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Adolescent Psychiatry
Dr Nasima Matine
Specialist Registrar in Child and Adolescent Psychiatry
November 2010
Adolescent Disorders
 What is an adolescent?
 Adolescent development
 Psychiatric disorders in adolescence
 Talking to adolescents -CASC
The Adolescent is travelling
a long way without seeming
to go very far………… ‘no man’s land’
Adolescence is..?????
 Adolescence = latin ‘growing up’
 Covers age 13 – 19
 Unique time between:
Dependent child..................->Independent adult
 ‘no man’s land’- developing adult bodies; finding a role,
acquiring more rights, finding balance independence and
being somebody’s child
Sturm and drang ‘storm and stress’or is this a myth????
Time of
turmoil
Inevitable conflict
Parents / Society
.
It’s his / her
Hormones doctor
Necessary for
Development
Wayne and Waynetta
What does it mean to be an
Adolescent………..?????
Drive
Relationships
Alcohol/
Drugs
Sex / Pregnancy
Exams
Leaving home
Work / University
Adolescence
Peers v
Parents
Voting
Money
What can you do, at what age???
 Criminal responsibility- 10y
 Criminal responsibility- age may
 Gillick competence PT work- 14-16y
 FT work- 16y
 Sex gay /straight- 16y
 Drive- 17y
 Alcohol- 18y
 Smoke- 18y
 Vote- 18y
 Legal Adult-18y
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be raised
Gillick Competence- accept not
refuse treatment
2008- Channel 4 study: 1/3 15y
sexually active
Work- prevent child labour
When women 1st got vote UK
had be 30+y
A right of passage
 North American Indians- Vision Quest
 Africa- traditionally learning skills manhood: hunting,
physical stamina & strength, passage adulthood decided by
Elders - (now changed)
 UK- age 18, party, alcohol, new legal rights
Developmental Changes in Adolescence
Emotional
Physical
4 Domains
of change
Social
Cognitive
Spots, breasts, menstruation, hair, muscles,
Sexual desire, the sex talk?………Embarrasing??????
PUBERTY
PHYSICAL
Changes Bodily Systems
• ANS, liver metabolism
• Consequences medication
Brain Development
• SYNAPTIC PRUNING
• ? imbalance subcortical
limbic & PFCx  heightened
Emotionality
Adolescent Brain development
Schematic depiction of the main regions contained within each of the 3
nodes of the Social Information Processing Network (SIPN)*
*Nelson
et al
Psychol
Med 35:
163-174,
2005
 A schematic depiction of the main regions contained within each of the three
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nodes of the social information processing network (SIPN).
Brain regions that make up the detection node include the fusiform face area,
the superior temporal sulcus and the anterior temporal cortex. These regions
are involved in carrying out basic perceptual processes on social stimuli and are
highlighted in green.
Brain regions that make up the affective node include the amygdala,
hypothalamus, nucleus accumbens, and bed nucleus of the stria terminalis and
are highlighted in red. These regions interact with the detection node to imbue
social stimuli with emotional significance.
Brain regions that make up the cognitive-regulation node include the
dorsomedial prefrontal cortex and the ventral prefrontal cortex are depicted in
blue. This node is involved in inhibiting motivated response tendencies and
understanding the psychological perspective of other individuals as in theoryof-mind tasks.
The gray arrows between the three nodes indicate that these nodes are
interactive.
Normal Neurocognitive Development
Synaptic Pruning
Neuronal
Proliferation
What architecture
will be left to play with?
10
15
Age
20
25
2430
Complex abstract thought
- Justice, Morality
Body image
Less concrete
Discourse &
Arguement
Growing verbal
ability
Compare Self
to others
COGNITIVE
Developing a
Sense Self
I am unique
12-19 Psychosocial Crisis
Identity v Role Confusion
Who am I?
Where am I going?
>11y Formal Operational thought
Change egocentricity  abstraction
Thinking, Reason, Conceptualise
Ethics & Justice
Erikson
Piaget
COGNITIVE
Freud
Superego
Socially appropriate behaviour
Conscience: right & wrong
Fit into society
Developmental changes in adolescencecognitive development
Christie, D. et al. BMJ 2005;330:301-304
Copyright ©2005 BMJ Publishing Group Ltd.
Developing thought
Piaget
 2-7 years: Pre-operational stage [e.g. not getting
the principal of conservation]
 7-11 years: Concrete operational stage [getting
conservation, but not abstract concepts]
 >11 years: Formal operational thought
[concepts, ideals, ethics, justice…]
 c.50% of population probably never achieve
formal operational thought.
Identifying emotions
Who do I talk to??
Complexity Emotions
Controlled
Listened to
Lonely
Respected
Angry
Judged
Criticised
Rejected
Frustrated
EMOTIONAL
Cared for
Supported
Capacity regulate emotionsmaturity
Sense of Identity
Exploratory Behavior
- drugs / alcohol
Emotional Separation
from parents
SOCIAL
Peer identification
Changes nature
relationships
Parents
Partners Education
Communicating with adolescents
Useful questions to gauge
developmental level
 What degree parental separation achieved?
 What identities are evolving?
 How is past/future perceived?
 Do they perceive themselves as responsible for self?
 Can they weigh consequences of choices?
 How are sexual/affectionate interests expressed?
Communicating with adolescents
.
• See young people by themselves as well as with their
parents- make sure to document that you’ve asked if they
want to be seen alone, if refuse.
• Be empathic, respectful, and non-judgmental,
• Assure confidentiality in all clinical settings- be aware when
confidentiality may need to be broken, tackle this with
sensitivity
• Be yourself. Don't try to be cool or hip—young people want
you to be their doctor, not their friend
• Try to communicate and explain concepts in a manner
appropriate to their development- think about what words you
use.
Face - to - Faceness
Authenticity
Working
Adult-Adolescent interface
Rapidly shifting positions
No jargon
Energy
Coping Dunno,
Boring…
Working with
Adolescents
Honesty
Validation- self validation
Hope- chance to alter the trajectory
Why is a knowledge of adolescent
development important ?
Background of developmental changes: impacts upon:
 Nature/ presentation of illness
 Consequences of illness
 Relationship between the adolescent patient and healthcare
providers
 Is the presentation age appropriate???? Think LD, sexualised
behaviours
Psychiatric disorder and development
in adolescence
 Disorder delay aspect of development
e.g. Anorexia delays puberty
 Delay in development/difficulty negotiating tasks
of adolescence Disorder
e.g. Delay in puberty predisposes to anxiety/depression
 Dysfunctional System surrounding the adolescent 
disorder and difficulties negotiating developmental tasks
eg. Chaotic family leads to academic/social delay-school refusal or
conduct disorder
Psychiatric disorder in adolescence
How do we differentiate from normal functioning?
Impact
Persistence
Duration
Eg- on emotions/relationships/school/biological symptoms
depression
Trajectory and Vulnerability
Social Function and the Time-critical
nature of Adolescence
Social Function
Independent living skills
Educational qualifications
Etc.
Available
Support
Complexity
of social and
emotional
challenges
Adolescent
“Discomfort
Zone”
MENTAL DISORDER
Time
11yrs
18 yrs
Mental Health Problems and disorders
in adolescents
Common:
 Depression
 Anxiety
 ADHD
 conduct disorder
 substance misuse
 disordered eating (inc eating
disorders)
 risky behaviours e.g. Self harm
Less common:
 Psychoses
 PTSD
 Autism
Epidemiology psychiatric disorders:
Isle of Wight Study
Classic study 2303 14 and 15 y olds. Rutter 1976.
Main conclusions have stood test of time:
1. Definite psychiatric disorders in 10% of sample.
Another 10% self reported marked ‘misery’
2. Most were emotional and conduct disorders.
Depression: 2% (42% M; 48% F misery).
3. Just under ½ with disorders at 14 had them at 10y.
4. Only minority were alienated from parents. Commoner if
psychiatric disorder.
Management: Bio-Psycho-Social
Best choice takes into account individual and family:
 Medications
 Psychological treatments: CBT, DBT, IPT, Family therapy,
group therapy
 Educational liaison/support
 Behavioural management: parents/children
Case 1
 JM is 16. Took overdose ibuprofen.
 Sexually abused by uncle at 8.
 Been in CAMHS services since age 11.
 Problems: recurrent depression, impulsive behaviour-self
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harm/fire setting/ alcohol.
School refusal- lost over 50% last year.
Problems with relationships
Mum and dad incapacitated-mum abdo problems, dad
depression/physical problems.
Acts as ‘carer’ in the home; fiercely protective of sibs
Factors to consider
 Therapeutic alliance: trust and choice
 Previous treatments
 Family system-maintaining factors
 Cognitive sophistication
 ? Developing diagnoses
 Harm reduction strategies
 SIRSE: Symptoms, Impact, Risk, Strengths, Explanatory
model
Management
 Antidepressants
 Psychology-CBT/IPT
 Psycho-education
 Family work
 Sexual abuse-specialist work e.g. New Beginnings
 School liaison
Case 2
 LG 15 y old hardworking girl.
 Perfectionist traits, difficulty fitting in, social anxiety.
 Sibling issues: rivalry, dieting.
 BMI 16. Eating minimally. Calorie counting. Body image
problems.
 Missed 2 periods.
 Very weak/fatigued. Fainted before.
 Poor concentration-grades falling behind.
Issues to consider
 Willingness to engage: where on cycle of change
 Family context: sister dieting, parental value
 Peer and social ideas about food/being accepted
 Physical health complications: menstruation/bone
loss/hypotension/lethargy/electrolytes.
 Education
 Psychological functioning.
Management options
 Psycho-education
 Physical: weight monitoring and restoration, blood tests and
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physical checks.
Psychological challenge: motivational enhancement work
Family work
CBT/antidepressants-anxiety
School liaison
Case 3
 14 y old girl with polysubstance misuse.
 GP asks ‘does she have underlying schizophrenia?’.
Threatened family with knife. Talking to herself at times.
 Chaotic behaviour. Prostituted self. Risky situations.
 Parents extremely worried about safety. Think underlying
anxiety disorder
 Social services crisis team involved.
Issues to consider
 Motivational level to change behaviour
 Willingness to engage
 Safety issues
 Family issues: 5 y old brother, mum ‘nervous breakdown’
 Underlying problems: previous notes and treatments
 School work
Management options
 Psycho-education: drugs, sex and risk
 Inter-agency working: substance misuse team, social services
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key worker to ensure safety
Underlying illnesses-explore
School liaison
Psychological work-motivational enhancement
Practical monitoring: drugs diaries
Parental support
Further reading
 BMJ series of ABC Adolescence
CASC 1A Eating Disorder
 Lucy is a 14 year old girl
 She is a national championship swimmer and wants to be in
the Olympic Team
 Her mother is her coach
 Her GP refers her, as he is concerned she is loosing weight
 Take a history to elicit signs and symptoms of an eating
disorder
CASC 1a –Key points
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FOOD
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METHODS WL
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Current eating pattern – ‘take me through what you’d eat through the day?’
Avoidance fatty foods
Rules about eating- can sometimes be quite OCD in nature
Binging
Over exercise- sit ups, running spot, up & down stairs
Restriction
Vomiting
Laxatives, diet pills
Rate W/L
BODY IMAGE
 Feel overweight, other people say I’m not
 Do you feel need to loose more weight
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PHYSICAL
 Ammenorrhoea, cold, chest pain, SOB, exhausted, hair, nails, dry skin
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MOOD
 Often co-morbid depression
 Suicide
CASC 1b Eating Disorders
 You have just assessed Lucy
 You have a made a diagnosis of Anorexia Nervosa
 Please speak with her mother and explain the diagnosis and
management options to her mother
 You have Lucy’s permission to speak to her
CASC 1b Eating Disorders
 AN:
 morbid fear fatness, distorted body image  self induced WL
 AIMS
 Weight restoration
 Treat physical complaints – monitor weight, bloods
 Managing anorexic thoughts
 Improve level functioning
 Support family
 TREATMENT OPTIONS
 OP – Dietician / Psychoeducation, CBT, FT / Meal support
 IP – Unable to restore weight Physical complication, rapid WL,
psychiatric risk
CASC 2a Overdose
 Mike is a 16 years old
 He recently split up with his boyfriend and felt that he didn’t
want to live anymore
 He took an overdose of 20 paracetamol tablets with some of
his mother sleeping pills
 Take a relevant history
 Perform a risk assessment
CASC 2a Overdose
 Details OD
 Planned / spontaneous, how get medication, note, did weight
until his was left alone, how did get AE
 How does feel now? Regret, Active/ Passive suicidal ideation,
self harming thoughts
 Previous OD
 Psychiatric: Mood, Psychosis
 Relationships –friends, parents (abuse??), partners
 Support
 Drugs / Alcohol
 Ask if it’s ok to speak with his parents??
CASC 2b Overdose
 You have just seen Mike
 Please present your findings to your Consultant
 Discuss your plan
CASC 2b Overdose
 Succinct summary
 age, name, what happened, any psychiatric illness, risk
 Plan
 discuss whether manage OP or IP, think about criteria for this
 If OP, what does he need? Frequency OPA, Psychological input,
medication
 Risk management plan for him: CAMH in hrs, out of hrs AE /
out of hrs GP service; identify friends /family member to say ‘I
struggling’
 Think about importance liaising with family-
CASC 3a Fire Setter
 Georgie is a 15 years old
 She is a looked afterchild and lives in a care home
 She recently set fire to the paper bin in her bedroom
 The police were called and she was brought to AE
 The staff are very concerned and say she has been behaving
oddly
 Please take a history
CASC 3a Fire Setter
 This is a station about being sensitive to the needs of the
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individual and taking a careful history & also think about risk
Georgie is a LAC child, she was brought into the care system
aged 13, after it was found out that her stepfather was
sexually abusing her. Her mother knew this was happening.
Her emotions switch rapidly, she cuts to relieve distress, she
often feels really angry. Sometimes she hears a voice telling
her to harm herself but there is no clear evidence of
psychosis
She has set fire to a bin once before, after seeing her mother
It was recently her birthday and her mother sent her a card