Editorial
Adolescent Psychiatry, 2015, Vol. 5, No. 1
1
Editorial Forty Five Years and Counting This volume marks the beginning of the fifth year of quarterly publication of Adolescent Psychiatry. If one counts from its origin as an annual hardcover publication, with the first volume being published in 1971, two years after the founding of ASAP, it marks the 45th anniversary of the journal. Recently I had the pleasure of speaking with Dr. Jack Davis, who was one of the founding members of ISAPP, and also the founder and CEO of the Grove school, one of the first residential treatment schools for adolescents in the US. Dr. Davis recalled for me the early days of adolescent psychiatry in which as he said, “no one thought about doing psychotherapy with adolescents.” This reminded me of an experience I had as a resident in psychiatry, when, in an introductory session to child and adolescent psychiatry, a supervisor noted that it was easy to develop a private practice if one was willing to see adolescents. The implication of this statement was that few people wanted to work with adolescents so you would have no trouble getting referrals. Adolescents were in a no-man’s land of psychiatry—the term child and adolescent psychiatry was not in general use—and many child psychiatry clinics didn’t see patients over 13. At Johns Hopkins, for example, where I trained, adolescents were seen in a special adolescent psychiatry clinic, which was part of the general psychiatry department, while children were seen in the child psychiatry clinic, which was under the department of pediatrics. This had its advantages and disadvantages. General psychiatry residents received excellent training in adolescent psychiatry, along with the child psychiatry fellows, who spent part of their second year in this clinic. The disadvantage was the sequestering of adolescent services meant that working with adolescents never became a central focus for many child psychiatrists. As adolescent psychiatry became increasingly incorporated into the child psychiatry training programs, the residents in those programs were better prepared to work with adolescents, but adolescent psychiatry was moved out of the core of general psychiatry, and general psychiatrists did not get adequate training in working with adolescents, and were often considered unqualified to treat them. One resident I know who left training after one year of child and adolescent psychiatry fellowship was actually told by the child psychiatry training director that he was not qualified to see adolescents. Forty-five years on, we are seeing unprecedented advances in our understanding of how things go wrong during adolescence, and what works and what doesn’t. There is an increased worldwide focus on adolescent health and mental health and recognition that the two are inextricably linked. We are seeing an increased focus on research in adolescence. In part this is due to the recognition that so many disabling conditions begin in adolescence, and in part to the increasing burden of disability that is accounted for by neuropsychiatric disorders worldwide, as morbidity and mortality due to other conditions decreases. On the other hand, most adolescents who need treatment still don’t get it, and teen suicide, substance abuse, self harm and high-risk behaviors have continued. There is an urgent need for more mental health professionals to be trained to work with adolescents, as well as for better policies to promote adolescent mental health. The journal’s and ASAP’s goal of expanding our knowledge and understanding of adolescence from biologic, psychological, and social perspectives hasn’t changed. These multiple perspectives were reflected in the presentations at the joint meeting of the American society for Adolescent Psychiatry (ASAP) and the International Society for Adolescent Psychiatry And Psychology (ISAPP) held in New York March 2015. This was the first ever joint meeting of the two organizations, and focused on critical issues in adolescent psychiatry and psychology. Topics included addictions and eating disorders, complementary and alternative medicine, cultural issues, psychopharmacology, psychotherapy, research on adolescent development, new treatments for schizophrenia, transition age youth, and youth violence. The proceedings from the meeting will be published in a future issue of Adolescent Psychiatry. In the meantime, we have this issue, which I think illustrates some of the breath and depth of our field. The issue begins with a report on research by Lazaratou and colleagues in Athens that explored differences in self-esteem in Greek adolescents before and after the global economic crisis that struck in the years following 2008 (pp. 3-11). Greece was hit particularly hard. Although the study was cross sectional, looking at a different group of high school students at each point in time, there were striking differences between the two groups. Emerging adulthood is normally a time of widening possibilities and expanding horizons. Increase in self-esteem is the norm, as young people discover new capabilities, and accomplish new tasks. This has not been the case for many adolescents, for whom the life dream has been deferred or worse, abandoned or never imagined in the first place. This research reminds us that economic and social factors play major roles in adolescent mental health.
2 Adolescent Psychiatry, 2015, Vol. 5, No. 1
Editorial
In “From Parents to Romantic Partners in a Globalized World: Coping with Relationship Stress in Adolescents from 20 Nations,” (pp. 12-21) Seiffge-Krenke reports on the latest results from a large scale multinational study that compared experiences among countries with varied cultural expectations for dating and intimate relationships. In the discussion, the author points out the important role that romantic relationships play in enabling adolescents to develop competence in dealing with relationship stressors, an important life skill. She and her colleagues were able to identify patterns associated with individualistic versus collective cultures, and interestingly found that coping styles were more influenced by culture than by gender. Furthermore, adolescents experienced more stress in relation to their parents than they did with romantic partners. In their article, “Transition from Children’s to Adult services for Patients with ADHD: A Model of Care,” (pp. 22-30) Moosa and Sandhu describe how, beginning with the norm of a lack of continuity of care between child and adult services for adolescents with ADHD, they were able to reconfigure mental health services to develop a model program in Birmingham, England, that successfully reversed the status quo. The program involves many linkages and structures for enhancing communication and making it easier for young adults to continue treatment. Young people with ADHD are a particularly challenging group—often only too happy to stop treatment when they’re no longer constrained my parents and schools to participate. In “’Ride or Die:’ Therapeutic interventions for Retaliatory Violence Among Youth,” (pp. 31-39) Barrett and Kallivayal use clinical examples to illustrate the importance of adapting psychotherapy to make it meaningful to youth whose cultural norms involve saving face at all cost and retaliating—sometimes lethally—against perceived insults. Although these youth recognize the dangers of their situations, they are unlikely to respond if a therapist tells them to “walk away” from a fight or ignore insults. Instead they need to be engaged in a mutual problemsolving endeavor with the therapist that acknowledges the reality of the difficulties they face in every day life. Holder and colleagues describe the introduction and the use of a relationship centered approach in a residential treatment center (pp. 40-49). Relationship-centered, patient-centered, and client centered treatment are all terms to describe a movement away from a hierarchical culture in which the professionals are the experts and authorities and patients and families the recipients of treatment. This movement has gained prominence outside the mental health field, and within mental health in the systems of care approach. In hospitals and residential programs, where staff roles are carefully delineated, it is a particular challenge to implement. Kaplin, Conca-Cheng, and Findling present an update on the psychopharmacologic treatment of children and adolescents with bipolar disorder (pp. 50-63). Their succinct summary outlines what we currently know, what we don’t know, and what we need to know about treating this disorder. There is a lot that we don’t know. They describe a new National Institute of Mental Health initiative termed Fast-Fail Trials (FAST), which uses small n studies and is aimed at finding specific brain receptors or biomarkers, with the goal of speeding up discovery of promising drugs that can then be tested in larger clinical trials. Finally, Inyang and Hua describe self-inflicted bilateral ocular perforation in a female adolescent patient with major depressive disorder and borderline personality traits (pp. 64-69). There is actually a literature on this phenomenon, which was first described in 1847. It occurs mainly in adult males with psychotic disorders, and the authors found no previously reported cases in adolescent females. Inyang and Hua found features in their patient consistent with non-suicidal self-injury, and also discuss the symbolic significance of the behavior as an attempt not to see a very painful reality. So, one may ask, have things really changed in 45 years? Sometimes I wonder. The breadth and depth of adolescent psychiatry and psychology continues to expand. It is clear that new models of service delivery have facilitated the translation of the expansion of knowledge into improved wellbeing and patient care. Whether this comes about for all adolescents depends on all of us-clinicians, researchers, educators, advocates and policymakers.
Dr. Lois T. Flaherty (Editor-in-Chief) Cambridge, MA USA E-mail:
[email protected]
