Adolescent Behavioral Health Issues for March, 2008 Primary Care List
Serve Discussion Forum:

The field we now commonly refer to as *behavioral health* was not long
ago more commonly referred to as *mental health*. I have no idea who
flipped the switch to make the change, or even why, but -- especially
when it comes to adolescents -- I think the terminology offers a useful
distinction. The turbulence of adolescence isn't always compatible with
a state of *mental* health. (And most self-respecting teenagers,
especially the guys, would never knowingly allow you any clues as to
what is going on in their twisted psyches anyway.) So carefully
assessing the objective evidence of behaviors and relationships often
provides a better approach than probing for verbal elucidation of the
teenager's deeply held emotions. And if we're lucky we can help to keep
them *behaviorally* healthy -- even if not perfectly mentally or
emotionally healthy -- by helping them understand the Risky Business of
adolescence: by identifying behaviors that put their futures at risk and
helping them understand these behaviors in a realistic context. (I think
for most teenagers, the adage from AA -- "Fake it till you make it" --
applies perfectly. If they can avoid entrenchment in self-defeating
behavior patterns by whatever means available, regardless of what's
going on inside, they will eventually emerge victorious out the other
end.) But the more we can help them in this without seeming too
intrusive in terms of their autonomy, and the more we can do so -- at
least initially -- without directly badgering them for closely guarded
information (e.g. anything having to do with their emotions) the more
receptive most of them are.

In this sense, few have greater potential to influence the psychosocial
milieu of the adolescent than the primary care provider. Ideally, the
PCP already knows the teen and also knows something about the family
relationships, strengths, and problem areas. Perhaps more importantly,
in the typical teen - PCP encounter, the adolescent doesn't feel like a
POW, which is often the case once he or she has been dragged, kicking
and screaming (if only inwardly) into the psychiatrist's office for a
waterboarding session.

The trajectory of a young person's life is profoundly determined by
events during adolescence, and the power of the PCP to modulate the
behaviors of teenagers at risk is enormous. But what to do when no
discussion or education is successful in containing behavior? What do we
do when substance abuse, school failure, anti-social behaviors or overt
self-destructive activity threatens to foreclose the future?

Is it all a matter of underlying depression that needs to be "treated",
and if so, what do we do? Is it more a matter of a normally-endowed kid
who needs more help overcoming a chaotic and traumatic childhood? Is it
bad genes come to roost, with no good outcome in sight? Or is it merely
a bump in the road, a more dramatic variant of a normally volatile
period, with a reasonable promise of an excellent outcome down the road?

In most cases, one never really knows except with the passage of much
time and turmoil. Nevertheless, it behooves all of us to understand as
much as we can about the complex biopsychosocial challenges faced by all
adolescents, and the current approaches favored by the behavioral health
community in dealing with these issues.

In this discussion forum, I would hope to provide some useful
information to help primary care providers understand more about issues
in adolescent behavioral health, including:

-   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.

I would also like to hear of success stories from the front lines --
things you've done or seen that may have influenced a kid's trajectory
through adolescence.

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.

A few links that may be of interest:

[http://www.nctsnet.org](http://www.nctsnet.org/)

This is the National Child Traumatic Stress Network. If you go to
"Products" you can find the following documents and lots more:
[Childhood Traumatic Grief Educational Materials - For Pediatricians and
Pediatric Nurses
(2004)](http://www.nctsnet.org/nccts/nav.do?pid=typ_tg); [Complex Trauma
in Children and Adolescents
(2003)](http://www.nctsnet.org/nccts/asset.do?id=478)

[2006 Columbia University Suicide Fact
Sheet](http://www.teenscreen.org/images/_getinformed/pdfs/GI4D_PDF_TeenSuicideFactSheet.pdf)
or
<http://www.teenscreen.org/index.php?option=com_content&task=view&id=80&Itemid=185>
and link to the Columbia paper, which is actually specific for Teen
Suicide, and as you can see, is part of the Teen Screen website.

<http://mentalhealth.samhsa.gov/cre/ch4.asp> This is the chapter on
Native American mental health issues in the Surgeon General's Report on
Mental Health: Culture, Race, and Ethnicity.

<http://www.nrepp.samhsa.gov/find.asp> You can look up interventions
that have evidence of outcomes, including the New Beginnings Program,
pioneered at ASU, and which involved Native Americans (though not
exclusively). You can search for programs by age ranges and conditions,
and by Native American as well.

<http://www.ama-assn.org/ama/pub/category/print/18112.html> \-- The AMA
Guidelines for Adolescent Preventive Services (Suicide and Depression).