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Adolescent Behavioral Health Issues
March 2008 Discussion
Adolescent Behavioral Health Issues
Moderator: Frank Armao, MD
Psychiatrist, Winslow IHS
Discussion Points:
- The complex influence of early life stress and trauma in shaping development.
- The increased burden of developmental stress as it pertains to Native Americans.
- How to distinguish teens with relatively normal perturbation in development from those needing more intensive management and/or referral to behavioral health.
- What constitutes a significant mood disorder in an adolescent, and what are the options for management.
- The serious limitations of DSM-IV and current nosology in “diagnosing” adolescent behavioral health conditions.
Case Study:
To kick off the exercise, let’s look at a case involving a 15 year old Navajo girl (we’ll call her Britney for verisimilitude to current celebrity adventures) who presented after discharge from inpatient psychiatric care in the Phoenix area. She had been hospitalized due to severe suicidal ideation which became evident at the faith-based boarding school she attended, some 120 miles from her home in the northern part of Dinetah. At that time, a close friend and roommate was having some alarming health problems, which culminated in an episode of protracted loss of consciousness in Britney’s presence. Britney became increasingly anxious and withdrawn over the next few days after her friend was hospitalized, and was plagued by fears of death and suicidal ideation. (At this point, she had already been taking sertraline for three weeks, which had been started at another IHS facility for a diagnosis of depression.) School officials brought her to WIHCC, where she was evaluated buy a locum tenems psychiatrist and admitted to a facility in Phoenix.
She was in hospital for about 6 days, did quite well, and was discharged on a different antidepressant, escitalopram, with a diagnosis of Major Depressive Disorder. On the ride home from Phoenix she got into an argument with her mother when (by patient’s account) her mother began berating her for all the trouble she had caused. Britney grabbed a bottle of her mother’s medicines from the glove compartment and swallowed the contents, at which point her mother called 911 and police came and took the patient to yet another psychiatric facility for admission. This time Britney came out on the atypical antipsychotic quetiapine as well as divalproex, now with a diagnosis of Major Depressive Disorder, R/O Bipolar Type I Disorder. When I first saw her two weeks later, she was back at the boarding school and doing much better according to her and the school counselor who accompanied her.
This case reflects several issues facing clinicians who care for adolescents: the potential suicide risk associated with antidepressants; the dramatically increasing diagnosis of bipolar disorder in young people; the increasing use of atypical antipsychotics for a variety of diagnoses; and of course, the underlying issues involving teen impulse control and modulation of emotions, as well as the underpinnings of their always volatile relations with parents.
Hello to all the dedicated front line IHS troops out there, and welcome to this month’s discussion. I hope we can make some progress in finding the forest among the overexuberant growth of trees camouflaging normal adolescence. If you are mystified about the 40-fold increase in Bipolar diagnoses among kids since 1994, or interested in current practices in antidepressant use in adolescents, or the interplay of early life stress and development, then this is the e-place for you.
The case of Britney serves to introduce some of these issues, as the unreported piece of the puzzle in her case is the psychosocial deprivation and early life stress that has left her bereft of the ability to modulate her emotions, control impulses, and cope with stressful situations. Britney’s parents are both alcoholics, and she was consequently raised by grandparents in a very poor and somewhat chaotic situation. She did spend enough time with her parents to have witnessed several episodes of violent and protracted assault upon her mother by her father, and she can, in fact, vividly recall her feelings of terror at the time, tempered by her need to comfort and protect her young siblings during the crises.
Since all of Britney’s subsequent development, symptoms, and behavior are consistent with what we’ve learned about the effects of early life traumatic stress, where does she properly fit in the currently accepted paradigms of diagnosis and treatment? What can we do for these kids?
External chaos, in the presence of some internal vulnerabilities and without consistent adult support, results fairly predictably in internal chaos. I think the dilemma with these kids and their families is how to create a consistently responsive and growth-oriented healing environment without shipping them off to distant treatment centers. In other settings this kind of the work has been done using services such as Homebuilders, a program that provides support to the family in the home. This can include 20 hours or more inhome assistance with parenting and similar activities. Britney is also challenged by the fact that her ?entire family is dysfunctional – begging the question of who else needs treatment here. The likelihood of establishing a consistent healing environment in these situations is complicated and difficult.
That said, there is hope here. Britney is old enough to be engaged in discussions about what she wants for herself, with some discussion and appreciation of the chaos her parents/other family bring into the picture. Helping her identify adults who she might better work to attach to and spend time with may be part of the solution (parentectomy in other words). Coming from a clan-oriented culture, the possibility of finding such adults who are willing to take on this role I believe is probably better than in more western oriented culture. Sometimes that adult is the therapist who takes the time to get to know the teen. While I’m not a big fan of boarding school, particularly for younger children, should there be a sympathetic dorm parent and general school support, boarding school participation may be the single source of significant, consistent support she has access to.
As to medications my experience has been that regardless of what we call the chaos (bipolar d/o, ptsd, depression, dissociative disorder) judicious use with long and slow treatment trials are generally in order. Many kids come back from residential tx and inpatient programs on what are basically sedative regimens with multiple meds – I usually start trying to taper and discontinue the most sedating agents, settling on one or two agents where possible. Part of this process is recognizing that if the tapering is occurring too quickly it is not uncommon to see withdrawal symptoms that are easily mistaken for active illness. With patience these can usually be worked through.
In the end, most of the youth simply stop the medications anyway on their own – these are often good opportunities to better determine what the baseline functioning is without. Avoid jumping back in with the whole pharmacopeia and you’ve won a skirmish, if not the war.
As my grandmother used to say – patience,
my child.
Peter Stuart, MD
Dr Stuart’s enlightened response emphasizes a key factor in attempting to work with these teens: attachment. It’s the basis for all of our interpersonal competencies and the bedrock for our self-esteem and self-efficacy. Unfortunately, some of us never get it in the necessary quantities from caregivers at the critical early juncture in life. We are all – even the lower animals with whom we share the planet – hard-wired for this, and when we don’t come by it naturally, it is very hard to compensate for later. The hypothalamic-pituitary-adrenal axis is, of course, exquisitely sensitive to disruption by stress, and the effects are not just limited to the short term. The deleterious effects of trauma mediated through corticotropin releasing factor and the glucocorticoids are well known, and are clearly involved in the etiology of PTSD and major depression. This HPA axis dysregulation has also been implicated in the subsequent development of medical disorders like diabetes, the metabolic syndrome, and possibly a whole host of other disease states – autoimmune disorders, fibromyalgia, chronic fatigue syndrome. Now researchers are able to link early life stress with diminished HPA function in terms of oxytocin and vasopressin as well, both of which are integral to nurturing and affiliative behaviors for all of us (even men).
So, short of oxytocin infusions, what can we do about attachment deficiency? This is really of paramount importance in helping traumatized kids, because one of their core deficits is this inability to form healthy, secure attachments. The framework for treatment developed by the National Child Traumatic Stress Network, consequently, is called ARC – for Attachment, Self-Regulation, and Competency.
There are lots of ways to help young people form healthy attachments or solidify existing ones. If we’re lucky, and there is a reasonable and consistent primary caregiver involved, we can help the caregiver with parenting skills, and work with both of them to effect positive changes in their lives that will strengthen their relationship. (It’s amazing what a little structure and routine in some households can mean for a family.) Unfortunately, all too often we are left desperately trying to figure out who we can tag with the assignment, because there doesn’t appear to be a worthy caregiver in sight. But this is where you can get lucky, and occasionally watch miraculous things happen as a relative or foster parent, coach or teacher swoops into a kid’s life and makes a significant difference. In the case of Britney, the family part remains a dream for the future. For now, we will have to rely on her boarding school, since Mom is in a homeless shelter in Phoenix, Dad hasn’t been in the picture for years, and the beleaguered grandparents and her siblings are at least a three and a half hour drive away. Fortunately, Britney is benefiting from a very understanding and supportive counselor, who has the uncommon ability to see her strengths and to focus on her talents and resiliency, and thus is doing a great job of mediating with other school staff.
Britney’s been doing better lately, and continues to do well in school. She is definitely one of those long-suffering little girls who found herself in the role of mother-protector to her sibs at home, and has a need to be perfect. She feels guilty about abandoning her brothers and sisters and spends a lot of time worrying about them. She had a few bad days two weeks ago when she was feeling guilty about “hurting” her mother and her brothers and sisters when she had her recent bout with suicidality. On the other hand, we have agreed to stop her divalproex and she is now taking low dose quetiapine. If we’re lucky, we may be able to help her outgrow her “bipolar disorder” with a minimum of medication.
Howdy... thought we would get back to the care and feeding of Britney. The fact that she was treated with antidepressants initially but soon transitioned to two “mood stabilizers” highlights at least two controversial issues in the psychiatric care of adolescents.
The first, of course, is the question of whether or not antidepressants increase the risk of suicidal ideation or behavior in adolescents, and if so, whether the benefits of treatment outweigh the risk. (The second question is whether bipolar disorder is being over-diagnosed in adolescents these days, but we can save that for later.)
In Britney’s case, it is perfectly understandable that a psychiatrist would discontinue her antidepressant, inasmuch as there was no evidence it had helped her. On the contrary, she had had suicidal ideation resulting in a hospitalization, and later a suicide attempt – both while taking an SSRI. So what is the relationship between antidepressants and the risk of suicidal ideation or behavior? Since the regulatory warnings and action of 2003-2004, there has been (rather predictably) an outpouring of research on this issue. Most of the research findings have favored the use of antidepressants as effective (which was not as clearly established at the time of the initial controversy), when used appropriately and with careful monitoring for the possibility of emerging suicidality. Much of the literature has examined statistical data that generally demonstrate an inverse correlation between anti-depressant usage and suicide rates in adolescents. An example of this approach was published in the American Journal of Psychiatry last autumn (1) by Gibbons et al. They analyzed rates of youth SSRI usage both in the US and in the Netherlands from 2003-2005. as well as suicide rates in a similar time frame. Prescriptions for SSRIs decreased about 22% in both countries, while suicide rates jumped 49% in the Netherlands and 14% here in the US. In the US, it should be pointed out, prior to the FDA warning teen suicide rates had steadily declined since 1988 – the year of fluoxetine’s introduction in this country.
A different approach was employed in a study by Simon et al (2), who examined a large database of patients treated with antidepressants. They studied records of over 65,000 patients with more than 82,000 episodes of antidepressant treatment from 1992-2003. Adolescents age 17 and younger comprised 6.2% of the sample. The findings overall were that the rate of suicide attempts was higher in the month prior to medication treatment, with a steady decline thereafter.
A recent meta-analysis (3), looking at treatment of obsessive-compulsive disorder, other anxiety disorders, and major depression, found that antidepressants are efficacious in all three, and that benefits significantly outweigh risks. Interestingly, the risk: benefit ratio was more favorable for treatment of OCD and anxiety disorders than for depression.
The bottom line appears to be that the judicious use of antidepressants in properly selected patients, along with appropriate monitoring, is still an appropriate standard of care. There has always been an association between the initiation of treatment for depression and the early emergence of suicidality – certainly for antidepressant treatment, but demonstrated as well for adolescent patients being managed with psychotherapy alone. (4)
The controversy over antidepressants has made us more cautious, however, and, especially for less severe cases of anxiety or depression, psychiatrists may be more likely to try psychotherapy first. And frequent follow-up is definitely important: I try to talk to the patient or caregiver within a few days after starting the medication, with a return visit in a week, and biweekly for 2-3 visits thereafter.
So my questions to the group: how has all the contorversy about antidepressants changed the way you prescribe these medicines? It seems that throughout the US, there has been a siginficiant shift away from primary care providers utilizing these meds for children and adolescents. In the facility where I work, I don't think it was ever common to begin with, i.e. PCPs were generally not the ones to initiate antidepressants in this age group. However, depending on the availability of a psychiatrist, and other variables, practices would probably vary significantly among facilities. What is the current comfort level among primary care providers on this issue? How do clinicians feel about initiating treatment in a primary care setting for depression among adolescents, as opposed to referring to a psychiatrist?
1. Gibbons
R, et al: Early evidence on the effects of regulators’ suicidality
warnings on SSRI prescriptions and suicide in children and adolescents. Am J
Psychiatry 2007; 164:1356-1363
2. Simon G, et al: Suicide risk during antidepressant treatment. Am J Psychiatry
2006; 163:41-47
3. Bridge J, et al: Clinical response and risk for reported suicidal ideation
and suicide attempts in pediatric antidepressant treatment. JAMA 2007; 297:1683-1696
4. Bridge J, et al: Emergent suicidality in a clinical psychotherapy trial for
adolescent depression. Am J Psychiatry 2005; 162:2173-2175
As has been stated by Dr. Armao, the source of mental health issues originates in early life experience—and, as this abstract points out, even to experience in utero. It’s amazing to think about how the physiology of depression gets passed on from generation to generation, especially in communities like ours where so much stress and trauma have occurred (and often still do). Luckily, it is possible to break that cycle—and having caring adults, such as Britney’s counselor, mirror back how important and valued these young people makes a huge difference. Better yet would be to teach young parents how to do this even before their children are born, such as the work by David Olds with the Nurse-Family Partnership program (discussed in a previous listserv discussion).
We in Cherokee are fortunate to have a psychiatrist as well as psychologists in our mental health clinic trained to work with children and adolescents. One of those psychologists is trained in Parent-Child Interaction Therapy, so he can do some of that early intervention work with very young children and their caregivers at the first sign of problems—hopefully long before they develop the complex issues Britney has. Before having those kinds of resources, we primary care docs would do the evaluation for medications in these patients—with the options for medications (and their risks) today, we’re grateful to have a team to be able to refer young patients to.
Ann Bullock, MD
Eastern Band of Cherokee Indians
Cherokee, NC
1: Neuropsychopharmacology. 2008 Feb;33(3):536-45. Epub 2007 May 16
Antenatal Maternal Anxiety is Related to HPA-Axis Dysregulation and Self-Reported Depressive Symptoms in Adolescence: A Prospective Study on the Fetal Origins of Depressed Mood.
Van den Bergh BR , Van Calster B , Smits T , Van Huffel S , Lagae L
1Department of Psychology, Katholieke Universiteit Leuven (KU Leuven), Tiensestraat, Leuven, Belgium.
Depressive symptomatology can proceed from altered hypothalamic-pituitary-adrenocortex (HPA)-axis function. Some authors stress the role that early life stress (ELS) may play in the pathophysiology of depressive symptoms. However, the involvement of the HPA-axis in linking prenatal ELS with depressive symptoms has not been tested in a prospective-longitudinal study extending until after puberty in humans. Therefore, we examined whether antenatal maternal anxiety is associated with disturbances in HPA-axis regulation and whether the HPA-axis dysregulation mediates the association between antenatal maternal anxiety and depressive symptoms in post-pubertal adolescents. As part of a prospective-longitudinal study, we investigated maternal anxiety at 12-22, 23-32, and 32-40 weeks of pregnancy (wp) with the State Trait Anxiety Inventory (STAI). In the 14-15-year-old offspring (n=58) HPA-axis function was measured through establishing a saliva cortisol day-time profile. Depressive symptoms were measured with the Children's Depression symptoms Inventory (CDI). Results of regression analyses showed that antenatal exposure to maternal anxiety at 12-22 wp was in both sexes associated with a high, flattened cortisol day-time profile (P=0.0463) which, in female adolescents only, was associated with depressive symptoms (P=0.0077). All effects remained after controlling for maternal smoking, birth weight, obstetrical optimality, maternal postnatal anxiety and puberty phase. Our prospective study demonstrates, for the first time, the involvement of the HPA-axis in the link between antenatal maternal anxiety/prenatal ELS and depressive symptoms for post-pubertal female adolescents. Neuropsychopharmacology (2008) 33, 536-545; doi:10.1038/sj.npp.1301450; published online 16 May 2007.
Discussion Summary from Dr. Armao:
This month’s discussion on adolescent behavioral health will be terminated prematurely due to the non-negotiable demands of Spring Break – certainly an imperative that all self-respecting adolescents would endorse enthusiastically.
I hope that the case discussed shed at least some light on issues bearing on the diagnosis and management of behavioral health disorders in adolescents. Precision in psychiatric diagnosis of children and teens is problematic to say the least. A major proportion of drug prescriptions in this population are off-label, which is perhaps appropriate, as I am not sure we have an exact label for many struggling kids. Many DSM diagnoses are derived from adult criteria, and often fail to encompass the nuances of child and adolescent disorders. No better example exists than the diagnosis of PTSD, which works pretty well when applied to an adult after a discrete trauma, but doesn’t capture the wide spectrum of behavioral and emotional responses we see in children exposed to early life stress, whether chronic or acute. Adult derived criteria for bipolar disorder, major depression, and even substance abuse all leave room for “diagnostic orphans”, and conversely, can stretch-to-fit some youth who may not meet the classic definition, but need help nevertheless.
As many of you know, the diagnosis of bipolar disorder in youth has increased dramatically in recent years – actually by 40-fold, according to the Archives of General Psychiatry.(1) This seems a bit excessive. I think we now have more kids in this country who are bipolar than bilingual, which is a sad indictment of both our educational system and our behavioral health care non-system. If you look at these pediatric bipolar cases, they are overwhelmingly boys, overwhelmingly young (median age in one study, 12.8), and overwhelmingly co-diagnosed with some classic non-zebra-like animals, such as ADHD, Oppositional Defiant Disorder, and Substance Use Disorders. Bipolar disorder is no longer a discrete diagnosis; it’s a right of passage for troubled youth. However much this trend may corrupt diagnostic purity while enhancing the ROI for pharmaceutical companies, I think it may be even more problematic in Indian Country. There is a fair amount of evidence from the research that Western/Caucasian-derived classification schemes for behavioral health don’t “fit” well at all with Native American conceptualizations of mental and emotional dysfunction. Add this factor to the difficulties with DSM criteria for youth in general, and throw in the reality that in psychiatry one would be hard pressed to declare one symptom, sign, or lab or imaging test as pathognomonic for any condition – well, it is easy to see how difficult it can be to acheive diagnostic clarity with Native American adolescents amidst such chaos.
We always need to remember that we in IHS are dealing with a population that has been subjected to massive amounts of psychosocial deprivation. It is well demonstrated that kids who grow up in such circumstances are far more likely to exhibit signs and symptoms of emotional dysregulation, disruptive behavior disorders, ADHD, substance use disorders, and the whole gamut of psychiatric disorders – whatever the formal diagnosis may entail. Given the complexities and controversies in medication management for these youth, the primary care provider needs to develop a feel for when and how to refer teens and their families to specialty care. And although child and adolescent psychiatrists are in extremely short supply in IHS, thankfully we have a few, and have attracted more in recent years. Most adult psychiatrists – particularly if they’ve been in IHS for a while – do the best we can, and inevitably acquire a lot of experience with youth. The American Academy of Child and Adolescent Psychiatry has published guidelines for referral (excerpted, with a link below):
Specific Criteria for
Referrals (AACAP)
The referring practitioner should consider the following criteria when considering
the decision to refer.
- When a child or adolescent demonstrates an emotional or behavioral problem that constitutes a threat to the safety of the child/adolescent or the safety of those around him/her. (e.g. suicidal behavior, severe aggressive behavioral, an eating disorder that is out of control, other self-destructive behavior),
- When a child or adolescent demonstrates a significant change in his/her emotional or behavioral functioning for which there is no obvious or recognized precipitant. (e.g. the sudden onset of school avoidance, a suicide attempt or gesture in a previously well functioning individual),
- When a child or adolescent demonstrates emotional or behavioral problems (regardless of severity), and the primary caretaker has serious emotional impairment or substance abuse problem. (e.g. a child with emotional withdrawal, whose parent is significantly depressed, a child with behavioral difficulties whose parents are going through a “hostile” divorce),
- When a child or adolescent demonstrates an emotional or behavioral problem in which there is evidence of significant disruption in day-to-day functioning or reality contact. (e.g. a child/adolescent who has repeated severe tantrums with no apparent reason, a child reports hallucinatory experiences without an identifiable physical cause),
- When a child or adolescent is hospitalized for the treatment of a psychiatric illness,
- When a child or adolescent with behavioral or emotional problems has had a course of treatment intervention for six to eight weeks without meaningful improvement,
- When child or adolescent presents with complex diagnostic issues involving cognitive, psychological, and emotional components that may be related to an organic etiology or complex mental health/legal issues,
- When a child or adolescent has a history of abuse, neglect and/or removal from home, with current significant symptoms as a result of these actions,
- When a child or adolescent whose symptom picture and family psychiatric history suggests that treatment with psychotropic medication may result in an adverse response. (e.g. the prescription of stimulants for a hyperactive child with a family history of bipolar disorder or schizophrenia),
- When a child or adolescent has had only a partial response to a course of psychotropic medication or when any child is being treated with more than two psychotropic medications,
- When a child under the age of five experiences emotional or behavioral disturbances that are sufficiently severe or prolonged as to merit a recommendation for the ongoing use of a psychotropic medication, or
- When a child or adolescent with a chronic medical condition demonstrates behavior that seriously interferes with the treatment of that condition.
When to seek referral or consultation with a child and adolescent psychiatrist
At any rate, primary care providers do have a major therapeutic role to play beyond referral. As was discussed earlier this month, attachment deficits are central to traumatized youth. Building on family and other interpersonal relationships is key, and encouraging participation in community activities (Boys and Girls Clubs, Big Brothers, Big Sisters, athletic activities), or organizing, mentoring or participating ourselves in these programs helps rectify attachment deficits. Participation in school and community activities also helps youth attain a sense of mastery, and building competence and self-efficacy for kids is invaluable. Often, teens will respond dramatically if given an opportunity to be of service to others in need. And sometimes, it is just a matter of helping a teen realize a strength or special talent that might have gone unrecognized. It all sounds simplistic, but it is often surprising how little effective guidance kids get from families in a perpetual state of crisis. And the problems often go unrecognized at school, where teens can either blend in with the crowd or act out enough so that staff give up on them.
These therapeutic interventions depend on the fact that teens’ brains are the ultimate in plasticity – always developing in response to environmental demands and influences. This is not just a vague concept, but based on research that demonstrates changes in synapses and even gene expression for neurotrophic growth factors in response to psychosocial and pharmacological interventions.
Adolescents and their families can and do respond to our efforts, although of course, not uniformly. But much of the success is built on the foundation of our primary care providers who take the time, even when there is no time, to try and bring order out of chaos.
1 Moreno C et al. Natural trends in the outpatient diagnosis and treatment of bipolar discorder in youth. Archive General Psychiatry. 2007; 64:1032-1039.
