Adolescent Conflicts

8/12/2019 Adolescent Conflicts

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Psychiatric Potpourri: Conflicts in

Adolescence

Patrick Shea PL3


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Topics covered in this discussion

Part I: Emotion, Stress, and Coping Part II: Risk-Taking, Delinquency, and Violence

Part III: Adherence in chronic illness


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Emotional experience in Adolescence

Adolescents have the same range and types ofemotions as adults, but their reactions tend to be

different (usually the reaction is >>>>that of an adult,

and faster).

The problem of reactivity The problem of impulsivity

Inability to understand and appreciate consequence

(especially long-term) at an adult level.

Tend to experience emotions more intensely in

adolescence due to hormonal influences and life

inexperience, but individual ranges still hold.


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Stress

Defined similarly to pressure in physics = force/area Psychological stress = change/perceived ability to

cope with change

Not all change is negative, but negative events exact

a higher toll in the numerator Stress is essentially unavoidable in adolescence, as

this is by definition a time of some upheaval, both

physiologically and psychologically!

Adolescents generally will have a more limited

repertoire of coping skills than adults.


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Classifying stressors: Relative MagnitudeSome examples from the modified Holmes and Rahe stress scale (0-100 rating

system):Failing a class56

Relationship break-up53

Beginning to date -51

Parental discord46

Being accepted to college43

Unplanned pregnancy/abortion - 100 Being a senior in high school - 42

Death of a parent - 100Getting married95

Parents divorce90

Acquiring a visible deformity80

Fathering a child70

Parent goes to jail70

Parents separate69

Death of a sibling68

Change in level of peer acceptance67

Unplanned pregnancy of sister64

Death of a friend63

Parent re-marries63


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Coping & Coping mechanisms

Coping: The cognitive and behavioral efforts by anindividual to manage demands and conflicts that

(s)he perceives as taxing. Mental effort to master,

minimize or tolerate stress or conflict.

Classifying coping mechanisms: Emotional vscognitive vs behavioral

Perhaps more important: Adaptive vs Maladaptive

The Linehan/DBT model: Only 4 things you can

really do: Solve the problem, change the way youthink/feel about the problem, accept the problem

(radical acceptance), stay miserable (!)


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Coping: Types of strategies

Cognitive: Focusing on the way one thinks about astressor: Denial, minimization/distancing, altering

goals, altering values, using humor.

Behavioral: Focusing on the stressor itself, and

learning new information about it and how tomanage it.

Emotional:Management of the emotions that

accompany an unavoidable stressor. Releasing

pent-up emotion in another way, managing hostilefeelings, self-distraction, escape/avoidance of

feelings caused by the situation.


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Coping: Adaptive vs Maladaptive

Adaptivecoping mechanisms are those which willhelp one successfully manage a stressor. These

include anticipation, seeking social support, careful

attention to basic needs/keeping fit, finding humor,

and finding meaning. Maladaptive coping mechanisms are those which

will perhaps manage negative emotions in the short

term without negotiating the conflict at hand. They

include denial, avoidance, escape (often via self-medication), and outward aggression toward those

perceived to be causing the stressor or conflict.

Low effort coping is an attempt to lower

expectations in a given situation.


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Risk-Taking Behavior in Adolescence: An

overview

Risk is inherent in life, and some risk-taking ishealthy.

Learning to negotiate risk is an important area of

development for adolescents.

People tend to exist on a continuum between risk-taking and risk-averse styles.

Adolescents are often more risk-averse in some

areas of their lives and more risk-taking in others.


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Healthy vs Unhealthy risks

In many cases, adolescents can be re-directed fromunhealthy risk taking to more healthy means of

meeting the same challenge.

What is the underlying motivation for the behavior?

What need is the adolescent trying to meet? Problem areas include: Eating disordered behavior,

drug/alcohol use, unhealthy sexual activity,

violence/bullying others, running away/staying out at

night, and shoplifting/stealing. Can represent rebellion which is normal as a part of

individuation.


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Effectively counseling adolescents with

concerning risk-taking behavior

Important to remain non-judgmental Prioritize: Adolescents have a short attention span

and may feel overwhelmed. Pick 1-2 behaviors to

focus on at any one visit.

Assess the underlying motivation. Suggest anotherway to meet the need.

Follow up to check on progress toward goals. If

appropriate could expand focus to other risky

behaviors. Parents still have an important influence, so it can be

helpful to get a sense of the parent(s) own risk-

taking behavior and history thereof.


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Specific risk-taking behavior: Prevalence

and trends

Smoking/tobacco use: About 20% (declining slowly) Alcohol use: About 40% (declining, was >50% until

2000)

Marijuana use: About 25% (currently at a 30-year

high) Sexual activity: Only 13% at 15, 70% by 19. Average

age of first time is 17.

19% of teens regularly have unprotected sex.

Pregnancy: Highest rate in the industrialized world,

but on the decline. 27% abortion, 59% birth, 14%

miscarriage. Utah has one of the lowest rates of the

states.


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Delinquency

Juvenile Delinquencyis defined as the commissionof criminal behavior by a person under 18.

Categories include: Property crime, violent crimes,

sex crimes, and status offenses.

Juveniles are involved in offense commission in 21%of violent crimes, and this rate is declining

Recent increase in property crime (the economy?)

Juvenile crimes tend to start happening around 3 pm

and peak 7-9 pm (nonviolent crime) and 8-10 pm(violent crime).


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Delinquency: Risk factors and

Demographics

Poverty Mental disorders (Particularly Conduct Disorder)

Single parent

Racial breakdown: African-American (1 in 3) >

Hispanic/Latino (1 in 6) > White/Asian

The male phenomenon: 80% of delinquent youth are

boys

Cradle to prison pipeline

Labeling (?) Controversial


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Health supervision in detention facilities

AAP publishes guidelines on health supervision visits(frequency, etc)

More aggressive screening recommended than for

non-incarcerated youth (STIs, TB)

No AAP guidelines regarding specific ATG orcounseling for delinquent youth.


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Violence

3 top causes of death in Adolescence: Accidents,Homicide, and Suicide.

Death rate in males is 89 per 1000, much higher

than 35 per 1000 in females.

20% of boys and 8% of girls who died were victimsof homicide.


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Violent crime: Causes and risk factors

Similar risk factors to delinquency overall:poverty/SES, poor social supports, particularly lack

of supervision/structure.

Gang involvement (which in itself requires exposure

to the milieu) Drug use (Alcohol is the most frequently a/w violent

crime).

History of more minor aggression in childhood


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Firearms and violence

When a gun is carried outside the home by an

adolescent, 50% are semiautomatic handguns and 30%

are revolvers.

Firearms account for 2/3 of successful suicides in

adolescents.

When the District of Columbia had a handgun ban, there

were no completed suicides from 2000-2002.

Firearms account for 27% of accidental deaths in

persons aged 10-19.

Persons under 22 are the victims of 25% of firearm

homicides.

Overall, firearms are the 2ndleading cause of death

(MVA is 1st) in all children, regardless of causality.

Ask about guns in the house, and counsel appropriately


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Adherence and non-adherence in

Adolescents with chronic diseases

Many adolescents are now living longer with chronicillnesses that require ongoing care.

Includes: Diabetes, IBD, HIV, HLHS w/ Fontan,

Biliary atresia s/p transplant, CF, etc, etc.

One of the big 4 psych consult questions (Theotherssomatization, psych admit for no bed at UNI,

psych side effects from medical therapy).


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Barriers to adherence

Need to fit in (Chronic disease makes themdifferent from peers). More of a problem in early

adolescence.

Need to rebel. Transference: Doctor is seen as a

parental figure, teen motivated to reject all thingsparental.

Need to individuate. Inventing own identity, which

they dont want DM/HIV/IBD etc to be a part of (Im

over it) Burnout, particularly in more high maintenance

illnesses such as Diabetes.

Distracted with the many other tasks and activities

that go along with adolescence.


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Evaluating adherence

Objective measures: HbA1c, blood levels ofmedication, FEV1, etc.

Still valuable to take an adherence history in order to

identify specific problems with adherence.

Have a frank conversation with the adolescent. Self-report evaluation (i.e. paper surveys) consistently

over-report adherence by 30%.

Non-judgmental and more troubleshooting in nature.


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Stages of Change


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Motivational Interviewing: Guiding

principles

Motivation to change is elicited from the patient, and is

not able to be imposed from outside forces It is the patient's task, not the physician's, to articulate

and resolve his or her ambivalence

Direct persuasion is not an effective method for resolvingambivalence

The counseling style is generally quiet and elicitsinformation from the patient

The physician is directive, in that they help the patient toexamine and resolve ambivalence

Readiness to change is not an intrinsic trait of the patient,but a fluctuating result of interpersonal interaction

The therapeutic relationship resembles a partnership orcompanionship


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Questions?

Adolescent Conflicts

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