in the boys' adherence to traditional notions of masculinity supports the utility of the gender role strain paradigm in clinical work.

Creating sanctuary in residential treatment for youth: from the "well-ordered asylum" to a "living-learning environment."

This paper addresses the need for a coherent conceptual therapeutic approach to guide work with disturbed children and adolescents in residential treatment centers. The paper identifies changes in the population currently in care; examines the two dominant approaches that historically have shaped the standard treatment models used by most residential centers; and discusses four longstanding debates that have complicated the development of a consistent therapeutic approach for residential programs. It concludes with a description of The Sanctuary Model. Integrating a variety of treatment approaches, this trauma-based systems approach to care was first used with adult inpatients traumatized as children. It is now being introduced by a major social agency into three of its residential centers to provide a systematic treatment model for use in their schools, living units, and treatment sessions.

A new priority in psychiatry: focused services for adolescents

Finland was the first European country to give a high priority to the development of specialized psychiatric services for adolescents. The aim of this paper is to 1) describe the development of these services, 2) study the status and the functioning of psychiatric services for adolescents in 2000 and 3) present some future challenges. The data have been collected from the social welfare register, from a questionnaire sent to Health Districts and via telephone interviews. In addition, the functioning of the treatment system has been studied in detail in one Health District by means of interviews and questionnaires. The general targets set in 1987 giving national priority to focused psychiatric services for adolescents were mostly reached in 2000, and resources for adolescents have increased markedly. In spite of this, minors still have to be treated in adult psychiatric wards. Many problems were detected in the functioning of the chains of treatment for adolescents. The differentiation between primary and secondary care was unclear. Primary care had a limited capacity in the early detection of mental disorders in adolescents. The services for adolescents were broken down into small units. Furthermore, there were no comprehensive future plans. The need for specialized psychiatric services for adolescents is evident. In addition to developing adequate resources, the quality of care should also be guaranteed by training and by competent long-term planning of psychiatric service systems.

Transforming psychotherapy in order to succeed with adolescent boys: Male-friendly practices

The purpose of this article is to describe a "male-friendly" therapeutic process with troubled adolescent boys. A male-friendly process is one in which the therapist employs a wide variety of strategies and activities that are likely to appeal to male youth and that facilitate the establishment and maintenance of rapport. The nuances of practicing a male-friendly approach are highlighted and then applied in a case study of psychotherapy with a depressed adolescent boy. The implications of this approach for redefining professional conceptions about boundaries in the client-therapist relationship and reexamining inaccurate stereotypes about the emotional lives of boys are discussed.

Assessing the implementation and effects of a trauma-focused intervention for youths in residential treatment

This paper describes methods being used to implement and assess the effects of a trauma-focused intervention in residential treatment programs for youths with emotional and behavioral problems, and histories of maltreatment and exposure to family or community violence. Preliminary baseline profiles of the therapeutic environments and youths are also presented. The intervention, referred to as the Sanctuary Model (Bloom, 1997), is based in social psychiatry, trauma theories, therapeutic community philosophy, and cognitive-behavioral approaches. Within the context of safe, supportive, stable, and socially responsible therapeutic communities, a trauma recovery treatment framework is used to teach youths effective adaptation and coping skills to replace nonadaptive cognitive, social, and behavioral strategies that may have emerged earlier as means of coping with traumatic life experiences.

The Juvenile Suicide Assessment: an instrument for the assessment and management of suicide risk with incarcerated juveniles

This article presents and describes the Juvenile Suicide Assessment (JSA). The JSA is a suicide risk assessment instrument that can be used by mental health professionals who work with youth involved in the juvenile justice system. The rationale and clinical significance of each of the suicide risk and protective factors comprising the JSA are discussed. The authors discuss important considerations for assessing suicide risk among incarcerated juveniles and identify how the JSA may have clinical-utility for accomplishing this task.

Caregiver understanding of adolescent development in residential treatment

PROBLEM

Caretaker knowledge and understanding of adolescent development and its application to clinical practice with severely emotionally disturbed adolescents in residential treatment.

METHODS

Twenty child-care workers and registered nurses participated in semistructured interviews analyzed using dimensional analysis, a grounded theory method.

FINDINGS

Three distinct categories of caregivers were identified based on level of expertise and engagement in developmentally appropriate treatment practices: inexperienced, party-liners, and transcenders. Developmental issues identified included lack of resident preparation for puberty and staff discomfort with adolescent sexuality.

CONCLUSIONS

Caregiver, institutional, and social barriers to developmentally sensitive practice were identified. Practice recommendations include direct preparation of children and adolescents in residential treatment for pubertal changes and sexual development, and careful discernment of age-appropriate and psychopathological adolescent behaviors.

Transformative change of self: the unique focus of (adolescent) mental health nursing?

In mental health nursing, inadequate nursing practice research has resulted in a deficit of knowledge concerning the nurse-client relationship; an area seen as the heart of practice. In turn, the specialty has experienced difficulty in identifying its unique domain of practice. Findings from a hermeneutic study into adolescent mental health nursing explicated its practice knowledge. These findings include: (i) 'engaging in therapeutic relationships'; (ii) 'guiding the potential for change'; and (iii) 'facilitating positive outcomes'. A higher order finding was named 'fostering a functional self'. These findings are discussed. Findings point to the nature, purpose and processes of the nurse-client relationship, and to outcomes from that relationship. It is suggested they also represent a beginning understanding of the specialty's unique contribution to nursing; that mental health nursing fosters transformative change of self.

Coding of pediatric behavioral and mental disorders

BACKGROUND

In response to changing reimbursement and other pressures in the health care environment, many physicians have reported the use of alternate coding to substitute for certain clinical diagnoses. However, very little information is available on how physicians who care for children approach diagnosis and coding dilemmas for behavioral and mental disorders, which often present unique additional challenges.

OBJECTIVE

Our study sought to describe the frequency of alternate coding, different approaches to coding, and attitudes toward diagnosis and coding practices by physician specialty.

METHODS

We conducted a mail survey of 1492 physicians--497 developmental/behavioral pediatricians (DBP), 500 pediatricians (PED), and 495 child and adolescent psychiatrists (PSY). The main outcomes were survey items on frequency of alternate coding (never, rarely, monthly, weekly, daily), use of different coding strategies (use of somatic symptoms, modifiers, and substitution with other terms), and attitudes on coding practices (Likert scales of agreement). We analyzed outcomes by physician specialty and demographics using Pearson's chi2 and multivariate logistic regression.

RESULTS

Overall response rate was 62% (787 of 1269 eligible physicians). The majority of physicians had used an alternate code (DBP 83%, PED 68%, PSY 58%), and many respondents reported monthly-daily alternate coding (DBP 60%, PED 36%, PSY 27%). Physicians used multiple approaches to diagnosis and a variety of coding options, which varied by physician specialty. Financial issues were commonly cited reasons for alternate coding--both to obtain patient services and to receive physician reimbursement. However, challenges of diagnostic classification and coding subthreshold symptoms were cited as frequently as reimbursement issues. Stigmatization, confidentiality, and parental acceptance were mentioned, but reported less frequently. Very few practices and providers have organized administrative methods of alternate coding (26%) or receive feedback on denied claims (46%). Most physicians believe that alternate coding is justified in the present system; however, some physicians expressed concerns that these practices may contribute to stigmatization or lead to improper management decisions.

CONCLUSIONS

Alternate coding is commonly reported; however, approaches to diagnostic coding vary by provider specialty. Reimbursement issues are important, but other challenges in diagnosis and classification hold special relevance to children with behavioral and mental disorders. There seems to be a great need to reconsider the separate goals and uses of clinical diagnosis and administrative coding. Additional study is needed to assess how reported coding practices may affect administrative data, patient care, and health care economics.

Deliberate self-harm in adolescence: a systematic review of psychological and psychosocial factors

AIMS

This paper is a systematic review of the research literature that identifies psychological and psychosocial factors associated with adolescent deliberate self-harm (DSH). The aims of this review were to identify the key psychological and psychosocial factors that aid the identification of individuals at risk of DSH, and suggest specific strategies for intervention.

BACKGROUND

Research has highlighted a parallel rise in rates of DSH referrals to general hospitals and rates of successful suicides in the younger age groups and gender groups. It is also highlighted that pressure on services in responding to these increases may be resulting in an inadequate response to both first-episode DSH and repetition of self-harm. One cause for concern is the lack of adequate psychosocial assessment for adolescents presenting at hospital following a DSH incident. Research of the literature suggests that there may be a paucity of research into after-care strategies in self-harm to prevent repetition and escalation of self-destructive behaviour.

METHODS

A systematic review of the literature was conducted to identify the psychological and psychosocial factors relating to DSH. Results. The results found typical psychological and psychosocial factors associated with DSH in adolescents, although psychosocial factors were less consistently measured because of the breadth of tools and methods used.

CONCLUSIONS

It is discussed whether associated factors are causative of DSH or the accompanying symptoms in DSH. It is suggested that positive psychosocial factors may have a part to play in providing protection against DSH behaviour. Therapeutic responses to DSH are suggested as preventative measures against repeat episodes.