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Discovery day focuses on youths' behavior

by Heather Woolwine
Public Relations
Some experts believe the higher incidence of mental illness in children can be blamed on genetic and environmental factors. Still, others argue that the increase reflects better testing methods and awareness.
 
Regardless of the cause, most experts agree that youth psychiatric issues are surging to the forefront of the field and are becoming relevant in understanding everything from teen drug use to high school massacres.
 
The MUSC Institute of Psychiatry sought to discuss a range of disruptive behaviors that get in the way of young lives and that of their families during the Day of Discovery Conference on Youth Psychiatric Issues: Disruptive Behavior, Disruptive Lives held Jan.11. Created to offer physicians and mental health care providers current information that could aid in the care of adolescents with brain disorders, the conference highlighted: marijuana use, behavior therapy for adolescents with borderline personality features, how the development of children is affected by abuse and neglect, determining the difference between moody and bipolar, and the neurobiology and impact of conduct disorder.

Marijuana and psychopathology
Kevin Gray, M.D., MUSC Psychiatry assistant professor, began his presentation by defining adolescence as a period of heightened stress with rapid physical, cognitive, emotional, social and behavioral changes.   A critical time for brain development, even the most well-adjusted adolescent experiences and creates challenges and difficulties, according to Gray. It’s also during this time that adolescents crave a sense of identity, their own path and independence from parents. Therefore, adolescents begin to trust heavily in what their peers are doing, saying, and thinking. Gray explained that during this time, “nearsightedness” is the norm, meaning that they want things on their own terms, which often is in conflict with what beliefs, values, morals, etc., that their parents are trying to instill in them. Drugs can enter the picture because adolescents are susceptible to peer influence, desire to challenge their parents, and they want to try new things. Gray noted that while not all adolescents use drugs on a regular basis, most have at least tried them.
 
A survey, Monitoring the Future, has been polling students since 1975 about attitudes toward the use of drugs and alcohol. The 2006 survey includes more than 50,000 students in a nationally representative sample. Among some of the more striking results is that 73 percent of 12th graders report trying alcohol, with 27 percent having at least five drinks in a row within a two week time period. Twelve percent of 12th graders reported smoking cigarettes daily; 42 percent tried marijuana, and 18 percent had used it in a month’s time. Percentages also are on the rise for inhalants, prescription drugs, and cold medicine, which some young people use to get high.
 
Gray said that substance abuse does not occur randomly; in fact behavioral and environmental predictors show some are more susceptible than others. Those factors are: genetic risk, parental substance abuse, academic failure, risk-taking, lack of parental involvement, abuse or neglect, aggression, peer substance use, exposure to violence, deviant peer group, victimization by assault, and up for debate, psychiatric problems.
 
Gray said it is important to single out marijuana use in determining its impact on adolescent psychopathology: it’s easy to get; there are mixed messages about its use; it’s viewed as natural and therefore harmless by some; its potency is increasing; and it has been viewed as a gateway to other substance abuse and poor choices. After discussing how it is used and its effects, Gray noted several correlations associated with marijuana use, including increased accident risk, impaired judgment and impaired driving performance.
 
Despite the many chronic effects of marijuana use in impairing a young life, most of the general population and adolescents don’t consider the consequences of picking up the pipe. Cognitive problems can be severe for chronic marijuana users, and the effects are even more pronounced in adolescents, especially in brain regions involved in mood, motivation, learning, and coordination, Gray said. These structures can be damaged while developing, thus possibly creating longstanding psychiatric conditions that will haunt adolescents well into adulthood. For illustration, Gray cited several studies all showing evidence that depression, anxiety, suicide, conduct disorder, attention deficit-hyperactivity disorder (ADHD), co-morbidity (other substance use), and severe psychosis like schizophrenia are linked to increased marijuana use.
 
So what is the psychiatric profession to do about treating adolescents who abuse marijuana when it is so easily obtained and use is beginning at an earlier age? “It is imperative that we screen for and treat co-occurring psychiatric and substance abuse disorders concurrently,” Gray said, offering the following treatment resources: Cannabis Youth Treatment study- free manuals at http://www.chestnut.org/li/cyt/products/; http://www.nida.nih.gov; and the MUSC Adolescent Substance Abuse Program at http://www.musc.edu/asap or 792-2388.

Borderline personality features and adolescents
Patients who demonstrate the feature of borderline personality disorder often are referred to as some of the most difficult patients to treat, because they fail to comply with treatment, frequently fail to respond to traditional therapy and take a demanding emotional toll on therapists. Developed by Marsha M. Linehan, University of Washington professor and psychologist, dialectical behavior therapy (DBT) is an innovative method of treatment that has been developed specifically to treat this difficult group of patients in a way that is optimistic and which preserves the morale of the therapist.
    
An adolescent exhibiting borderline personality features can be an even greater challenge with the numerous physical, emotional and cognitive changes that occur during this rite of life. McLeod F. Gwynette, M.D., Psychiatry assistant professor, described her experiences using DBT to treat groups of adolescents with borderline personality features. In particular, Gwynette wanted to target mood liability (sever depression/irritability), self-harm and suicidal behaviors, drug and alcohol abuse, conduct symptoms and impulsivity. Other symptoms of her patient group that were targeted addressed post-traumatic stress disorder (PTSD), abusive relationships, unsafe sex practices, violent behaviors, poor academic progress, and chaotic relationships. After breaking down barriers to treatment, like the “cool” factor (unwillingness to discuss topics deemed boring), Gwynette set about getting her group into exercises that would help them better deal with their symptoms, including story telling, role play and instructional materials that introduced new vocabulary to the patients. Using DBT, adolescents are learning mindfulness (focus on what an individual needs to do in order to be mindful, and how they are going to do it); interpersonal effectiveness (focus on assertiveness in saying no, making a request, and coping with problems); distress tolerance (skill set for accepting, finding meaning for, and tolerating distress by learning to bear the emotional pain that comes with distressing circumstances and events that the individual may encounter); and emotional regulation (identifying and labeling emotions, finding barriers in changing emotions and applying distress tolerance skills, while increasing positive emotional events through activities, healthy living, and by participating in activities that increase self-confidence). “When a patient connects skill to their own experiences, it’s extremely powerful,” Gwynette said. In addition to discussing therapy techniques, Gwynette also reminded health care professionals that other adjustments are required with this patient population, including safety measures, rules, a consistent agenda, seating arrangements, and the presence of an experienced supervisor in the event of a clinical emergency during group session.
 
While the study using DBT at MUSC has not concluded, Gwynette expects to see outcomes measures evident via number of incidents (hospitalizations, 911 calls, cutting), substance abuse, and decreased suicidal ideation and/or depression.

Development and abuse and neglect
At the beginning of her presentation, Eve Spratt, M.D., Psychiatry associate professor, outlined her goals for participants, specifically to help them understand the psychiatric, cognitive, developmental and health outcomes of youth with a history of child maltreatment (CM); to gain a better understanding of possible patho-physiological effects of CM on the developing brain; and to review treatment priorities for changing the social ecology of families.
 
The number of referrals concerning child welfare is up, with a victimization rate offered by Spratt of 12.4 per 1,000 children. Approximately four children die due to CM per day, and 76 percent of those children are under the age of four. In 2003, parents made up 80 percent of the perpetrators of child abuse or neglect.
   
Spratt outlined the various risk factors for different types of child maltreatment and divided those factors into four categories: child, parent, community and family. She also spoke of how to predict a repeat offender and the numerous economic costs associated with CM. Spratt then discussed into neurodevelopment, and just how the brain is affected by various forms of CM.
   
First, Spratt explained that symptoms of CM are mediated by biologic factors in the brain that are influenced by events that happen to a child. The hard wiring needed to form relationships and attachments is intact, but traumatized by CM— or in Spratt’s words, “The software becomes programmed to distrust and fear.”
   
A classic study involving rhesus monkeys and several other animal studies Spratt offered highlighted the concept that traumatic separation from a mother caused behavioral agitation, hippocampal degeneration, and elevated stress responses that popped up later in life.
   
Citing CM as a huge public health problem, she further explained its impact on personal education, how the system contributes to more problems for adolescents with a history of CM, and how it can lead to numerous consequences including depression, alcohol and substance abuse, eating disorders, aggression, early pregnancy, attachment disorders, domestic violence, school failure, lifelong poor health, sexual promiscuity, and arguably the worst of all, victims turning into perpetrators themselves.
   
Spratt reported that adolescents with a history of CM have four times the risk of teenage pregnancy, increased risk of sexually transmitted diseases, and are more likely to be involved with delinquency. In addition, the earlier children experience harsh physical treatment by significant adults the more likely they are to have adolescent adjustment problems. Eighty percent of victims of CM will have at least one psychiatric disorder by age 21. Spratt further solidified her points by offering numerous studies looking at level of neurotransmitters and other chemicals in the brain and their role in determining or stunting normal development, with one study in particular noting that children and adolescents suffering from maltreatment related PTSD had overall smaller brains than normal children.
 
In summarizing physical findings, Spratt said, “Brain development is dependent on the optimum biochemical environment but vulnerable to disruption. Trauma and abuse produce neurobiological alterations including brain damage…. Contribut(ing) substantially to a variety of psychiatric symptoms.”
 
By and large, her message was clear-that traumatic experiences are an undeniable component of psychiatric disorders and cognitive delays, and that by understanding the psychobiology of adolescents with a history of CM, clinicians may be able to improve early identification, educational, psychotherapeutic and pharmacologic treatments. “A better understanding of common trajectories will lead to earlier and more effective interventions,” Spratt said. She concluded by providing information about a study needing participants, and goals for child evaluation and treatment and family treatment.
    
Conduct disorder
Conduct disorder in adolescents is a collection of behavioral and emotional problems. Children and adolescents with this disorder have great difficulty following rules and behaving in a socially acceptable way. They often are viewed as “bad” or delinquent, rather than mentally ill. Many factors may contribute to a child developing conduct disorder, including brain damage, child abuse, genetic vulnerability, school failure, and traumatic life experiences.
 
Adolescents with this disorder can exhibit unacceptable behaviors in any of the following areas: aggression to people and animals; destruction of property; deceitfulness, lying, or stealing; or serious violations of rules and/or laws.
 
Markus Kruesi, M.D., MUSC psychiatry professor and director of the Youth Psychiatry Division and Fellowship program, explained the importance of understanding the neurobiology of lying in conduct disorder.
 
Of the many disruptive behaviors that characterize conduct disorder, lying is probably the most common and is an important component to executing many of the other symptoms of the disorder.
 
Overall, conduct disorder is little understood, yet it has significant social cost.
 
In one study mentioned by Kruesi, the cost of crimes committed by a “delinquent” who began prior to age 10 was estimated at $80,000-$350,000. Per case, Kruesi noted, this translates into possible long term economic savings in the millions of dollars per patient if proper treatment is enacted. However, poor treatment due to a lack of understanding of the neurobiological mechanisms at work in conduct disorder has thus far inhibited major treatment advance. No “magic pill” exists for conduct disorder, and the results are even more disappointing because of the lack of proven treatments for the adult or child psychopath. Conduct disorder, when left untreated, often leads to other more detrimental mental illness, including antisocial behavior and deception (lying with the intent to con or deceive).
 
Kruesi noted the overlap between lying and aggression in the adolescent with conduct disorder. Specifically, lying is prevalent in severe and pervasive cases of conduct disorder, or 73 percent of cases. Aggression is more predatory in psychopath cases and both precede substance abuse.
 
Physical evidence of conduct disorders can be found in the frontal lobe of affected individuals, where lesions on the brain could be deemed responsible for aggression and personality changes. In fact, violent psychopaths (the most extreme form of conduct disorder) have exhibited dysfunctional frontal lobe neuropsych test results. In the temporal lobe, lesions and/or seizures have led to case reports of aggression and antisocial behavior in those individuals. Further, Kruesi noted that in psychopaths, the corpus callosum is thicker, has more volume, and an increase in functional connectivity.
  
All of these differences in brain function and development for those with conduct disorder seem to indicate fundamental differences in biology for those with conduct disorder, but in order to look at the circuitry and devise what is different from the normal brain, Kruesi stressed the need to parse the relationships of conduct disorder, deception, aggression, substance abuse, and psychopathy away from one another. All are detectable in adolescence, and most will pre-date substance abuse, he said. It’s at this threshold that Kruesi believes it vital to parse the neurobiology of these overlapping disorders to decrease not only the possibility for substance abuse, but also to alleviate the great pain and suffering caused by individuals with conduct disorder to themselves and others.
 
“We don’t have any definite treatments, but we can identify new treatment targets by better understanding the neurobiology of each symptom,” he said. “We need your help in revealing targets for future interventions.”
 
Kruesi is seeking patients with early onset conduct disorder, preferably who lie with the intent to deceive or con. Adolescents who participate must be between ages 10 and 15 to participate in the MRI imaging study.
 
For more information call 792-5453.

Friday, Feb. 2, 2007
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