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Treating Adolescents
A Dynamic and Challenging Age Group
A Volume in the Jossey-Bass Library of Current Clinical Technique
It is an ambitious undertaking to distill the knowledge base, summarize the clinical wisdom, and provide vivid case illustrations for the full range of psychopathology presenting in adolescence. This first rate book succeeds on all counts while conveying the challenge and excitement of working with teenagers who have psychiatric problems.
--Gregory K. Fritz, M.D., professor of psychiatry and director, Child and Adolescent Psychiatry, Brown University School of Medicine
This concise, up-to-date summary of adolescent development presents step-by-step guidance for effective clinical treatment of issues such as anxiety disorders, depression, eating disorders, somatization, conduct disorders, and psychosis.
A Volume in the Jossey-Bass Library of Current Clinical Technique
It is an ambitious undertaking to distill the knowledge base, summarize the clinical wisdom, and provide vivid case illustrations for the full range of psychopathology presenting in adolescence. This first rate book succeeds on all counts while conveying the challenge and excitement of working with teenagers who have psychiatric problems.
--Gregory K. Fritz, M.D., professor of psychiatry and director, Child and Adolescent Psychiatry, Brown University School of Medicine
This concise, up-to-date summary of adolescent development presents step-by-step guidance for effective clinical treatment of issues such as anxiety disorders, depression, eating disorders, somatization, conduct disorders, and psychosis.
418 pages, Paperback
First published January 15, 1996
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November 5, 2024
Disruptive behavior disorders, including ODD and CD, are among the
oldest of the behavioral issues facing mankind. Their significance and roots
lie in the basic survival instincts present in all mammalian species widely
known as the “fight or flight” response. In this regard, children react at an
early age to many novel stressors with disruptive or aggressive behaviors
because these processes are built into the very fabric of their being. The
twin developmental processes of socialization and attachment produce the
environment within which children learn to regulate aggressive responses.
In other words, they learn the social rules to manage aggressive responses
and are taught better and more appropriate techniques for dealing with
frustration, threats, or perceived attacks. These social rules and their
internalization are what enable human societies to maintain an order or
social structure.
Oppositional defiant disorder (ODD) is characterized by a pattern of
marked irritability, anger, and defiant and vindictive behavior. While all
children do not demonstrate each of these traits, those diagnosed with
ODD will display a range of disruptive behaviors. Conduct disorder (CD)
is a pattern of destructive behaviors marked by deliberate aggression,
destruction, and ignorance to rules. These behaviors are often carried out
to a greater extent than ODD behaviors, and are typically associated with a
lack of empathy regarding others.
Youth who demonstrate these defiant behaviors are at an increased
risk for suicide attempts, emotional disorder, and other disruptive
behaviors. Specifically, those who present with defiance, argumentative
tendencies, and vindictiveness are at an increased risk for developing
conduct disorder.
In addition, low intelligence and poor academic achievement at age 10
has been found to predict the development of disruptive behavior patterns.
Cauffman, Steinberg, and Piquero similarly found that low intelligence was
a common characteristic of disruptive youths, especially in terms of verbal
abilities. As a result of verbal deficits, disruptive youths are less able to use
verbal skills to solve problems that may arise, and instead resort to physical
forms of problem solving.
Academic achievement is detrimentally impacted in disruptive youths,
which researchers attribute to conduct problems impeding learning.
Specifically, youth with disruptive behavior disorders were observed to
spend significantly less time on tasks, have more difficulty remaining in
their seat and answering questions, complete less homework, and miss
more school days compared to nondisruptive peers.
Youth diagnosed with CD show greater deficits in impulse
control, concentration and attention, cognitive flexibility, sequential
behavior, response inhibition, and creating, planning, organizing, and
executing goal-directed behavior compared to youth without CD.
Specifically, it is often prudent to
obtain a toxicology screen, in addition to thyroid studies, heavy metal
levels, and complete blood counts. In our clinic, we often request these
collaboratively with the primary care doctor, when able.
Mariela also reported having
trouble following conversations during social gatherings, especially
when there were multiple people involved in a conversation. She
described herself as “forgetful,” losing her cell phone multiple times
over the previous year. Mariela complained that she would often not
“hear” her parents’ instructions or she would “forget” to complete
chores in spite of intending to do so. She felt that teachers had
low expectations of her and that some in the past had referred to her
as “lazy.”
It is also common for parents or
teachers to report that a teenager with ADHD does not pay attention when
spoken to. Tasks ranging from simple chores to school reports often go
unfinished. Finally, teens with ADHD and their loved ones often report
that they are prone to losing things (e.g., homework, cell phones, house
keys, purses, backpacks).
Teens with ADHD can often be observed fidgeting or
squirming in their seats during class or at the dinner table. Although
hyperactive children tend to leave their seats and climb about at
inappropriate times (e.g., class, religious gatherings, bus rides), teenagers
and adults often report feeling very restless. Hyperactive and impulsive
teenagers tend to be loud, boisterous, and have difficulty waiting their turn,
or as my grandfather used to say, “act like a bull in a china shop.”
Some ADHD patients experience a cluster of symptoms identified as
sluggish cognitive tempo (SCT). SCT is most often seen in individuals who
primarily display inattentive symptoms associated with the disorder and is
characterized by slowed thinking, drowsiness, daydreaming, fluctuating
attention, absentmindedness, and becoming easily confused.
Individuals with ADHD are at an increased risk of having reading,
spelling, or math problems compared to children and adolescents without
ADHD.
Psychostimulants include methylphenidate (Ritalin, Concerta, Metadate,
Daytrana), dexmethylphenidate (Focalin), amphetamine-dextroamphetamine
(Adderall), dextroamphetamine (Dexedrine, Dextrostat),
and lisdexamfetamine (Vyvanse). Methylphenidate drugs are the most
commonly used, and all are available in short-acting and long-acting dosages.
Common side effects associated with stimulants include headache,
insomnia, reduced appetite, and weight loss. Less common, yet noteworthy
side effects include new onset or exacerbation of tics and irritability.
Psychostimulants carry cardiovascular risks, and should not be used in
patients with heart conditions or structural heart problems.
Bupropion (Wellbutrin) is an antidepressant medication that acts as a
dopamine and norepinephrine reuptake inhibitor.it has a modest evidence base and may be useful for children with comorbid ADHD and depressive disorders.
There are many facets of executive functioning (e.g., planning and organization, monitoring, task initiation and completion, emotional regulation). Three fundamental facets include:
. Impulse control, the skill we use to pause and think before we act and to resist temptations and impulses. Impulse control makes it possible for us to selectively focus, sustain attention, prioritize, and take action. It is what we use when we push aside daydreams about what we would rather be doing so we can focus on an important task at hand.
. Working memory, the capacity to hold and manipulate information
in our mind over short periods of time. It provides a mental
“surface” where we can place important information briefly to
accomplish tasks like mentally calculating the sales price of an
item that is 25% off. An adolescent uses working memory to
remember and connect information from one paragraph to the
next when reading and to perform an arithmetic problem with
several steps.
. Cognitive flexibility, the skill that allows us to quickly shift from
one activity to the next, adjust to interrupted or changed routines or
priorities, and apply different rules to different settings. Cognitive
flexibility allows teenagers to not be rigid when attempting to work
through a problem and to think “outside the box.” Adolescents need
this skill when they learn exceptions to rules in grammar or need to
approach a science experiment in a different way.
Some studies have suggested that learning disorders can be commonly comorbid with anxiety and mood disorders, while other studies have not found similar results. Different types of learning disorders can also be comorbid with each other. Seventeen percent to 70% of children with arithmetic disorders also show reading problems, and 11% to 56% of children with reading disorders also have arithmetic problems.
Safety planning is important in both assessment and ongoing intervention
with adolescents. We work with the adolescent to identify several
types of strategies, including distraction and self-soothing, social activities,
specific people to engage with (e.g., “Shoot hoops with my friend,
Tanner,”) and helpful coping thoughts (e.g., “I can get through this,”
“It’s okay to ask for help”). It is also important for the safety plan to have a
list of names and contact information for at least two adults in the
adolescent’s life,
Parent/caregiver involvement in the safety planning process is key.
Parents should be educated about the risk of self-harm in those with past
behavior and/or urges to self-harm; the need for increased monitoring and
supervision; the need to restrict access to potentially dangerous means,
such as locking up medications and razors and removing guns from the
home; and any underlying psychiatric conditions and possible treatment
options.
Bulimia nervosa and binge eating disorder are both less well
understood. These disorders likely represent a more specific interaction
between impulsive behaviors and a prevalence of food.
There are often a multitude of factors that impact the development, onset,
and perpetuation of an eating disorder, including psychosocial factors. A
history of physical and/or sexual abuse is a risk factor, and significant stressors
and transitional periods, like changing schools, going to college, parental
marital discord or divorce, death of a loved one, or loss of a friendship or
romantic relationship, can trigger an eating disorder’s onset.
First psychotic episodes in schizophrenia occur commonly in late adolescence,
with a peak incidence between the ages of 15 to 30 years, by which time the
symptoms are no different than those in adults.
The physiological need for sleep still largely remains a mystery. It has
been found to have homeostatic regulation properties, and some researchers
believe that REM sleep plays a role in memory formation and learning
processes. Positron emission tomography (PET) studies have shown that
patterns of brain activity that occur while learning a task when awake are
selectively reactivated during the next night’s sleep, which supports the
concept of sleep being important during memory consolidation.
oldest of the behavioral issues facing mankind. Their significance and roots
lie in the basic survival instincts present in all mammalian species widely
known as the “fight or flight” response. In this regard, children react at an
early age to many novel stressors with disruptive or aggressive behaviors
because these processes are built into the very fabric of their being. The
twin developmental processes of socialization and attachment produce the
environment within which children learn to regulate aggressive responses.
In other words, they learn the social rules to manage aggressive responses
and are taught better and more appropriate techniques for dealing with
frustration, threats, or perceived attacks. These social rules and their
internalization are what enable human societies to maintain an order or
social structure.
Oppositional defiant disorder (ODD) is characterized by a pattern of
marked irritability, anger, and defiant and vindictive behavior. While all
children do not demonstrate each of these traits, those diagnosed with
ODD will display a range of disruptive behaviors. Conduct disorder (CD)
is a pattern of destructive behaviors marked by deliberate aggression,
destruction, and ignorance to rules. These behaviors are often carried out
to a greater extent than ODD behaviors, and are typically associated with a
lack of empathy regarding others.
Youth who demonstrate these defiant behaviors are at an increased
risk for suicide attempts, emotional disorder, and other disruptive
behaviors. Specifically, those who present with defiance, argumentative
tendencies, and vindictiveness are at an increased risk for developing
conduct disorder.
In addition, low intelligence and poor academic achievement at age 10
has been found to predict the development of disruptive behavior patterns.
Cauffman, Steinberg, and Piquero similarly found that low intelligence was
a common characteristic of disruptive youths, especially in terms of verbal
abilities. As a result of verbal deficits, disruptive youths are less able to use
verbal skills to solve problems that may arise, and instead resort to physical
forms of problem solving.
Academic achievement is detrimentally impacted in disruptive youths,
which researchers attribute to conduct problems impeding learning.
Specifically, youth with disruptive behavior disorders were observed to
spend significantly less time on tasks, have more difficulty remaining in
their seat and answering questions, complete less homework, and miss
more school days compared to nondisruptive peers.
Youth diagnosed with CD show greater deficits in impulse
control, concentration and attention, cognitive flexibility, sequential
behavior, response inhibition, and creating, planning, organizing, and
executing goal-directed behavior compared to youth without CD.
Specifically, it is often prudent to
obtain a toxicology screen, in addition to thyroid studies, heavy metal
levels, and complete blood counts. In our clinic, we often request these
collaboratively with the primary care doctor, when able.
Mariela also reported having
trouble following conversations during social gatherings, especially
when there were multiple people involved in a conversation. She
described herself as “forgetful,” losing her cell phone multiple times
over the previous year. Mariela complained that she would often not
“hear” her parents’ instructions or she would “forget” to complete
chores in spite of intending to do so. She felt that teachers had
low expectations of her and that some in the past had referred to her
as “lazy.”
It is also common for parents or
teachers to report that a teenager with ADHD does not pay attention when
spoken to. Tasks ranging from simple chores to school reports often go
unfinished. Finally, teens with ADHD and their loved ones often report
that they are prone to losing things (e.g., homework, cell phones, house
keys, purses, backpacks).
Teens with ADHD can often be observed fidgeting or
squirming in their seats during class or at the dinner table. Although
hyperactive children tend to leave their seats and climb about at
inappropriate times (e.g., class, religious gatherings, bus rides), teenagers
and adults often report feeling very restless. Hyperactive and impulsive
teenagers tend to be loud, boisterous, and have difficulty waiting their turn,
or as my grandfather used to say, “act like a bull in a china shop.”
Some ADHD patients experience a cluster of symptoms identified as
sluggish cognitive tempo (SCT). SCT is most often seen in individuals who
primarily display inattentive symptoms associated with the disorder and is
characterized by slowed thinking, drowsiness, daydreaming, fluctuating
attention, absentmindedness, and becoming easily confused.
Individuals with ADHD are at an increased risk of having reading,
spelling, or math problems compared to children and adolescents without
ADHD.
Psychostimulants include methylphenidate (Ritalin, Concerta, Metadate,
Daytrana), dexmethylphenidate (Focalin), amphetamine-dextroamphetamine
(Adderall), dextroamphetamine (Dexedrine, Dextrostat),
and lisdexamfetamine (Vyvanse). Methylphenidate drugs are the most
commonly used, and all are available in short-acting and long-acting dosages.
Common side effects associated with stimulants include headache,
insomnia, reduced appetite, and weight loss. Less common, yet noteworthy
side effects include new onset or exacerbation of tics and irritability.
Psychostimulants carry cardiovascular risks, and should not be used in
patients with heart conditions or structural heart problems.
Bupropion (Wellbutrin) is an antidepressant medication that acts as a
dopamine and norepinephrine reuptake inhibitor.it has a modest evidence base and may be useful for children with comorbid ADHD and depressive disorders.
There are many facets of executive functioning (e.g., planning and organization, monitoring, task initiation and completion, emotional regulation). Three fundamental facets include:
. Impulse control, the skill we use to pause and think before we act and to resist temptations and impulses. Impulse control makes it possible for us to selectively focus, sustain attention, prioritize, and take action. It is what we use when we push aside daydreams about what we would rather be doing so we can focus on an important task at hand.
. Working memory, the capacity to hold and manipulate information
in our mind over short periods of time. It provides a mental
“surface” where we can place important information briefly to
accomplish tasks like mentally calculating the sales price of an
item that is 25% off. An adolescent uses working memory to
remember and connect information from one paragraph to the
next when reading and to perform an arithmetic problem with
several steps.
. Cognitive flexibility, the skill that allows us to quickly shift from
one activity to the next, adjust to interrupted or changed routines or
priorities, and apply different rules to different settings. Cognitive
flexibility allows teenagers to not be rigid when attempting to work
through a problem and to think “outside the box.” Adolescents need
this skill when they learn exceptions to rules in grammar or need to
approach a science experiment in a different way.
Some studies have suggested that learning disorders can be commonly comorbid with anxiety and mood disorders, while other studies have not found similar results. Different types of learning disorders can also be comorbid with each other. Seventeen percent to 70% of children with arithmetic disorders also show reading problems, and 11% to 56% of children with reading disorders also have arithmetic problems.
Safety planning is important in both assessment and ongoing intervention
with adolescents. We work with the adolescent to identify several
types of strategies, including distraction and self-soothing, social activities,
specific people to engage with (e.g., “Shoot hoops with my friend,
Tanner,”) and helpful coping thoughts (e.g., “I can get through this,”
“It’s okay to ask for help”). It is also important for the safety plan to have a
list of names and contact information for at least two adults in the
adolescent’s life,
Parent/caregiver involvement in the safety planning process is key.
Parents should be educated about the risk of self-harm in those with past
behavior and/or urges to self-harm; the need for increased monitoring and
supervision; the need to restrict access to potentially dangerous means,
such as locking up medications and razors and removing guns from the
home; and any underlying psychiatric conditions and possible treatment
options.
Bulimia nervosa and binge eating disorder are both less well
understood. These disorders likely represent a more specific interaction
between impulsive behaviors and a prevalence of food.
There are often a multitude of factors that impact the development, onset,
and perpetuation of an eating disorder, including psychosocial factors. A
history of physical and/or sexual abuse is a risk factor, and significant stressors
and transitional periods, like changing schools, going to college, parental
marital discord or divorce, death of a loved one, or loss of a friendship or
romantic relationship, can trigger an eating disorder’s onset.
First psychotic episodes in schizophrenia occur commonly in late adolescence,
with a peak incidence between the ages of 15 to 30 years, by which time the
symptoms are no different than those in adults.
The physiological need for sleep still largely remains a mystery. It has
been found to have homeostatic regulation properties, and some researchers
believe that REM sleep plays a role in memory formation and learning
processes. Positron emission tomography (PET) studies have shown that
patterns of brain activity that occur while learning a task when awake are
selectively reactivated during the next night’s sleep, which supports the
concept of sleep being important during memory consolidation.
December 10, 2007
A good solid professional manual that can be used to educate families, teachers and other helpers.
October 22, 2013
Some interesting ideas and case studies. Seemed a little wordy and didn't always seem to be specifically addressing ways of working with people.
Displaying 1 - 3 of 3 reviews