Psychiatric Potpourri: Conflicts in Adolescence

Patrick Shea PL3

Topics covered in this discussion

Part I: Emotion, Stress, and Coping Part II: Risk-Taking, Delinquency, and Violence Part III: Adherence in chronic illness

Emotion

Emotion can be defined as the psychophysiologic experience created by internal biochemical milieu interacting with external stimuli. Emotions provide the affective component of motivation. Emotion is well known to drive behavior, but this is a limited reciprocal relationship as well. Its difficult to efficiently or meaningfully classify emotion into categories, but the most widely accepted dichotomy is biologic/anatomic, i.e. primal emotions originating in the amygdala being one group, and more complex emotions originating in the prefrontal cortex being the other.

Emotional experience in Adolescence

Adolescents have the same range and types of emotions as adults, but their reactions tend to be different (usually the reaction is >>>>that of an adult, and faster). The problem of reactivity The problem of impulsivity Inability to understand and appreciate consequence (especially long-term) at an adult level. Tend to experience emotions more intensely in adolescence due to hormonal influences and life inexperience, but individual ranges still hold.

Stress

Defined similarly to pressure in physics = force/area Psychological stress = change/perceived ability to cope with change Not all change is negative, but negative events exact a higher toll in the numerator Stress is essentially unavoidable in adolescence, as this is by definition a time of some upheaval, both physiologically and psychologically! Adolescents generally will have a more limited repertoire of coping skills than adults.

Classifying stressors: Relative Magnitude

Some examples from the modified Holmes and Rahe stress scale (0-100 rating system):
Failing a class 56 Relationship break-up 53 Beginning to date -51 Parental discord 46 Being accepted to college 43 Being a senior in high school - 42

Unplanned pregnancy/abortion - 100 Death of a parent - 100 Getting married 95 Parents divorce 90 Acquiring a visible deformity 80 Fathering a child 70 Parent goes to jail 70 Parents separate 69 Death of a sibling 68 Change in level of peer acceptance 67 Unplanned pregnancy of sister 64 Death of a friend 63 Parent re-marries 63

Classifying stressors: basic types

Acute crises: Unpredictable, unforeseen and out of the individuals control. Includes natural disasters, wars, acute sudden injuries/accidents, sudden death or serious injury of loved ones. Major life events: Going to college, starting a new job, getting married, having a child, death of a loved one after prolonged illness, etc. These are foreseen but mean big changes. Microstressors: Traffic, meeting deadlines, dealing with difficult personalities at work, ongoing low-level conflicts with family/spouse/children, Having to complete reams of paperwork to write prescriptions for Medicaid.

Coping & Coping mechanisms

Coping: The cognitive and behavioral efforts by an individual to manage demands and conflicts that (s)he perceives as taxing. Mental effort to master, minimize or tolerate stress or conflict. Classifying coping mechanisms: Emotional vs cognitive vs behavioral Perhaps more important: Adaptive vs Maladaptive The Linehan/DBT model: Only 4 things you can really do: Solve the problem, change the way you think/feel about the problem, accept the problem (radical acceptance), stay miserable (!)

Coping: Types of strategies

Cognitive: Focusing on the way one thinks about a stressor: Denial, minimization/distancing, altering goals, altering values, using humor. Behavioral: Focusing on the stressor itself, and learning new information about it and how to manage it. Emotional: Management of the emotions that accompany an unavoidable stressor. Releasing pent-up emotion in another way, managing hostile feelings, self-distraction, escape/avoidance of feelings caused by the situation.

Coping: Adaptive vs Maladaptive

Adaptive coping mechanisms are those which will help one successfully manage a stressor. These include anticipation, seeking social support, careful attention to basic needs/keeping fit, finding humor, and finding meaning. Maladaptive coping mechanisms are those which will perhaps manage negative emotions in the short term without negotiating the conflict at hand. They include denial, avoidance, escape (often via selfmedication), and outward aggression toward those perceived to be causing the stressor or conflict. Low effort coping is an attempt to lower expectations in a given situation.

Risk-Taking Behavior in Adolescence: An overview

Risk is inherent in life, and some risk-taking is healthy. Learning to negotiate risk is an important area of development for adolescents. People tend to exist on a continuum between risktaking and risk-averse styles. Adolescents are often more risk-averse in some areas of their lives and more risk-taking in others.

Healthy vs Unhealthy risks

In many cases, adolescents can be re-directed from unhealthy risk taking to more healthy means of meeting the same challenge. What is the underlying motivation for the behavior? What need is the adolescent trying to meet? Problem areas include: Eating disordered behavior, drug/alcohol use, unhealthy sexual activity, violence/bullying others, running away/staying out at night, and shoplifting/stealing. Can represent rebellion which is normal as a part of individuation.

Effectively counseling adolescents with concerning risk-taking behavior

Important to remain non-judgmental Prioritize: Adolescents have a short attention span and may feel overwhelmed. Pick 1-2 behaviors to focus on at any one visit. Assess the underlying motivation. Suggest another way to meet the need. Follow up to check on progress toward goals. If appropriate could expand focus to other risky behaviors. Parents still have an important influence, so it can be helpful to get a sense of the parent(s) own risktaking behavior and history thereof.

Specific risk-taking behavior: Prevalence and trends

Smoking/tobacco use: About 20% (declining slowly) Alcohol use: About 40% (declining, was >50% until 2000) Marijuana use: About 25% (currently at a 30-year high) Sexual activity: Only 13% at 15, 70% by 19. Average age of first time is 17. 19% of teens regularly have unprotected sex. Pregnancy: Highest rate in the industrialized world, but on the decline. 27% abortion, 59% birth, 14% miscarriage. Utah has one of the lowest rates of the states.

Delinquency

Juvenile Delinquency is defined as the commission of criminal behavior by a person under 18. Categories include: Property crime, violent crimes, sex crimes, and status offenses. Juveniles are involved in offense commission in 21% of violent crimes, and this rate is declining Recent increase in property crime (the economy?) Juvenile crimes tend to start happening around 3 pm and peak 7-9 pm (nonviolent crime) and 8-10 pm (violent crime).

Delinquency: Risk factors and Demographics

Poverty Mental disorders (Particularly Conduct Disorder) Single parent Racial breakdown: African-American (1 in 3) > Hispanic/Latino (1 in 6) > White/Asian The male phenomenon: 80% of delinquent youth are boys Cradle to prison pipeline Labeling (?) Controversial

Health supervision in detention facilities

AAP publishes guidelines on health supervision visits (frequency, etc) More aggressive screening recommended than for non-incarcerated youth (STIs, TB) No AAP guidelines regarding specific ATG or counseling for delinquent youth.

Violence

3 top causes of death in Adolescence: Accidents, Homicide, and Suicide. Death rate in males is 89 per 1000, much higher than 35 per 1000 in females. 20% of boys and 8% of girls who died were victims of homicide.

Violent crime: Causes and risk factors

Similar risk factors to delinquency overall: poverty/SES, poor social supports, particularly lack of supervision/structure. Gang involvement (which in itself requires exposure to the milieu) Drug use (Alcohol is the most frequently a/w violent crime). History of more minor aggression in childhood

Firearms and violence

When a gun is carried outside the home by an adolescent, 50% are semiautomatic handguns and 30% are revolvers. Firearms account for 2/3 of successful suicides in adolescents. When the District of Columbia had a handgun ban, there were no completed suicides from 2000-2002. Firearms account for 27% of accidental deaths in persons aged 10-19. Persons under 22 are the victims of 25% of firearm homicides. Overall, firearms are the 2nd leading cause of death (MVA is 1st) in all children, regardless of causality. Ask about guns in the house, and counsel appropriately

Adherence and non-adherence in Adolescents with chronic diseases

Many adolescents are now living longer with chronic illnesses that require ongoing care. Includes: Diabetes, IBD, HIV, HLHS w/ Fontan, Biliary atresia s/p transplant, CF, etc, etc. One of the big 4 psych consult questions (The otherssomatization, psych admit for no bed at UNI, psych side effects from medical therapy).

Barriers to adherence

Need to fit in (Chronic disease makes them different from peers). More of a problem in early adolescence. Need to rebel. Transference: Doctor is seen as a parental figure, teen motivated to reject all things parental. Need to individuate. Inventing own identity, which they dont want DM/HIV/IBD etc to be a part of (Im over it) Burnout, particularly in more high maintenance illnesses such as Diabetes. Distracted with the many other tasks and activities that go along with adolescence.

Evaluating adherence

Objective measures: HbA1c, blood levels of medication, FEV1, etc. Still valuable to take an adherence history in order to identify specific problems with adherence. Have a frank conversation with the adolescent. Selfreport evaluation (i.e. paper surveys) consistently over-report adherence by 30%. Non-judgmental and more troubleshooting in nature.

Stages of Change

Motivational Interviewing: Guiding principles

Motivation to change is elicited from the patient, and is not able to be imposed from outside forces It is the patient's task, not the physician's, to articulate and resolve his or her ambivalence Direct persuasion is not an effective method for resolving ambivalence The counseling style is generally quiet and elicits information from the patient The physician is directive, in that they help the patient to examine and resolve ambivalence Readiness to change is not an intrinsic trait of the patient, but a fluctuating result of interpersonal interaction The therapeutic relationship resembles a partnership or companionship

Motivational interviewing: Technique

1.

2.

3.

4.

Express Empathy Listen to the patient speak frankly about life through their eyes. Ask what makes it easier for them not be adherent. What are they getting out of it? Develop discrepancy Discuss how non-adherence is interfering with the patients other life goals. This is important to help them resolve the ambivalence that they experience regarding adherence. Roll with Resistance Resistance is natural, not pathological, and part of the ambivalence the patient feels. Confronting it directly will only reinforce the patients argumentativeness and shut down dialogue. Support Self-EfficacyEncourage patient autonomy. Encourage patients to find their own solutions for change. Encourage Change talk.

Motivational Interviewing: Efficacy

Motivational Interviewing for 14 -17 year old with Type 1 Diabetes was shown to result in a 1 point drop in HbA1c after 12 months, with no change in control group. In adults, drop in mean alcoholic beverage consumption from 60 drinks per week to 20 drinks per week.

Questions?