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Psychiatric Evaluation and Referral to Treatment of Adolescents
Essentials
- Adolescents need psychiatric care more often than children. About 20-30% of adolescents have psychological disturbances.
- Comorbidity is common; e.g. depression and symptoms of anxiety are often concomitant.
- Most mental problems that threaten the functional ability of adults begin in adolescence at about the age of 16. About 75% of mental disorders of adulthood begin before the age of 24.
- Early intervention and low threshold to treatment are essential when encountering adolescents with mental problems.
- The prevalence of mental problems in adolescence is so high that even in well-organized health care systems 40-60% of young persons are left without treatment that they need.
Examination of an adolescent
- The adolescent himself is the most important source of information, but an interview of the parents may give vital additional information.
- School and school health care personnel often recognize a teenager's mental difficulties in their initial stages.
- Several interviews, reserving enough time and a free atmosphere aid in the examination of an adolescent.
Perspectives in encountering an adolescent
- Remember that adolescents are neither children nor adults.
- Encourage the adolescent to express his/her own experiences; show interest. Due to a strong need to become independent it may be contradictory for an adolescent to rely on an adult.
- Respect the adolescent's pursuit for autonomy and independence.
- Be neutral, avoid taking "sides" with instances that oppose the teenager.
- Make observations on the following:
- relationship with his self and parents; how he feels about his body; sense of reality
- relationship with authorities
- attitude towards future
- physical health; phase of pubertal development; indications of an eating disorder Eating Disorders Among Children and Adolescents
- relationship with peers, does the adolescent have friends or does he withdraw from others
- do the symptoms hamper everyday life; school absenteeism
- does the adolescent show signs of a severe mental disorder that would require a more thorough investigation.
- It is important to chart the history of possible self-mutilation. Self-destructive thoughts and behaviour should be openly discussed.
Most common mental disorders in adolescence
Signs of severe mental disorder
- Consultation with a psychiatrist specialized in problems of adolescents is always indicated in the following situations:
- poor success at school, deterioration of school outcomes
- suicide attempt or self-destructive thoughts associated with a conscious will to die
- uncontrolled behaviour at home, assault of parents, breaking of furniture, locking oneself in room
- belief that one's body has changed or is changing
- physical aggression as a reaction to an oral insult
- impaired sense of reality or withdrawal from reality, for example, use of i.v. drugs, severe eating disorder, self-mutilation
- withdrawal from social relationships.
Impaired sense of reality
- See Adolescent Psychosis
- Severe psychoses, e.g. schizophrenia, start in adolescence.
- It is important that a young person is taken into treatment when possible early symptoms of psychosis emerge even if the confirmation of a psychosis diagnosis at a young age is often unreliable. The treatment of the early symptoms should be started before actual psychosis appears.
- The symptoms of actual psychosis resemble the symptomatology encountered in adults Adolescent Psychosis.
Depression
- See Depression in Adolescents.
- Feeling of depression is common in adolescents. In the majority the feeling is associated with the normal growth and development of adolescence.
- Low self-esteem is a risk factor of depression and anxiety in adolescents.
- Severe depression in an adolescent may, instead of being expressed as overt depressed mood, be obscured by behavioural disorders (bad temper, pilfering, substance abuse).
- It is important to take a young person's depression seriously. Severe depression causes adverse health effects and increases the risk of self-harm, which is why the diagnosis, treatment and follow-up are organized in specialized care.
- Treatment of mild depression in young persons has been successfully carried out also as part of student welfare services, with consultative support from specialized health care.
Anxiety disorder
- Disorder develops usually in adolescence. Prevalence is 3-4%.
- The symptoms include overwhelming mental distress, as well as worrying and anxiety independent of external circumstances.
Eating disorders
- See Eating Disorders Among Children and Adolescents
- An adolescent with an eating disorder defines him/herself through body weight, size or form, or through eating.
- Detection and initial assessment take place in primary care.
- The investigation and treatment of severe eating disorders of adolescents are organized, at least in the initial stage, in specialized care.
Self-destructive behaviour
- See Risk of Suicide in Adolescence
- Depression, bipolar disorder, emotionally unstable personality disorder, substance abuse problems and conduct disorders are risk factors.
- Fewer than one out of four of those who committed suicide and every second of those who attempted suicide have received psychiatric help.
- The family's role is significant and it is both an predisposing and protecting factor. Parents' participation in the care is important.
Attention deficit and hyperactivity disorders
- Core symptoms include inattentiveness, hyperactivity and impulsiveness. Typical symptoms in the adolescents include learning difficulties, difficulties in social interaction, problems with self-esteem, accident-proneness, and uncompleted (interrupted) education.
- The diagnosis is based on a careful investigation by a physician and broad interviewing of the adolescent and close relatives.
- More common in boys than girls; ratio 4:1. In childhood much more common than in adolescence.
- Hereditary factors are estimated to account for about 80% of the aetiology.
- Symptoms are reduced by pharmacotherapy and psychosocial therapies.
Aggression
- Is typical for this age-it is important to recognize situations in which the adolescents' aggressive behaviour or images hinder personal development.
- Signs of pathological aggression; see the section on signs of severe mental disorder.
Conduct disorders
- Symptoms associated with conduct disorders include disregard for the rights and well-being of others and of common norms, as well as behaviour that impairs functional capacity.
- Prevalence is higher in boys than in girls.
- Family has an important role both in the development of conduct disorders and as a factor preventing the development of disorders. Effective treatment methods require the participation of parents in the therapy, and hence it is important to start working with the family already at an early phase.
- Adolescents with severe conduct disorders are often also directed towards child protection services.
- Therapy takes place in outpatient settings; episodes of hospital care are usually short.
- A Finnish Current Care guideline emphasizes the use of multidimensional systemic methods, carried out in an outpatient setting, for the treatment of severe conduct disorders during adolescence instead of conventional individual and family therapies.
Abuse of alcohol or drugs
- Heavy abuse of alcohol and/or drugs Substance Abuse of Adolescents is a sign that the young person is in need of help. For the assessment of the abuse problem, information from persons in close contact with the adolescent is also often needed.
- Problematic use of intoxicants is often associated with mental health problems. The abuse symptom may signify an attempt of self-care, and it may alter or mask the symptoms of another disturbance of mental health, thus making the recognition of the disturbance more difficult.
Psychosomatic symptoms
- Are common in adolescents, occur in certain situations, and are temporary.
- Thoughts and images that are connected to the symptoms should be assessed (for example, fear of a serious illness or death).
- Generally discussion and providing the adolescent with realistic information help the symptoms disappear.
- Serious, long-lasting psychosomatic symptoms require consultation with a psychiatrist specialized in adolescents' problems.
Treatment
- Moderation is recommended in the psychotropic medication of adolescents. The knowledge about the effects of e.g. SSRI drugs on adolescents is for the time being insufficient, and caution is thus recommended when prescribing drugs.
- Psychotropic medication in an adolescent is started by a specialist in youth psychiatry, by some other psychiatrist or by a physician who has special expertise in psychotropic medication of adolescents.
- Assess the risk of dependence before issuing anxiolytic medication. (Dependence on alcohol and notable separation difficulties indicate a risk of developing dependence on medication).
- A psychotherapeutic examination is usually essential for adolescents. Their need for psychotherapeutic treatment is often short-term, however.
- Combining medication with psychotherapy is often necessary when more severe disorders are being treated.
- In the treatment of adolescents' psychoses a long period of hospital care in an adolescent unit that combines medication and psychotherapy is often necessary and often also proves successful.
- Adolescents' independence and autonomy from their parents creates an ethical problem with respect to treatment: Who has the authority to decide on matters concerning the developing adolescents' body and treatments? An attempt is generally made to respect the autonomy of the adolescent.