Marked reduction in serotonergic activity in a sexually aggressive adolescent male.

Serotonergic dysfunctions are implicated in conduct disorder, impulsivity, and aggression. Early adverse experiences increase the risk for these behaviors in adolescents. The authors investigated serotonergic activity in one adolescent male who experienced maternal abandonment and childhood abuse and exhibited severely aggressive sexual offenses. Platelet serotonin (5-HT) concentration, [14C]-5HT uptake kinetics, and plasma prolactin, cortisol response to D,L-fenfluramine (D,L-FEN) were measured. Results showed extremely low 5-HT concentration (2.9+/-0.7 ng/108 platelets), [14C]-5HT uptake rate (0.5+/-0.04 mM/min/107 platelets), undetectable Km and Vmax, and abnormally blunted prolactin, cortisol response to D,L-FEN. These abnormalities in this sexually aggressive adolescent may be a consequence of childhood abuse.

Multiple vantage points on the mental health effects of mass shootings.

The phenomenon of mass shootings has emerged over the past 50 years. A high proportion of rampage shootings have occurred in the United States, and secondarily, in European nations with otherwise low firearm homicide rates; yet, paradoxically, shooting massacres are not prominent in the Latin American nations with the highest firearm homicide rates in the world. A review of the scientific literature from 2010 to early 2014 reveals that, at the individual level, mental health effects include psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms in relation to the degree of physical exposure and social proximity to the shooting incident. Psychological repercussions extend to the surrounding affected community. In the aftermath of the deadliest mass shooting on record, Norway has been in the vanguard of intervention research focusing on rapid delivery of psychological support and services to survivors of the "Oslo Terror." Grounded on a detailed review of the clinical literature on the mental health effects of mass shootings, this paper also incorporates wide-ranging co-author expertise to delineate: 1) the patterning of mass shootings within the international context of firearm homicides, 2) the effects of shooting rampages on children and adolescents, 3) the psychological effects for wounded victims and the emergency healthcare personnel who care for them, 4) the disaster behavioral health considerations for preparedness and response, and 5) the media "framing" of mass shooting incidents in relation to the portrayal of mental health themes.

Factors affecting recruitment into child and adolescent psychiatry training.

OBJECTIVE: The authors studied the factors affecting the recruitment into child and adolescent psychiatry training in the United States. METHODS: Medical students (n=154) and general and child and adolescent psychiatry residents (n=111) completed a questionnaire to evaluate career choice in child psychiatry (n=265). RESULTS: Compared with medical students, general and child and adolescent psychiatry residents were more likely socially related; extroverted; empathic; warm; tolerant of ambiguity; interested in quality of life, social systems, and a developmental perspective; and to espouse greater satisfaction working with psychiatric patients, but less interested in sports or outdoor activities. Seventy-eight percent of medical students considered psychiatry as a potential career, and 28% indicated a strong interest in psychiatry. Sixty-four percent of general psychiatry residents considered child psychiatry as a career. Reasons precluding child psychiatry were preference for working with adults (33%), the clinical child rotation (19%), years of training (13%), and indebtedness (3%). CONCLUSIONS: More effort is needed to address the barriers to selecting child psychiatry as a career among medical students and general psychiatry residents.

Chance happenings in life and psychotherapy.

This paper will focus on chance happenings and man's struggles to make sense of those random events that occur in everyday life. There is a readiness to deny chance happenings as powerful mediators in our life course and to transfer the guidance of the world to divine providence, to anthropomorphize fate, to search for blame, and to create conspiratorial theories out of natural disasters. Emphasis will be placed on understanding chance happenings from an exploration of coincidences, experiences perceived beyond coincidences, scientific predictors of causality, and developmental perspectives, as well as the individual's psychological strategies for coping with a fateful event, an acute traumatic moment in which there is sudden awareness of a perceived threat of injury and to life itself. The role of chance and environmental happenings in psychotherapy will be discussed with clinical vignettes.

The acute traumatic moment-psychic trauma in war: psychoanalytic perspectives.

The acute traumatic moment is defined as the sudden conscious, awareness of intense and devastating feelings of helplessness to cope before the, fear of injury and death. The sudden overwhelming of three processes often precipitates the acute traumatic moment: (1) the ego ideal with specific narcissistic, defenses associated with the idealized self, (2) the illusion of safety; and (3) the, mechanisms of denial. The author discusses the developmental origins of the illusion of safety, rational and irrational contributions to its configuration, and its, importance as a psychological construct in the life of the individual soldier. The, author examines the acute traumatic moment as it may occur upon exposure to, threats of injury and death during war from a psychoanalytic perspective., Clinical vignettes of soldiers are presented.

Adolescent Victims of Commercial Sexual Exploitation versus Sexually Abused Adolescents.

We have discovered in our clinical review that sexually abused girls have significantly better therapeutic outcomes than girls who have been victims of sex trafficking. Thus, we compared the mental health records of 25 adolescent female victims of commercial sexual exploitation with a group of 25 girls with a history of sexual abuse matched for age. Exclusion criteria included IQ <70, organicity, and psychosis. Victims of sexual exploitation were more likely to be in foster care; to have arrests, suspensions from school, and a history of running away; to abuse drugs; to be more impaired in social and school activities; to be withdrawn and depressed; to manifest social and thought problems and aggressive and rule-breaking behaviors; and to have a diagnosis of mood or conduct disorder or both. The results of this study suggest that the psychopathology of girl victims of sexual exploitation is markedly different from that of sexually abused girls.

A 10-year prospective study of prodromal patterns for bipolar disorder among Amish youth.

OBJECTIVE: Prospective study of well children at risk of bipolarity to identify the frequency and pattern of potentially prodromal symptoms/behaviors for bipolar disorder type I (BPI) disorder. METHOD: A total of 110 at-risk children with a BPI parent and 112 children with well parents were studied. Ten-year data collection used structured and semistructured annual interviews covering developmental, medical, and behavioral features. Randomized histories for 222 children were submitted blindly for risk rating of bipolarity by a panel of clinicians. RESULTS: Children in the bipolar sample had an overall risk rating of 41% as compared with 16% for control children. Features noted more frequently among the at-risk group were anxious/worried, attention poor/distractable in school, easily excited, hyper alert, mood changes/labile, role impairment in school, somatic complaints, and stubborn/determined. Five additional manic-like behaviors became more evident among at-risk adolescents at the 10-year follow-up: high energy, decreased sleep, problems with thinking/concentration, and excessive and loud talking. CONCLUSIONS: The children of a parent with BPI manifested, episodically, mini clusters of potentially prodromal characteristics more frequently than the children of normal controls. None of these children met any of the sets of diagnostic criteria for prepubertal bipolar disorder.

A pathway to spirituality.

The phenomenology of mystical experiences has been described throughout all the ages and in all religions. All mystical traditions identify some sense of union with the absolute as the ultimate spiritual goal. I assume that the pathway to both theistic and secular spirituality and our readiness to seek a solution in a psychological merger with something beyond the self evolves out of our human experience. Spirituality is one of man's strategies for dealing with the limitations of the life cycle, separation and loss, biological fragility, transience, and non-existence. Spirituality may serve as the affective component to a belief system or myth that is not rooted in scientific evidence but is lived as if it is true. Spirituality may take many forms, but I will suggest that in some instances it may serve as a reparative process in which one creates in the external world, through symbolic form, a nuance or facet of an internalized mental representation which has become lost or is no longer available to the self; or it may represent the continuity of the self-representation after death through a self-object merger. Lastly I will illustrate from the writings of two of our greatest poets, Dante Alighieri and William Wordsworth, how their poetry became interwoven with a profound spirituality. In Dante we will see the elaboration of a religious spirituality, while in the writings of Wordsworth a secular spirituality emerges interwoven with nature and belatedly his identification with "tragic man" as his mythos.

The Capacity to Mourn: Thoughts for a Developmental Line.

OBJECTIVE: The purpose of this article is to examine the developmental transformative milestones and cognitive achievements that mediate the mourning process. METHOD: Selected literature review and theoretical considerations to formulate hypotheses referencing mourning. RESULTS: We identify three predominant venues through which we experience losses: (1) The child moving from dependence to independence with the shedding of infantile ties. (2) The uncertainties of the life cycle with the inevitable and fateful losses of family members and loved ones; and (3) the passage of time with diminishing options and inevitable decline. Mourning requires consideration of the role of object constancy, the capacity for ambivalence, the successful negotiation of the normative adolescent mourning process, critical cognitive achievements including the acceptance of transience and chance happenings, and identification and the stabilization of the inner relationship with the mental representation of the lost object. CONCLUSION: Our life experiences require that we develop strategies for dealing with the various losses associated with our journey through the life cycle. The complex process of mourning and the ability to mourn evolves along a developmental line. There are certain developmental transformative milestones and cognitive achievements which if achieved facilitate mourning and which if not achieved may impede the process of mourning.

Prospective study of prodromal features for bipolarity in well Amish children.

OBJECTIVE: A prospective study of psychiatrically well Amish children to determine differences in the frequency and pattern of clinical features that may be prodromal for bipolar I disorder. METHOD: Children with a bipolar I parent (n = 100) and children of well parents in a matched control sample (n = 110) were assessed annually for 7 years with semistructured interviews covering medical/developmental features and symptoms/behaviors that are possibly prodromal for bipolarity. Randomized histories of these 210 children were evaluated blindly by 4 clinicians for independent ratings of risk for bipolarity. RESULTS: Thirty-eight percent of the children of bipolar parents were rated as at risk compared with 17% of children in the control sample. Most control sample children with risk ratings had well parents with a bipolar sibling (i.e., family history positive). Children with family histories negative for mental illness rarely received even a low risk rating. Clinical features significantly (p

Practice parameter for use of electroconvulsive therapy with adolescents.

Electroconvulsive therapy (ECT) may be an effective treatment for adolescents with severe mood disorders and other Axis I psychiatric disorders when more conservative treatments have been unsuccessful. ECT may be considered when there is a lack of response to two or more trials of pharmacotherapy or when the severity of symptoms precludes waiting for a response to pharmacological treatment. The literature on ECT in adolescents, including studies and case reports, was reviewed and then integrated into clinically relevant guidelines for practitioners. Mood disorders have a high rate of response to ECT (75%-100%), whereas psychotic disorders have a lower response rate (50%-60%). Consent of the adolescent's legal guardian is mandatory, and the patient's consent or assent should be obtained. State legal guidelines and institutional guidelines must be followed. ECT techniques associated with the fewest adverse effects and greatest efficacy should be used. The presence of comorbid psychiatric disorder is not a contraindication. Systematic pretreatment and posttreatment evaluation, including symptom and cognitive assessment, is recommended.

Practice parameter for the assessment and treatment of children and adolescents with enuresis.

Enuresis is a symptom that is frequently encountered in child psychiatric evaluations. Careful assessment is required to identify specific urologic, developmental, psychosocial, and sleep-related etiologies. For most children with enuresis, however, a specific etiology cannot be determined. Treatment then involves supportive approaches, conditioning with a urine alarm, or medications--imipramine or desmopressin acetate. The psychosocial consequences of the symptom must be recognized and addressed with sensitivity during the evaluation and treatment of enuresis.

Practice parameter for the use of stimulant medications in the treatment of children, adolescents, and adults.

This practice parameter describes treatment with stimulant medication. It uses an evidence-based medicine approach derived from a detailed literature review and expert consultation. Stimulant medications in clinical use include methylphenidate, dextroamphetamine, mixed-salts amphetamine, and pemoline. It carries FDA indications for treatment of attention-deficit/hyperactivity disorder and narcolepsy.

Practice parameter for the prevention and management of aggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusion and restraint.

This parameter reviews the current state of the prevention and management of child and adolescent aggressive behavior in psychiatric institutions, with particular reference to the indications and use of seclusion and restraint. It also presents guidelines that have been developed in response to professional, regulatory, and public concern about the use of restrictive interventions with aggressive patients with regard to personal safety and patient rights. The literature on the use of seclusion, physical restraint, mechanical restraint, and chemical restraint is reviewed, and procedures for carrying out each of these interventions are described. Clinical and regulatory agency perspectives on these interventions are presented. Effectiveness, indications, contraindications, complications, and adverse effects of seclusion and restraint procedures are addressed. Interventions are presented to provide more opportunities to promote patient independence and satisfaction with treatment while diminishing the necessity of using restrictive procedures.

Risk factors for psychosocial dysfunction among enrollees in the State Children's Health Insurance Program.

OBJECTIVE: The authors studied enrollees in the State Children's Health Insurance Program (SCHIP) (Title XXI) to characterize risk factors for psychosocial dysfunction among children of the working poor. METHODS: Medical and psychosocial variables were included in a survey completed by 393 parents of children enrolled in SCHIP. Regression analysis was used to examine the relationship between these variables and scores on the Pediatric Symptom Checklist, a measure of psychosocial dysfunction among children. RESULTS: Stepwise multiple regression showed that parental dysphoria, parental history of psychiatric or substance use problems, childhood chronic medical illness, and exposure to traumatic events each contributed independently to variance in psychosocial dysfunction in this population, explaining 34 percent of total variance. CONCLUSIONS: Despite strong progress in implementing SCHIP at the state level, the behavioral health care needs of children of the working poor have not been well defined. This study identified risk factors that can be easily found in the patient's medical record or detected during an interview by the primary care physician. Thus screening to identify children at risk of psychosocial dysfunction is warranted among SCHIP enrollees.

Children exposed to war/terrorism.

This paper reviews the prevalence of psychological morbidities in children who have been exposed to war-related traumas or terrorism as well as the diversity of war-related casualties and their associated psychological responses. The psychological responses to war-related stressors are categorized as (1) little or no reaction, (2) acute emotional and behavioral effects, and (3) long-term effects. Specific categories of war-related casualties discussed include refugee status, traumatic bereavement, effects of parental absence, and child soldiers. Psychological responses associated with terrorism and bioterrorism are presented. Lastly, mediators of the psychological response to war-related stressors are discussed, to include exposure effects, gender effects, parental, family and social factors, and child-specific factors. Children exposed to war-related stressors experience a spectrum of psychological morbidities including posttraumatic stress symptomatology, mood disorders, externalizing and disruptive behaviors, and somatic symptoms determined by exposure dose effect. Specific questions for future research are identified.

Aggressive adolescents benefit from massage therapy.

Seventeen aggressive adolescents were randomly assigned to a massage therapy group or a relaxation therapy group to receive 20-minute therapy sessions, twice a week for five weeks. The massaged adolescents had lower anxiety after the first and last sessions. By the end of the study, they also reported feeling less hostile and they were perceived by their parents as being less aggressive. Significant differences were not found for the adolescents who were assigned to the relaxation group.

Child disaster mental health interventions, part I: Techniques, outcomes, and methodological considerations.

This review of child disaster mental health intervention studies describes the techniques used in the interventions and the outcomes addressed, and it provides a preliminary evaluation of the field. The interventions reviewed here used a variety of strategies such as cognitive behavioral approaches, exposure and narrative techniques, relaxation, coping skill development, social support, psychoeducation, eye movement desensitization and reprocessing, and debriefing. A diagnosis of posttraumatic stress disorder (PTSD) and/or posttraumatic stress reactions were the most commonly addressed outcomes although other reactions such as depression, anxiety, behavior problems, fear, and/or traumatic grief also were examined. Recommendations for future research are outlined.

Child disaster mental health interventions, part II: Timing of implementation, delivery settings and providers, and therapeutic approaches.

This review summarizes current knowledge on the timing of child disaster mental health intervention delivery, the settings for intervention delivery, the expertise of providers, and therapeutic approaches. Studies have been conducted on interventions delivered during all phases of disaster management from pre event through many months post event. Many interventions were administered in schools which offer access to large numbers of children. Providers included mental health professionals and school personnel. Studies described individual and group interventions, some with parent involvement. The next generation of interventions and studies should be based on an empirical analysis of a number of key areas.

Andrew Wyeth and N.C. Wyeth: a psychodynamic perspective on father and son.

This paper examines the relationship between two extraordinary artists, father and son--N.C. Wyeth (1882-1945) and Andrew Wyeth (1917-2009)--and their art. N.C. Wyeth, the father, the most famous illustrator of his day, painted scenes full of drama and action, often of men engaged in violent life and death struggles. N.C. was unable to separate from his powerful mother and yearned for his iconic father. He thought himself an artistic failure and dedicated himself to raising his children to be geniuses. The youngest son, Andrew Wyeth, who lived a "secret life," painted scenes often characterized by pathos: bleak and barren landscapes, leaden skies, tire tracks, gray framed houses, desiccated fields, and circling buzzards. In the father-son relationship, we often seen three themes perpetuated developmentally: (1) the son's identification with the innermost conflicts of his father; (2) the yearning for the iconic father of his youth; and (3) a continuation and disavowal of his father's life. These themes are played out in the relationship between Andrew Wyeth and his father.