Attachment representations in adolescence: further evidence from psychiatric residential settings

The Adult Attachment Interview (AAI) has afforded the opportunity to profile the various ways in which people make sense of early experience. While the initial research with the AAI was primarily based on non-clinical populations, this paper extends the growing body of knowledge concerning attachment representations in clinical samples, specifically among severely emotionally disturbed adolescents. The study investigated 39 adolescents resident on five regional adolescent units in the south-east of England. As predicted, the number of adolescents presenting as securely attached was low (n = 4), whilst the incidence of insecure attachment patterns in the sample was high (n = 35). When interviews were rated additionally in terms of lack of resolution, 59% of the sample were unresolved with respect to experiences of trauma or loss. Discussion addresses the possible uses of the AAI in therapeutic interventions for severely disturbed adolescents, which are centrally based on the formation of a secure, safe relationship with a non-threatening adult.

[Transcranial magnetic stimulation in child and adolescent psychiatry: excitability of the motor system in tic disorders and/or attention deficit hyperactivity disorders]

Motor system excitability can be investigated in vivo by means of single and paired pulse transcranial magnetic stimulation (TMS). Whereas the cortical silent period reflects the general degree of inhibitory mechanisms mainly within the sensorimotor loop, intracortical excitability measures the focused degree of inhibitory and facilitatory mechanisms within the motor cortex. In child and adolescent psychiatric disorders with uncontrollable motor behavior such as tics in tic disorder or motoric hyperactivity in attention deficit hyperactivity disorder (ADHD), different dysfunctional patterns of motor system excitability could be demonstrated compared to age-matched healthy controls: (1) In tic disorder, a shortened cortical silent period was observed, providing evidence of deficient inhibitory mechanisms within the sensorimotor loop, probably primarily at the level of the basal ganglia. (2) In ADHD, a decreased intracortical inhibition was found, probably reflecting deficient inhibitory mechanisms within the motor cortex (but enhancement of intracortical inhibition after oral intake of 10 mg methylphenidate). In order to investigate neurophysiological aspects of comorbidity, (3) motor system excitability was also measured in children with combined ADHD and tic disorder. The findings of a reduced intracortical inhibition as well as a shortened cortical silent period in these comorbid children provide evidence of additive effects at the level of motor system excitability. These decreased inhibitory mechanisms within the entire sensorimotor loop and especially the motor cortex could be essential neurobiological substrates of the deficient inhibitory motor control and regulation, respectively, in tic disorder and ADHD.

School-based behavioral treatment for social anxiety disorder in adolescents: results of a pilot study

OBJECTIVE

To provide preliminary estimates of feasibility and effectiveness for school-based behavioral treatment in adolescents with social anxiety disorder.

METHOD

Six adolescents with social anxiety disorder were treated in a 14-session group treatment program conducted at their school. Assessments were conducted at baseline and after treatment.

RESULTS

All participants were classified as treatment responders (markedly or moderately improved). Half of the participants did not meet diagnostic criteria for social phobia after treatment. Clinician severity ratings, as measured by the Anxiety Disorders Interview Schedule for Children for DSM-IV: Child Version and the Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA), decreased significantly after intervention, with effect sizes of 2.5 and 1.8, respectively. All LSAS-CA scale scores decreased significantly after treatment. Self-reported social phobia symptoms on the Social Phobia and Anxiety Inventory for Children were not significantly reduced. Fear and avoidance ratings of the 10 most feared situations significantly decreased after treatment, with effect sizes of 1.5 for anxiety and 2.1 for avoidance.

CONCLUSIONS

This study provides preliminary support for the promise of school-based behavioral intervention for treating social phobia in adolescents. The school environment may be a rich and innovative setting for implementation of behavioral treatment because this is the setting where adolescents with social phobia endure the most distress.

[Dangers and possible negative effects of inpatient child and adolescent psychiatric treatments--recognition and prevention]

Psychiatric hospitals for children and adolescents have for a period of time many possibilities of impact on their patients who cannot be treated successfully in other conditions. However, inpatient treatment may display unwanted effects, too, which compromise the treatment goals. Ten possible areas of unfavourable collusion occurring with patients and their families will be presented. Measures to prevent them will be proposed. The relative lack of reliable research data on how inpatient treatment works and on outcome will be mentioned. The knowledge of emotional pitfalls pointed out help clinicians to cope with clinical problems arising within this area.

School crisis consultation

School crisis consultations are services necessary to assist school communities recover from disruptions that interfere with a learning environment. Child and adolescent psychiatrists are ideal participants in such consultations owing to their knowledge of child development, familiarity with school systems, family dynamics, stress reactions in children, and crisis intervention skills. The exciting challenge is to tailor a consultation based on a needs assessment, degree of impact of event, and other resources. Every consultation is a unique and stimulating learning experience. Those who develop expertise in this area will be poised to lead future consultation efforts. These consultations are now informed by an increasing body of research on children's stress reactions and various types of interventions.

Psychiatric school consultation. An organizing framework and empowering techniques

As the myriad biopsychosocial factors contributing to school success become better understood, opportunities will expand for child psychiatrists to contribute to schools. More collaborative roles with school staff will improve both the individual student's success and also the redefinition of schools as they better address the future needs of their students. Psychiatric consultation, including techniques that empower school staff, will become increasingly valuable.

Consultation about violent students

Violence in the schools is a growing problem. Psychiatrists consulting to schools can play an important role in helping school-based professionals with early identification, diagnostic evaluations, program planning, and prevention. They can also serve as educators and child advocates and help to coordinate and to organize a team approach.

Emerging models

In all these models, the potential of child psychiatrists and other mental health professionals in decreasing student barriers to learning is promising. While expanding the traditional client service model, child psychiatrists can serve as advocates for identifying student's unmet mental health needs, encourage schools to build capacity for effective responses, be vigilant for quality assurance, develop and initiate new programs that systematically respond to needs of the school community, and provide training opportunities that demystify the psychiatric concepts that can help administrators and teachers. Relatively few child psychiatrists are active in the school setting or have developed a presence in the national movement to provide mental health services in schools. In recognition of the fact that traditional models of psychiatric care such as outpatient clinics and hospital-based programs do not reach many children and adolescents, it is hoped that child psychiatrists will be more motivated to have a more active and rewarding presence in the school setting. Even with the variety of responses to the need for increasing mental health services to children, there are a lot of unanswered questions. With only 8000 child psychiatrists in the United States and 80,000 schools, it is clear that we need to be strategic about how best to utilize our resources. The big question is whether there are predictable and alterable characteristics, mechanisms, and interactive processes that enable high-risk students to attain educational and personal success, despite seemingly poor odds. Emerging models have the potential to begin answering this question.

Consultation to administrators

Mental health specialists can contribute to improvements in children's school experience when they work with administrators to incorporate up-to-date mental health knowledge into educational practice. Effective consultation is not simply a knowledge dissemination exercise. The impact of the consultant's input is determined by how responsive the consultation process is to the needs and assets of faculty, students, and the broader community.

School-based prevention of problem behaviors

Sex and violence are the major sources of morbidity and mortality among American youth. Problem-behavior prevention programs based in schools have been found to be feasible, acceptable, and desirable to school personnel, parents, and students for improving students' health status and educational outcomes.

High school consultation

High schools painstakingly plan their academic standards, curricula, instructional approaches, technology, and facilities. Also essential to the vision is a systematic plan for developmental guidance, prevention, at-risk services, intervention, crisis responding, and postvention. The consultant, working in partnership with a caring school staff, can promote safety and well-being and reduce risk-taking behaviors so that adolescents can get the most benefit from school experiences. Several protocols have been described that may guide a consultant in helping school personnel.

Consultation in the classroom

The advantages of classroom, playground, and hallway observation are that the diagnosing child and adolescent psychiatrist can directly observe the difficulties the child is having. When the psychiatrist is an employee of the school district, there can be easier access and quicker help for challenging students.

Opportunities within a large metropolitan school district

As a school district employee, the child psychiatrist can offer valuable school consultations at multiple levels as an "insider." The access to teamwork within the district system is particularly empowering and advantageous. This article outlines the richness and variety of school consultative opportunities within the school district.

Intensity and predictors of treatment received by adolescents with unipolar major depression prior to hospital admission

We sought to characterize the type and intensity of treatment received in the community by 80 adolescents with unipolar major depressive disorder prior to hospital admission for this index episode of illness. Structured clinical interviews were used to rate the presence and severity of a wide range of depressive symptoms and to derive global measures of episode subtype and degree of impairment. Multiple sociodemographic and clinical variables were considered as predictors of level of antidepressant treatment exposure. Although the majority of patients sought help prior to admission, only 58% received antidepressant medication, and fewer than half of these treated patients received levels of treatment deemed adequate by conventional standards. More aggressive levels of pharmacotherapy were received by only a small minority of the sample, and overall severity of illness had little effect on intensity of treatment. Specific clinical features associated with endogeneity were the most robust predictors of more intense antidepressant pharmacotherapy. A disturbingly high proportion of adolescents with serious depressive illness receive less than optimally aggressive treatment in the community relative to the seriously handicapping nature of their illness. The potential implications of these observations are considered.

The milieu and milieu therapy in adolescent mental health nursing

The milieu is a well discussed concept in the mental health nursing literature; so too is milieu therapy. Nevertheless, despite evidently clear understandings of the milieu's significance, and of its therapeutic potential, little published mental health nursing research focuses on these areas of practice. As a result, within the specialty, theoretical conceptualizations of the milieu remain unchallenged and theory development remains in its infancy. Findings from an inquiry into the practice of adolescent mental health nursing demonstrate the: (1) nature, (2) construction, (3) maintenance, (4) function, (5) therapeutic effects, and (6) outcomes of the milieu. Through these findings, present theoretical conceptualizations of the milieu are examined and expanded, and a beginning theory of the adolescent milieu, and of milieu therapy, is presented.

[Heidelberger study on psychoanalytic therapy of children and adolescents: methodology]

In the representative studies published so far on the outcome of analytic child psychotherapy (Dührssen 1964; Fonagy and Target 1996) no techniques of treatment were mentioned. The following paper describes in detail the technique of treatment on which the Heidelberg Study "On the Therapeutic Outcome in Child and Adolescent Psychotherapy" is based, as it developed from 1975 to 1993 at the Heidelberg Institute for Child and Adolescent Psychotherapy. Starting from Piaget's findings that the cognitive faculties of a child up to the age of 11 completely differ from those of an adult and taking into consideration the cerebral information processing and "the intellect pervadet sensory" (Schopenhauer) it is demonstrated that children take their intrapsychic and interpersonal conflicts into analytic play therapy or into role play on analogous levels. Protected by a safe distance from being aware of their conflicts they will on the analogous levels understand, work through, partially solve their conflicts and make use of it in reality without conscious recognition. The term "analogous level" is defined and the manifold possibilities of therapeutic intervention on this level are demonstrated. The efficacy of therapeutic treatment on analogous levels is discussed.

Appropriately timed interventions with the family and the adolescent: the role of the therapist

Family therapy conducted with a troubled adolescent is a difficult process. In this article the case scenario of a troubled teenager is presented. The adolescent's behavior is scrutinized through an examination of her growth, dynamics, family/parent interactions, and social support. Therapeutic and timely interventions--a blueprint for family therapy integrating psychoanalytic, Bowen, Milan, and behavioral approaches--are explained. The blueprint can be used to assess and assist in the change process of the adolescent. It is extremely important that new therapists realize when they are getting drawn into the content without appreciating the process of therapy. This realization will foster second-order change in the growth of a family therapist.