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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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