This document provides guidance for clinicians working with adolescents. It discusses important considerations for engagement, confidentiality, and language. It also addresses common adolescent issues like depression, suicide, deliberate self-harm, and substance use. For each topic, the document outlines assessment approaches and treatment strategies. The overarching messages are to engage adolescents, establish trust, address issues in developmentally-appropriate language, and involve family when possible and beneficial.

1. Adolescent Problems
Developmental Issues and
Treatment Approaches
prepared by
Dr Elizabeth Cosgrave
2007

2. Some considerations before you
make a start…

3. Engagement
 Nothing will work if you are not
engaged with the adolescent
 Engagement takes time
 Things that might help
 Explain your role clearly
 What to expect from seeing you (be
specific & give examples)

4. Confidentiality
 Explain it at the beginning of the 1st session,
preferably with the parent also in the room
 Be specific & give examples
 What you will & won’t tell parents
 Establish ground rules
 What if your Mum rings me to ask how you’re
going?
 How do I contact you if you don’t turn up?

5. Language
 Explaining things
 Needs to be simple, non-pejorative & not too
jargonistic
 Most adolescents won’t respond well to being
asked to monitor their “dysfunctional cognitions”
 Age-appropriate questioning (CBT)
 “what would you say to a friend who came to you
with this problem?”
 “If you surveyed 100 Year 9 students, would they
all have reacted in the same way you did?”

6. Homework
 Monitoring Sheets
 Tailor them to the individual if at all
possible, & involve the adolescent in this
process
 Completing Homework
 Non-completion is not necessarily a poor
prognostic indicator
 Adolescents will often complete
homework…of sorts

7. Dilemmas associated with
working with adolescents
 Involvement of family
 Who wants this & who is likely to benefit
from this?
 Making a diagnosis
 Diagnosing a personality disorder
 The use of medications
 Deciding when there is a problem
 How to differentiate from normative
adolescent development

8. Deciding when there is a problem - I
 Is the adolescent distressed about the
Sxs?
 Is anyone else concerned? Who & why?
 Is the problem having an impact on the
adolescent’s functioning?
 Do the Sx represent a change from the
adolescent’s normal functioning?
 Measure the frequency, intensity &
duration of the problem/Sx

9. Deciding when there is a problem - II
 What is the potential for the adolescent (or
anyone else) to be seriously harmed by the
problem?
 Consider what is problem behaviour & what is
developmentally normal experimentation
 Substance use
 Health risk behaviours
 View of selves as omnipotent

10. Depression in Adolescence-I
 Incidence of depression, attempted suicide &
completed suicide increases significantly in
adolescence (cf. childhood)
 Depressive symptoms experienced by
15-40% of adolescents
 Evidence that early onset depression is a
more serious form of the disorder

11. Depression in Adolescence-II
 Adolescent depression predictive of a
number of negative outcomes:
 Academic difficulties
 Delinquency
 Unemployment
 Substance use
 Forensic involvement

12. Adolescent Depression: the Myths
 “Adolescents don’t get depressed”
 “Depressed adolescents will just get
over it”
 “All adolescents will become depressed
at some stage because adolescence is a
time of turmoil”
 “(S)he’s just being lazy/grumpy/difficult
to live with”

13. Risk Factors for
Adolescent Depression-I
 Previous MDE
 Being female
 Family Hx of psychopathology
 Stressful life events
 Low social support
 Subthreshold depressive Sx
 “out of sync” pubertal development

14. Risk Factors for
Adolescent Depression-II
 Other psychopathology (current or past)
 Serious physical illness
 Previous suicide attempt
 “depressogenic” cognitive style
(pessimistic, internal, global, stable)
 Poor coping skills

15. Recognising depression in
adolescents-I
 Disturbance of mood:
 May be sad or gloomy, but also very likely
to be irritable
 May describe mood as “angry”, “numb” or
“nothing”

16. Recognising depression in
adolescents-II
 Disturbance of thinking:
 Self blame, self criticism
 Negative thoughts re future
 Difficulty making decisions
 Time of important vocational choices
 Inability to think clearly
 Time when organisational & cognitive demands
increase
 Memory & concentration problems
 Impact on schooling

17. Recognising depression in
adolescents-III
 Disturbance of thinking (cont.):
 Hypersensitive to feedback from others
 Perceived as criticism
 Thoughts about being hurt, hurting oneself, dying
or committing suicide
 Useful to think of these along a continuum
 May manifest as ambivalence about living,
passive death wish or overt suicidality
 Need to assess for presence of other health risk
behaviours

18. Recognising depression in
adolescents-IV
 Disturbance of behaviour:
 Decrease in activity levels
 May no longer engage in extracurricular
activities
 Decrease in energy
 May seem very drowsy or fall asleep in class
 Tearfulness
 Agitation
 May manifest as difficulty attending to a task
until it is completed

19. Recognising depression in
adolescents-V
 Disturbance of behaviour (cont.):
 Change in social interaction
 Substance use
 Change in sleep &/or appetite
 Loss of sexual interest
 Difficult to assess in adolescents
 Somatic complaints
 May manifest as frequent visits to “sick bay”

20. Gender Differences in
Adolescent Depression
 From adolescence, females twice as likely to
develop a depressive illness than males
 Gender differences in coping with depressed
mood (Nolen-Hoeksema)
 Ruminative vs. instrumental strategies
 Gender differences in subjective meaning of
puberty
 Confluence of demands for adolescent
females
 e.g., pubertal changes, school transition

21. Treating Adolescent Depression-I
 Evidence for the efficacy of CBT & IPT
& pharmacotherapy
 Adjunctive group and/or family therapy
can also be useful
 Important to provide psycho-education
for client and her/his family
 May need to address beliefs that
adolescent is just “lazy”

22. Treating Adolescent Depression-II
 Provide honest feedback to your client
 Diagnosis (explain it)
 Formulation
 Provide clear rationale for any treatment
strategies you suggest
 This will hopefully maximise engagement &
likelihood of compliance
 Importance of using appropriate language
 Don’t be put off by the non-completion of
homework
 Be flexible with treatment strategies

23. Suicide in Adolescence-I
 There has been a steady increase in the rates
of youth suicide (15-24 years) in Victoria &
Australia since 1960 in males, but not in
females
 Adolescent females more likely to attempt
suicide than adolescent males
 Gender differences in methods:
 Females more likely to overdose or jump from
heights or under vehicles
 Males more likely to use firearms & car exhausts

24. Suicide in Adolescence-II
 A history of suicide attempts is a risk factor
for suicide completion
 ~50% of adolescents who attempt suicide will
make subsequent attempts
 Of those, between 0.1% & 11% will eventually
complete suicide
 The presence of psychopathology is a risk
factor for suicidality BUT:
 not all adolescents who attempt suicide are
depressed
 not all adolescents who are depressed are also
suicidal

25. Assessing for Suicide Risk in
Adolescents-I
 There is no evidence that asking
someone about suicide will make them
suicidal
 Ideation
 Be frank
 Plan
 Realistic?
 Perceived & actual lethality?
 Intent
 How serious? Compare with plan & means

26. Assessing for Suicide Risk in
Adolescents-II
 Means
 Despair & hopelessness
 Presence of psychopathology
 History of suicide attempts
 Take thorough history
 Family history of suicide
 Suicide in community
 Significant psychosocial stressor
 Consider adolescent’s perception of stressor

27. Assessing for Suicide Risk in
Adolescents-III
 Physical health
 Change in status, e.g., STD, HIV,
unplanned pregnancy, onset/exacerbation
of chronic illness)
 Coping skills
 Inflexibility, impaired ability to generate
possible solutions
 Impulsivity

28. Assessing for Suicide Risk in
Adolescents-IV
 Trust your clinical judgment
 If in doubt, consult with a colleague
 Remember that confidentiality is not
absolute

29. Deliberate Self-Harm-I
 DSH is defined as hurting oneself with the
intention of inflicting pain, rather than to die
 e.g., cutting, burning, scratching skin, punching
walls, head banging
 Suicidality & DSH usually occur on a
continuum
 Important to conduct risk assessment, as
adolescents may not realise the potential
lethality of the DSH

30. Deliberate Self-Harm-II
 Important to be flexible with your
definition of DSH when working with
adolescents
 e.g., starving oneself, train surfing,
substance use, risky sexual practices
 Difficult to establish prevalence rates,
as young people don’t often seek
medical advice for DSH & there is a lack
of clarity about definition of DSH

31. Why Do Adolescents Engage in DSH?
 Expression of emotional turmoil
 Expression of self hatred
 Lack of ability to express difficult emotions
(sadness, anger, guilt, shame)
 As a means of feeling something if “numb”
 Physical pain welcome relief from emotional
pain
 Patterns of DSH can be hard to break
because usually involves facing intense
emotions and/or memories

32. Managing DSH-for the
clinician
 Highly anxiety-provoking for clinician
 Importance of self care
 Labour intensive for clinician
 Disrespectful attitudes of some workers.
Can be punitive, angry, disrespectful,
not take the young person seriously or
witholding of appropriate treatment

33. Managing DSH – for clients
 If in doubt, ask the adolescent why
(s)he engages in this behaviour
 Conduct a cost-benefit of DSH
 Acknowledge that the young person is
doing the best that (s)he can to
manage intense emotional distress
 If a pattern of DSH has been
established, improvement will take time

34. Managing DSH – for clients
 Important to encourage clients when
they take small positive steps
 Take them seriously
 Young people who engage in DSH can
& do accidentally kill themselves

35. Adolescent Substance Use - I
 Adolescence is a peak time for the initial use of
many substances, including tobacco, alcohol &
illicit drugs
 potential for serious sequelae:
 school failure
 medical problems
 psychiatric morbidity
 fatal accidents
 suicide
 violent crimes

36. Adolescent Substance Use - II
 Future patterns of drug use often result
from drug exposure and use in
adolescence
 incidence of illicit substance use in
adolescents is increasing
 evidence that “gateway” use (of
cigarettes & alcohol) can lead to illicit
substance use & SUD

37. Adolescent Substance Use - III
 Australian studies consistently identify
1-2% of secondary students whose
pattern of alcohol, tobacco or other
drug use is problematic
 having an initial episode of a SUD
places adolescents at risk of developing
subsequent episodes

38. Adolescent Alcohol Use
 Approximately 30% of Australian
adolescents engage in problematic
alcohol consumption
 alcohol-related deaths in young people
are underestimated
 alcohol use is higher in young people
not enrolled in schools (cf. students)

39. Adolescent Cannabis Use
 Cannabis is the illicit drug that is most
commonly used by Australian
adolescents
 adolescents who use cannabis are more
likely to progress to using other illicit
substances
 early cannabis use associated with
escalation of use

40. Problems Associated with Use
 Habitual use can result in decrease in
functioning
 social stigma associated with use
 can impact on availability of services
 health risks associated with illicit
substance use
 regulation of composition

41. Assessing Problematic Substance Use
in Adolescents - I
 Majority of adolescents do not develop
problematic patterns of substance use
 when assessing use, should be able to
categorise use according to:
 initiation of use
 continuation of use
 maintenance & progression within class of drugs
 progression across class of drugs
 cessation
 relapse

42. Assessing Problematic Substance
Use in Adolescents - II
 important to assess why the young person
engages in substance use:
 relief from boredom
 weight control
 coping with stress
 avoiding negative emotional states
 conformity
 social reasons
 to avoid withdrawal

43. Assessing Problematic Substance Use
in Adolescents - III
 Important to also assess misuse of legal
substances (alcohol, inhalants) & prescribed
medications
 if you don’t ask, they probably won’t tell you
 may need to educate yourself & client re risks
associated with pattern of use
 principles of motivational interviewing are
useful
 need to understand what the adolescent thinks is
good about using the substance

44. Managing Adolescent Substance Use
 Don’t pretend you know which drugs are
which - ask the adolescent if unclear
 Acquaint yourself with the local drug &
alcohol service, either individually or by
setting up regular secondary consultation
 important to inform yourself & advise client
with accurate information (e.g., signs of
intoxication, withdrawal, dangers of
overdose, etc.)

45. Harm Minimisation
 Common & useful policy of youth
agencies in Australia
 cf. zero tolerance policy, common in US
 some strategies are specific to
particular substances (e.g., SSRIs &
ecstasy, size of bags with chroming),
but others are relevant to all substances

46. Harm Minimisation Principles
 Don’t use alone. Try to use with friends
& nominate one sober person
 know your limits (safe vs. unsafe
intoxication)
 dangers of illicit substance use
 use a regular dealer
 have a “taste” first, i.e., test strength of
substance (useful with heroin injection
& ecstasy tabs)

47. Personality Disorders: Background
 Clients diagnosed with a PD have historically
been perceived as untreatable. This is not
necessarily the case, but reflects the lack of
RCTs in the area
 lack of rigour associated with diagnosis of
PDs
 complexity (time needed)
 importance of gathering information across
time (many clinicians don’t do this)

48. Personality Disorders: Background
 Clients with PDs can evoke difficult emotions
in clinicians
 important difference between:
 Axis I (by definition episodic in nature)
 Axis II (by definition pervasive & longstanding)
 definition of personality traits are “stable &
enduring”
 in PDs it is these that lead to distress or
impairment

49. Personality Disorders: Background
 Important to assess how your client’s
personality impacts upon those around her/him
 for Dx of PD: need evidence that the client’s
way of interacting is maladaptive
 can be difficult to differentiate between a PD &
an Axis I disorder, especially if Axis I disorder
has an early onset & is stable over time
 e.g., social phobia & Avoidant PD

50. Personality Disorders in Adolescence
 Can be difficult to identify during this time, as
onset is usually in adolescence or early
adulthood
 difficulties associated with assessing how
your client’s personality impacts upon those
around her/him:
 nature of adolescent relationships can be intense
& rapidly changing
 frequent increase in conflict with parents:
evidence of PD or normative?

51. Eating Disorders in Adolescence - I
 Symptoms usually emerge in
adolescence (cf. low prevalence in
childhood)
 Associated with extensive mortality &
morbidity
 20% mortality rate for AN at 20yr follow up
 symptoms usually stable over time

52. Eating Disorders in Adolescence - II
 subthreshold symptoms are prevalent in a
number of cultures
 13% of US adolescents report purging
 predictive of full blown disorders
 subthreshold symptoms associated with significant
dunctional impairment
 dieting is a risk factor for the developments
of eating disorders
 60% of Australian 15yo females diet at a
moderate level ( Patton et al., 1999)

53. Associated Features
 Depressive Symptoms (especially for BN)
 DSH
 Substance abuse
 Suicide attempts
 Poor school performance
 Withdrawal from peer relationships
 Deterioration in family relationships
 Physical complications *

54. Physical Complications - I
 Amenorrhea
 Starvation syndrome
 Reduced metabolic rate
 Bradycardia
 Hypotension
 Anaemia
 Intolerance to cold
 Lanugo

55. Physical Complications - II
 Delayed gastric emptying
 Electrolyte abnormalities
 Can lead to potentially fatal cardiac arrhythmia
 Renal problems
 Erosion of dental enamel
 Oesophageal tears
 Reduction in bone density

56. Management of Eating Disorders
in Adolescents - I
 Know how to calculate a BMI
 Be aware that I/P treatment may be
needed (especially for AN)
 Be ready to work in conjunction with a
medical practitioner
 Limitations of psychological treatment if
young person is physically compromised

57. Management of Eating Disorders
in Adolescents - II
 Evidence for the efficacy of CBT & IPT in the
treatment of BN
 May also need to treat comorbid depressive Sx
 For AN literature is less clear
 Treatment is rarely brief
 Adjunctive family therapy is often very useful
 Use of support groups/organisations for
families
 e.g., EDFV