Adolescent Behavior

Introduction

Mental health professionals encounter adolescent behavior issues in a variety of contexts. These include family and individual therapy, high schools, residential facilities, group settings, and other institutional and treatment settings.

Adolescence is a very turbulent time for most teens. Their bodies are changing as well as their hormones. The period of adolescents is from about age 13 to about age 20. Adolescence is known as a time of confusion regarding identity and roles, as well as a time of potential conflict with parents and other authority figures. Many adolescents engage in some behaviors that challenge societal norms. This can include delinquent behaviors. A significant percentage of adolescents, however, have significant psychiatric or emotional problems that can hobble their transition into a fulfilling adulthood. Problems in the social environment such as gang activity, availability of drugs, and other peer group problems are heightened risks for adolescents that are having difficulty with identity development or whose communities are saturated with such influences.

Adolescents are highly influenced by their environment. So much so, that effective programs that promote appropriate behavior tend to lose their effect rapidly when they cease. At the same time, they increasingly spend time with their peers, without supervision.

The most intense areas of adolescent development include emerging abstract thought and a broader fund of knowledge about society and human nature, sexuality, experimentation with adult behaviors, developing higher responsibilities, choosing or resisting self-destructive behaviors, and gaining independence.

Families come to clinicians for a wide range of concerns regarding their adolescent children. These problems range from difficulties with normal developmental challenges, to severe acting out or mental illnesses. Parents range from being insightful and committed, to having very limited abilities to understand their child\'s behavior and to adopt new strategies. The variety of situations calls for a variety of approaches.

Families often need more intervention that an individual clinician can provide. This can be vexing when the needed resources or gatekeepers are dysfunctional or overwhelmed. In any case, clinicians must have a good understanding of community resources (or at least know how to get this information efficiently), and to work effectively with case managers and other who can assist them in getting access for their clients.

Normal and Abnormal Adolescent Behavior

A Biological, Developmental, Familial, and Cultural Phenomenon

To understand adolescent behavior problems, we must see adolescence through multiple lenses. These include the biology, development, family dynamics, and cultural context of the adolescent. We must also see the natural developmental drives, the values, and the intentions of adolescents that their negative behavior may distract us from.

Normal is Not Always Positive

What is normal in any given population is not necessarily optimal for the development and eventual adult adjustment of the adolescent. Therapists often must work to educate families about adolescent development and facilitate change in a manner that is sufficiently in harmony with the cultural and family contexts. At the same time, cultural traditions can be a source of unity, strength, identity, and meaning. But when the adolescent is torn between the ways of their immigrant family and the larger culture, the therapist may be in the position of helping the family distinguish between real threats to the child\'s well-being and the child\'s need to function and adapt to the environment.

Sexuality and Parenting

Issues

There are numerous concerns regarding adolescent sex, pregnancy, and parenting. These include the following:

• Dating and intimate partner violence
• Coercion, rape, and drugs used in eliciting sexual contact
• Sexually transmitted diseases
• Violation of family and social norms and resulting conflict and legal complications
• Psychoemotional effects of early sexual activity
• Prostitution and related problems of violence and crime
• Pornography and posting of compromising media on the Internet
• Loss of focus on childhood development, school, advanced schooling, and early efforts at establishing security through income-producing employment too early in life
• Medical complications of early pregnancy
• Medical or personal difficulties associated with termination of pregnancy or adoption
• Inadequate skills and financial resources for effective parenting
• Demands placed on grandparents not only for parenting of grandchildren, but in attempting to respond to additional complications of their child\'s life
• Inadequate payment of child support or legal or practical complications in ascertaining paternity
• Personal and financial stress for males that know that they are not the actual father, but are held responsible by the court for child support
• Disadvantages to children raised in single-parent families, particularly the mostly unwanted or unplanned children.
• The low likelihood that young parents will have the resources or skills to care for children with special needs
• Demands on social resources stemming from any of the above

Reason for Concern

Adolescent pregnancies reached record-setting levels in the 1980s and 1990s. Following this period, the rates lowered a great deal until the most recent years for which data are available as of this writing. Beginning in 2005, the trend reversed, and rates began to rise. (Lewin, 2010)

Experts have attributed this to the abstinence-oriented sex education programs championed under the Bush administration. The Obama administration has re-instituted programs that include contraception, so it is hoped that this trend will reverse again. The administrated has created an initiative in which most funding will go to evidence-based programs that have been shown to reduce teen pregnancy, as well as some experimental ones. (Lewin, 2010)

The abortion rate also fluctuates along with the pregnancy rate. From 1990 to 2005, teen pregnancies declined 41%, from 116.9 pregnancies per 1,000 to 69.5/1,000 in 12004. Abortion declined 56% during that period. Births declined 35%. (Lewin, 2010)

An added impetus to look to social policy for answers lies in the fact that U.S. teen pregnancy rates have far exceeded other developed nations to a magnitude of 2 to 10 times. (Moore, Miller, Sugland, Morrison, Glei, & Blumenthal, 1995)

According to Moore, Miller, Sugland, Morrison, Glei, Blumenthal (1995), "Of all births to young women under age 20, only 15 percent were nonmarital in 1960, compared to 30 percent in 1970, 48 percent in 1980, and 71 percent in 1992." The very large majority of these births were unwanted (84%, according to a 1990 poll cited by the authors). The authors state that most sex prior to age 15 is coerced, and coerced sex is much less likely to involve birth control or STD prevention measures. There is a very high rate of STDs among teens.

Intervention

Efforts at intervention target parents of adolescents, organizations and professionals responsible for adolescents, and the adolescents themselves. Because there is a series of known turning points or events that potentially lead to sexual intercourse, pregnancy, and parenting decisions, interventions can be tailored according to any of these events. Encouraging parents to regularly communicate about issues of sexuality can promote strategies that are in keeping with the values of the family. It is important for parents to develop methods of communication that elicit involvement rather than resistance.

Interventions target issues such as postponing sexual activity, prevention of risk factors such as drug and alcohol abuse, using measures to protect against pregnancy and STDs, and family planning matters. These interventions range from provision of information to alternative activities and more complicated measures and programs.

Somewhat over 50% of females and nearly 66% of males have sex prior to age 18. In recent decades, the proportion of younger females (age 14-16) has especially risen. The span of years between first sex and marriage is a large window during which unwanted pregnancy can occur.

Issues associated with this younger age range include:

• Longer period of risk
• Lower likelihood of contraception
• More sexual partners
• Higher likelihood of high-risk sexual behavior, including alcohol or drug use in connection with sex or having a series of partners (impairment that is associated with drug use reduces the capacity to make sexual decisions and effectively use contraception or safe sex)

A great deal of attention to this issue has concentrated on the evaluation of programs that can impact sexual practices of adolescents, including behaviors that may prevent STDs. For example, in a large study of African American girls aged 15 to 21 years that were seeking sexual health services, it was shown that STD/HIV prevention intervention significantly improved condom use and incidence of chlamydial infections. (DiClemente, et. al., 2009) African American females in this age range have been especially of concern because of possible biological susceptibility to HIV infection, poor access to health and intervention programs, and high rates of STDs and pregnancy. (DiClemente)

It has been speculated that teens engaging in high-risk behavior may be especially prone to high-risk sexual behaviors, but research is showing great variety in degree of high-risk sexual behavior that is independent of other high-risk behaviors. (Santelli, Carter, Orr, & Dittus, 2009)

Therapists play an important role in public health, because of their level of contact and trust with families and adolescents that they can influence. For example, therapists can acquaint family members with useful information that may affect their decisions regarding child-rearing and sex-related behaviors.

One area of concern is that of media exposure. Media include television, Internet, texting, music players, video players, Internet social media, and any other mode of transmitting information through media. Research has repeatedly shown a variety of effects of television on children and their later development. For example, a study showed a 33% increase in individuals having sex in early adolescence who were exposed to adult-targeted television and movies. (Children\'s Hospital Boston, 2009) This kind of information may influence parents of young children in particular, over whom they have the most control when it comes to media consumption. According to Science Daily, "The researchers encourage parents to follow current American Academy of Pediatrics viewing guidelines such as no television in the bedroom, no more than 1 to 2 hours of screen time a day, and to co-view television programs and have an open dialogue about its content with your children." (Children\'s Hospital Boston)

Also, the effect of therapeutic programs in reducing distress in adolescents may reduce behaviors that create vulnerability to STDs and pregnancy in adolescents. Research suggests that for many, distress precede unwanted pregnancy, rather than the other way around. (Mollborn & Morningstar, 2009)

This provides additional motivation to make screening for symptoms of depression and distress a part of standard health screening for adolescents. This includes talking frankly with teens about their sexual behavior and the nature and consequences of responsible behavior. This includes the importance of birth control and safe sex for sexually active adolescents.

Crime and Communities

Environment and peer group have a strong influence on the likelihood of criminal and violent offending in adolescents. For this reason, therapists are well justified in encouraging parents to, whenever possible, to choose locations for home, school, and activities, where the prevailing climate is low in crime and violence.

Many urban areas are like war zones, according to researchers involved in studying the effect of violent communities on adolescent behavior. There is interest in the biological tie-in of trauma affecting the adrenal pituitary axis as well as on the effect of violence on adolescent\'s perception of his or her own odds of longevity. Research has shown that young offenders from such communities have a high rate of having been victimized, and having seen violence, including dead victims of violence. Much work is needed to understand the psychological aspects of such violence. Surprisingly adolescents who feel that they are likely to be killed before age 21 or 35 are only somewhat more likely to offend, by a factor of 3.5%, according to a very large survey of adolescents.

(Brezina, 2009) The result of growing up in high-crime areas is, for many, to have a, "bleak outlook on life and a sense of \'futurelessness\'." (Brezina) The study included interviews with young offenders, and a review of the National Longitudinal Study of Adolescent Health, also known as Add Health, which contains responses from over 20,000 adolescents.

Even disastrous circumstances that do not involve crime have a profound impact on mental health of adolescents. Research on survivors of Hurricane Katrina found durable increases of mental health problems as long as 27 months on follow up provided. These serious emotional disturbances (SED) included, " Characteristics of SED include inappropriate behavior, depression, hyperactivity, eating disorders, fears and phobias, and learning difficulties." (Virginia Tech, 2010) The incidence of SED believed to be directly attributable to Katrina was 9.3% for the population, and the level of SED overall for the population was 14.9%. According to the report, "The study found that youth who experienced death of loved one during the storm had the strongest association with SED. Exposure to physical adversity was the next strongest."

Although mental health professionals are typically concerned with the recovery of individuals and families, social conditions have a profound effect on levels of violence and unwanted pregnancy. While poverty is associated with these rates, analysis across nations and U.S. states reveal that the level of inequality between rich and poor also correlate. Pickett, Mookherjee, and Wilkinson (2005) state, "… homicides and adolescent pregnancies appear to be associated with relative rather than absolute poverty. Indeed, the degree of income distribution within a society has been linked to homicide rates within and outside the United States…" Thus, in addition to diagnostic factors pertaining to trauma and personality, cultural factors and attempts to overcome the humiliation of inequality must be accounted for in programmatic responses. For example, attraction to gangs and the relative opulence of successful gangsters can be seen as an effort to break out of the limitations of one\'s social conditions. Sociopathy and seeking protection are not the only factors that contribute to gang affiliation.

Prostitution is much more common than many parents realize, and it is fueled by the financial needs of males who attempt to make a career of pimping. They have a variety of strategies for enlisting girls in prostitution. Pimps who are not as risk averse will not consider the age of majority to be a barrier.

It is difficult to do justice to prostitution, because it takes diverse forms, and can involve many types of victimization, victimizing, and danger. The most common motive for adolescent prostitution is money, especially as an answer to poverty and having limited marketable skills or education. Prostitution is a typical way for runaways to survive and attempt to get established.

However, better-educated individuals may become involved because of the even greater rewards to be derived from their potentially higher-class clientele. It is often associated with drug use and other crime, especially in males. Females are most likely to be caught, because they are easier to identify as prostitutes. A history of physical and, especially, sexual abuse and incest is strongly associated with prostitution. (Flowers, 1990) Parents who are mystified as to why their middle-class child would engage in prostitution may find the answer in the highly materialistic attitudes of many teens, and their intense motivation to have expensive clothes and shoes and other finery. They may also get a thrill out of the initial feeling of sexual power and affiliation with people who are older, more powerful, and have lots of possessions. A substantial percentage of prostitutes are male. The percentage has been estimated to be one third.

Studies indicate that only a small percentage of females enter prostitution as the result of kidnapping, physical coercion or even induction by a pimp. However, those who work under a pimp, tend to be highly coerced through manipulation and violence. There are many ways that prostitutes are in danger, including violence from customers, and drug addicts, STDs, and violence experienced in the course of other crimes or drug use. (Flowers, 1990)

Problems and their Sources

Assessment

Early detection and intervention are proving to be very important in preventing the development of a variety of behavioral and psychiatric problems. Risk for behavior and psychiatric problems often show as signs by childhood or early adolescence. These signs must be detected, as early intervention can greatly reduce later problems and suffering. (Natsuaki, Cicchetti, & Rogosch, 2010)

A thorough assessment is as important for adolescent behavior problems as for any population. Many of the issues in this course will help to sensitize the therapist to assessment considerations.

Situational factors: Adolescents are very sensitive to their familial environment as well as to their peers and communities. Stress in any of these domains may result in behavior problems. Determining the source may make all the difference in developing a relevant treatment plan. Consider situations such as parental job loss, violence at school, and pressure to join gangs in the community. A single individual may be the source of stress, but in a situation that the adolescent does not want to disclose. Although it is controversial as to how much parents should investigate their adolescent children, the life-and-death nature of adolescent problems such as suspected drug abuse or cyber-harassment are incentives for monitoring. Many parents feel that installing monitoring software on the family computer is a safeguard.

It is important to think outside of the consultation room. Problems are not always resolved there. Often, especially with families, plans are made there so that problems can be solved through additional parenting strategies and family structure.

Cognitive problems: Poor adaptation and other behavior issues often have cognitive problems as a source. This area is very neglected in the mental health field, but it is a tremendous source of crime, homelessness, and suicide. Poor forethought and impulse control problems contribute to domestic violence and other behavioral problems. Whether the cognitive difficulties are permanent or amenable to recovery, it is important to recognize them and consult regarding the needs the represent.

Interplay of Genes and Environment

Overview: It is well-established that vulnerability to stress and risk for psychiatric disorders and behavior problems results from a combination of genetic and experiential factors. (Knowlton, 2005) For example, in a large study, males with low MAOI activity who suffered maltreatment were more likely to develop antisocial scores. Those who had high MAOA activity did not have elevated antisocial scores, despite maltreatment. Findings such as these have been replicated. (Knowlton)

On the other hand, many studies have implicated the behavior and attitudes of parents and other authority figures in having a profound effect on child and adolescent development. For example researchers have studied differences in the way parents treat two siblings. A large study looked at same-sex siblings who developed antisocial behavior and found that conflictual and negative parental behavior accounted for 60% of the variance. IT accounted for 37% of depressive behavior. The siblings who did not receive negative parental attention were much less likely to develop antisocial behavior. (Knowlton, 2005; Reiss et al., 1995)

However, external factors can counteract genetic vulnerability. Even in maltreated children with a known genetic vulnerability (a short allele for the serotonin transporter gene), those with social support had much lower depression ratings. (Knowlton, 2005) Animal studies have come to similar conclusions. For example, rats born to highly nurturing and low-nurturing mothers are strongly affected by parenting, even when they were not the biological descendent of a mother that was differently nurturing than the pups\' biological mother. The pups resembled their caretaking mother in behavior and temperament more than their biological mother. (Knowlton, 2005)

Interplay of factors: By understanding the roots of adolescent behavior problems, we can design more effective intervention. Researchers have been giving a lot of attention to the interplay of biological and environmental factors in producing behavioral problems in children, adolescents, and adults. Although there is much to learn, it is clear that brain anomalies, genetics, and environment not only have effects on behavior and development, but also interact to produce such effects.

Neuroimaging studies: Researchers are studying functions and structure of the brain with neuroimaging. A growing number of studies are investigating aggressive and violent behavior from a neurological perspective. Special attention is being directed to children and adolescents because of the crucial developmental stages they experience in which durable behavior patterns are established.

So far, most of these studies have investigated and given credence to the idea that deficits in the brain\'s circuits for processing emotions are the cause of pathological aggression. But research is also pointing to problems with the neural processes that enable both inhibition of behavior and the ability to be flexible and adapt to changes in how behavior is reinforced. There also appear to be problems with the areas of the brain that handle social cues and manage how people respond to social situations and act on their goals. (Sterzer & Stadler, 2009)

Genes and environment: An emerging area of research has to do with the interactive effects of upbringing and genetics on behavior. A large study provides a good example. This was a follow-up study of 1,037 children in New Zealand, followed from birth to age 26. It was a differential parenting study. Such studies look at people with the same genetic heritage, but different childhood experiences. In the case of differential parenting studies, the source of the different experience is one or both parents treating one child in the family different from another that has the same parents. (Caspi et al., 2002)

Among other things, the study found a high correlation between subjects with low monoamine oxidase A (MAOA) gene activity and antisocial behavior. However, the correlation applied only to those who had histories of childhood maltreatment. 85% of those with low MAOA activity and severe maltreatment had elevated antisocial scores. Subjects with maltreatment histories but normal MAOA activity did not have elevated antisocial scores. This shows that genetics can exert a very strong influence on how people respond to stress. These results have been replicated in another study. (Foley et al., 2004)

Differential parenting studies not only help us see the effects of genetics, but can also show us how environment can trump genetics. One large study found that 60% of the variation in antisocial behavior was accounted for by conflictual and negative parental behavior toward the adolescent, while not at the same-sex sibling. However, for depressive symptoms, the factor was only 37%. (Reiss et al., 1995)

Altered genetic expression: Researchers are discovering that a source of enduring personality traits that emerge from environmental factors is the alteration of genetic expression. That is, genes may be activated or suppressed by environment. This has profound developmental consequences, as well as short-term effects.

A study believed to support this contention was a 15-year randomized, controlled trial on the effect of home visits by a nurse to young, low-income women with children. As adolescents, the children of the women had much lower rates of antisocial behavior, chemical dependence and less lifetime sex partners. (Olds et al., 1998)

Intervention\'s generational effects: The effect on children of psychotherapy provided to their parents is not well researched, but these results are very encouraging. (Knowlton, 2005) It is likely that the impact of psychotherapy on parents effects their children\'s\' development through effects on gene expression, particularly in subgroups with specific genetic vulnerabilities. (Knowlton) The meaning of traumatogenic (potentially traumatizing) experiences to the child has a great deal to do with whether the child is traumatized. The role of parents and others in contextualizing (giving meaning that includes the significance to the larger social systems) in a positive, identity-affirming manner is very valuable. (Knowlton, 2005) Therapists contribute a great deal to the ability of parents and others to provide this guidance. A sufficiently consistently positive contextualization of trauma and stress most likely has a great effect in attenuating (reducing the intensity of) the expression of genetic vulnerabilities. Animal studies have shown reliably that environmental changes alter gene expression. (Knowlton)

We know that many well-adjusted individuals have experienced childhood maltreatment or trauma. It is becoming clear that many of those who experience the greatest negative impact are members of vulnerable subgroups with identifiable genetic polymorphisms (specific variations in genetic structures).

But the genetic view has provided reasons for optimism not only in protecting against vulnerabilities, but in bringing out positive genetic potentials. An illuminating animal study relates to this latter point. In rats bread into two types, highly nurturing and not nurturing, when the not-nurturing rats were raised by a nurturing rat mother, they developed normal maternal behavior as adults, despite their genetic predisposition to be not-nurturing. (Knowlton, 2005) Similar research was conducted with monkeys in preventing sociopathic and alcoholic behavior in monkeys genetically predisposed to these traits and lower serotonin production. (Knowlton)

Reading facial expressions and the amygdala: Another vulnerability factor for adolescent behavior has to do with misreading of others\' intentions and facial expressions and having exaggerated emotional responses that result from misperceiving that others have hostile or judgmental facial expressions when they do not. This is an aspect of borderline personality disorder (BPD). BPD and a tendency to misread faces are associated with smaller hippocampus and amygdala volumes. (Driessen et al., 2000; Schmahl et al., 2003; Tebartz van Elst et al., 2003) Early trauma causes changes in volume of brain structures that last into adulthood and affect behavior.

Hyper-reactivity of the left amygdala to facial expressions is found in persons with BPD. This is true for happy, sad, and fearful facial expressions. These individuals tend to attribute negativity to neutral facial expressions.

A study of response to facial expressions found that patients with BPD showed significantly greater left amygdala activation to happy, sad and fearful expressions compared with normal controls, and attributed negative qualities to neutral faces (Donegan et al., 2003)

Genetic vulnerability: There is probably a genetic connection as well, as a study found that subjects with the short allele (variation) of the serotonin transporter (5-HTT) promoter gene showed higher amygdala activity when they were exposed to fearful stimuli than were subjects had had the normally occurring long allele. (Hariri, et al., 2002)

Sociopathy is complicated by the fact that it comes with a high rate of other problems, particularly anxiety, depression, and ADD. Another correlation with the short allele is a higher rate of suicidal ideation or attempts. (Capsi, et al., 2003)

In keeping with the modulating affect of the social environment on genetic predisposition, a study showed that social support was an especially important factor affecting depression in maltreated children with the short allele of the serotonin transporter gene compared to controls. (Kaufman et al., 2004) These children were significantly more depressed without social support, and those who had social support had a much lower risk of depression.

There is a strong relationship between early trauma and having BPD, at a rate of 60% to 80%. It is likely that both the high level of childhood trauma and the BPD is largely accounted for by the genetic inheritance of both the child and the child\'s parents. Research is suggesting the same thing for adolescents and adults that are violent.

Note that clinicians are advised to refrain from offering personality disorder diagnoses for adolescents, because of their stigmatizing nature, and because of the fact that teens are in a volatile stage of development. However, characteristics of BPD in adolescents who are later diagnosed with BPD as adults are very consistent with the diagnosis.

Sociopathy and psychopathy: A great deal of attention is being given to sociopathy and psychopathy. Brain activation patterns show a type of arousal to images of harm to others that may indicate vigilance for opportunities for instrumental violence or even pleasure in others\' suffering. (Instrumental violence is highly purposeful violence, as opposed to reacting with rage.) Decreased responsiveness to stimuli that would normally elicit empathy may be an indication of being disconnected to social cues and consequences that encourage lawful and considerate behavior. This pattern is also associated with thrill seeking, presumably because thrill seeking produces a more normal range of subjective excitement in this population, creating greater feelings of well-being and mastery. This combination of insensitivity to others\' suffering and a need for excitement appears to be a formula for dangerous criminal behavior.

Family Dynamics with Poor-Functioning Adolescents

Stigma and moralism: Parents may lack an intuitive understanding of how to set expectations and bring out the best in their child. Often, such parents default to a moralistic stance that compound the problem by eliciting defenses or braking down the child\'s functioning. Defenses can include argumentativeness, avoidance, aggression, greater reliance on dysfunctional peers, drug abuse, and other acting out. Such results may also come from authority figures such as teachers adopting a judgmental stance.

Educating parents as to the child\'s developmental capacities and needs is crucial. Helping the parents to become motivated to acquire and enhance specific skills relevant to the situation is important.

About natural consequences or hitting bottom: It is commonly believed that the consequences of behavior will cause the child to change. However, deficits of the child, reinforcers, or established family dynamics patterns may prevent such development and change. If anything, the situation can get worse. This is important in substance abuse. The idea that people abusing substances need to hit bottom is only true when it\'s true. It is not a general truth. Many people do not have bottoms. Death or permanent impairment is often the consequence. Thus, a strategic and resourceful response must be engineered in concert with the therapist, family, and others involved in the child\'s life.

Repeating mistakes: The therapist must also be aware of limitations of the parents. One or both may have an impaired ability to learn from experience. Thus, they will repeat the same mistakes without modifying their approach to the problem adequately. This can include behaviors such as bailing out a child or making excuses or eliciting worsened behavior. This may be compounded by the psychological or cultural pressures pertaining to parenting or maintaining relationships. It may result from the child being effective at manipulation, perhaps quite intuitively and unconsciously. It may result from difficulty facing issues what will trigger grief in individuals who have difficulty experiencing grief and processing losses.

The therapist may be able to enhance the treatment plan by developing an understanding of the roots of repeated mistakes.

Failure to foster independence and relinquish control: Parents may be attempting to control and discipline their child in ways that are no longer appropriate now that the child is older. The child\'s efforts to be more independent may clash with the parents. This can cause escalation in both the child\'s and the parents\' behavior. This often responds to basic education from the therapist. In many cases, the child has developmental deficits, perhaps subtle ones that trigger the parent\'s efforts to exercise more control. These efforts may be well advised. However, the child will be attempting to exercise independence that his or her peers have. This requires more careful work with the family. Establishing clear understandings as to what kind of behavior from the child will result in which privileges is a helpful strategy that gets the child and parents communicating and collaborating more effectively. This is not appropriate if the needs of the child exceed the capacity of the parents, as occurs with severe emotional and behavioral problems. However, it is important not to underestimate the capacity of families to resolve such problems.

Fatigue and dyscontrol: Burnout in any family member may need to be addressed. Poor judgment, impulsive action, withdrawal, and signs of depression may be from fatigue caused by ongoing family conflict or worry about the child. Anxiety and poor self control may occur and express as increasing feeling of threat in which situations are disproportionately described as threatening. It is very important to adjust the treatment plan for such issues. Treatment that emphasizes desensitization and reprocessing (appropriate memory consolidation) may be important for anxiety symptoms. Individual psychotherapy or psychiatric evaluation may be needed for depression or anxiety.

Unresourceful cognitions: Also known as negative of dysfunctional cognitions or thoughts, such cognitions may be targeted in treatment. These are generally irrational thoughts, and may not be verbally expressed without help from the therapist in identifying them. They generally result from early or extreme trauma, a mood disorder, or the drive to control anxiety. The nature of the cognitions usually gives clues as to their source. They may respond to cognitive therapy or reprocessing such as that of EMDR or a somatic approach.

The therapist may need to help the parent boil down a stream of thoughts into a single, terse phrase, such as, "My child must do as I say." Once the essence of the thinking is identified, it is easier to treat. In the case of a "must" statement, such as the one identified above, reducing related anxiety is often important. Such resolution can result in a much easier path to improved and consistent parenting strategy adoption.

Family patterns: Family dynamics as conceptualized by current family therapy should be assessed and treated. Examples are referred to at various points in this course. Dynamics such as boundary problems, hierarchy problems, and emotional cut-off require intervention. Improvements in parenting and boundaries can greatly reduce anxiety and other factors that may be contributing to the adolescent\'s behavior.

Genetics: Multigenerational problems tend to have a significant genetic basis. This tells us that it is very important to evaluate parents for psychiatric issues, especially those that tend to exist in clusters in families with members that have the problems diagnosed in the adolescent. For example, there is a high concordance between parent and child ADD. ADD often comes with comorbidities such as bipolar disorder. An exclusive focus on learned patterns of behavior through factors such as modeling will limit the therapist unnecessarily.

Misapplied consequences and negotiation: It is important to ensure that parents are applying consequences to behaviors that will actually respond to those consequences. The same is true for negotiation. The child must be set up to succeed as much as possible. This alters the child\'s self-concept and role in the family. In the case of more serious behaviors or limitations, some kind of intervention may be necessary so that the child is able to respond to parenting efforts. This requires careful assessment and planning. Even more subtle behaviors, such as those seen with inattentive ADD, may require medication and coping skills before the child can overcome behaviors such as disorganization or not listening. Also, parenting strategies must be adjusted to accommodate any deficits of the child, just as intervention must be adjusted according to any deficits of the parent.

Cognitive Problems

A Very Common Problem: Cognitive difficulties often play a role in mental disorders and poor adaptation. They are very often an important factor in revolving door families. Cognitive deficits often go undetected and untreated. A large percentage of prisoners and homeless persons have cognitive deficits that have contributed to their problems. Cognitive deficits can impair the ability of individuals to benefit from psychotherapy, consultation, and other interventions.

Traumatic brain injury is a common source of cognitive and memory problems, and can be incurred through falls, sports accidents, car accidents and any other impact to the head. (Wongvatunyu & Porter, 2008) Often, the impact does not appear to observers or even to the victim to be serious enough to cause the problems that result. This is a primary cause of inadequate help seeking, diagnosis, and treatment. The result is that many people fall through the cracks and experience severe consequences in school, career, and social spheres.

Problems suggestive of cognitive impairment include difficulty initiating and planning tasks and activities, being organized, remembering information, and staying focused on a task. There may also be, "Behavioral problems that are difficult to manage, such as irritability, aggression, and disinhibited behavior..." (Wongvatunyu & Porter) The authors state that such problems, "...can become major sources of stress for family members...all members are likely to be affected." and that the family may experience, "higher levels of family dysfunction than families with psychiatric patients."

Often Misunderstood and Mistreated: Often, the therapist must cut through moral judgement and conflictual interactions to help parents see that they are actually fighting with long-term cognitive difficulties that require consultation and accommodation. People recovering from mental illness or drug addiction often have residual cognitive problems. When cognitive problems are made clear, a great deal of what has been going on begins to make sense, and families can become much more focused and productive in taking action to help the child. It may be advisable to have a neuropsychiatric assessment. This may be difficult to get funding for. Insurers may pay if there is a recommendation from the primary care physician.

Miscues: Parents and others can have difficulty understanding the nature of cognitive problems because they may wax and wane and may affect only one aspect of the child\'s functioning. The capabilities of the child may "prove" to the parent that there cannot be a disability. Parents may automatically take the behavior personally, feeling that they are being defied or sabotaged. This may be compounded by emotional dyscontrol that feeds into conflictual interactions with an uninsightful parent. Even mild impairment can cause many of these problems, depending on the level of understanding in the family. Parental expectations and rigidity can escalate mild problems.

Developmental and Personality Problems

Developmental Deficits

Generally, developmental disabilities are detected early, and parents have had a good deal of input prior to seeing a therapist. However, there are many points along the way in which parents may seek counseling. One example is the transition in which parents realize that they will not always be there for their child, and that steps must be taken to transition their child into independent living training. This usually occurs after the teen years, however.

Personality Disorders

Although it is not advisable to provide a personality disorder diagnosis to adolescents, characteristics are usually quite evident by adolescence. When parents consult with the therapist, they are likely to need consultation in which the child is not present, so that they may learn about the personality style and needs of the child. The rigid and stereotypic and sometimes manipulative nature of personality disorders may make such consultation difficult in the presence of the child, especially if the child is highly defensive. There is also the consideration of the impact on the child. The initial barrage of information and reactions by parents is unlikely to foster the security and development of the child.

The drive on the part of parents to support their child and defend against accepting the limitations of their child are especially evident with antisocial personalities. Parents have attempted to sacrifice themselves by taking responsibility for a crime committed by their child, even murder. In some cases, these were well educated, high-functioning parents.

Violence

The treatment plan must include realistic plans for reducing violence and providing safety. Therapists are unable to predict violence, but can review the situation for elevated risk.

Therapists may have to make safety-related decisions where threat of violence is concerned. This can include discussing actions that parents must take to protect themselves or siblings of the child, mandatory reporting to child protective services regarding threat to siblings, and even safety of the therapist. A careful assessment must determine the level of risk and possible need for placement. Parents must be trained on how to avoid being charged with child abuse or domestic violence after acting out by the child or a false allegation.

Psychiatric evaluation is indicated, particularly where mental illness is a possible source of threats or violence. It appears that risk of violence is elevated only in certain subpopulations of individuals with mental illnesses. Some of them have identifiable risk factors. (Elbogen & Johnson, 2009; Nestor, 2002; Swanson, et al., 2002)

In a longitudinal analysis, Crocker, et al., (2005) found that, among persons with severe mental illnesses and substance abuse, "ASPD, thought disturbance, negative affect, and earlier age at psychiatric hospitalization were predictive of aggressive behavior." However, "the SRP-II did not predict violence or criminality in this population. The antisocial lifestyle factor, which demonstrated good internal consistency and convergent validity, also did not predict violence." (Crocker, et al.)

Among the strongest risk factors for violence in the mentally ill population are history of violence, recent stressors, drug or alcohol abuse, thought disturbance, and comorbid antisocial personality disorder. (ASPD) (Crocker, 2005) The first episode of psychotic illness prior to treatment is a period of elevated violence risk. Earlier age of first psychiatric hospitalization also elevates risk. (Crocker)

Suicide

Suicide is the leading cause of death for persons aged 15 to 24 years. It is the sixth leading cause for those aged 5 to 14. The volatile nature of adolescence as a time of changing biochemistry and emerging identity can amplify the effects of stresses such as divorce, moving, and major events in the community. It is easy to underestimate the risk of suicide in any population, and certainly in adolescents. In the developing mind of an adolescent, this is heightened risk that suicide may appear to be a solution. Suicides that gain media attention, especially if it is highly sentimentalized in some fashion, are associated with an increase in suicides in the same age group. The American Psychiatric Association takes the position that suicide is a treatable mental health condition.

It is very important to validate concerns regarding possible suicide and to investigate and respond in a timely manner. Assess for the following suicide risk factors in all intakes:

Observable Suicide Risk Factors

• Signs of psychosis, such as hallucinations and bizarre thoughts.
• Change in eating and sleeping habits
• Withdrawal from friends, family, and regular activities
• Violent actions, rebellious behavior, or running away
• Drug and alcohol use
• Unusual neglect of personal appearance
• Marked personality change
• Persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork
• Frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc.
• Loss of interest in pleasurable activities
• Not tolerating praise or rewards

Actions that may be Suicide Risk Factors

• Expressions of low self-esteem such as being a bad person or feeling rotten inside.
• Making statements that are nihilistic: I won\'t be your problem much longer. Nothing really matters. What\'s the point, anyway? I won\'t be seeing you again.
• Putting their affairs in order such as by giving away meaningful possessions, and cleaning their room.
• Suddenly becoming cheerful after a period of feeling depressed.

Actual suicidal statements, such as, "I want to kill myself" should be taken seriously and evaluated.

Direct, supportive questioning about suicide is appropriate and will not increase the threat of suicide. If anything, awareness and concern from the therapist and family, especially when specific resources and help are mentioned, may reduce the level of threat.

It is not usually appropriate to expect a family to successfully monitor a teen to prevent suicide. Therefore, inpatient evaluation is often indicated during times of heightened suicide risk. It may be necessary to be assertive with the insurance and to facilitate the process of gaining approval and determining which facility to use. For pre-approval, there is usually a specialized mental health toll-free number to call. There is usually 24-hour emergency coverage, or an emergency number.

Policies will pay for emergency treatment that is not previously authorized, so long as it is shown that the admission was an emergency to a facility equipped for treatment of that emergency or to an emergency room. However, including a call to the insurer during preparation and transport of the teen if not sooner is advisable. The facility for initial emergency assessment and monitoring may not be a facility that can be approved for additional inpatient treatment. This is most likely a separate approval process, and will almost certainly require pre-approval, and may be dependent on which facilities are in the insurer\'s network. It is more difficult to get approval for inpatient non-emergency treatment in that the insurer is likely to have very restrictive standards for approving it. Families should be assisted in becoming aware of the limitations and requirements of their policies so that they are able to make informed decisions.

Much research has looked at demographic and stress variables associated with adolescent suicide risk. However, these variables are moderated, sometimes completely, by factors including social support from peers and family. For example, gay, lesbian, and bisexual teens overall have shown increased suicide risk, but this was not elevated in those who had such support. (Rutter & Soucar, 2002)

That said, the following are factors commonly associated with adolescent suicide risk: substance abuse, psychiatric disorders, family stress, antisocial behavior, and family suicide history. (Rutter & Behrendt, 2004) Hopelessness and hostility have been associated with elevated suicide risk. (Rutter & Behrendt) There is concern that racial and ethnic minorities\' suicide risk may be missed because of differences noted in their expression of suicide risk. Rates of suicide of minorities have increased, but Caucasian males continue to lead in risk.

Self Injury

Self-injury is an emerging area of study. It has been noted in diverse areas of the world. Demographic information is limited, but it has been seen across the age span. Female gender and adolescent age are most at risk. It is associated with elevated risk for axis I disorders and borderline personality disorder. It is most commonly thought of as cutting, usually on the underside of the forearm, but can take diverse forms, including poisoning. It is not intended to cause death, but is a suicide risk factor. (Nock, Joiner, Gordon, Lloyd-Richardson, Prinstein, 2006) It can usually be distinguished from a suicide attempt by the fact that it does not correspond anatomically or is superficial. It can serve as a release for inner pressure, a distraction from emotional pain, or a way of expressing anger at the self or others. It has not been shown to be an attempt to gain attention or help. A history of child abuse and living in a home that suppresses emotional communication are associated with self-harm. Bereavement and major stressors including discord between parents may lead to or escalate self-harm. Self-harm often coincides with alcohol use.

Research on treatment is only beginning, but cognitive behavioral therapy and dialectical behavior therapy are recommended. It may be that it is reported to remit with progress in family therapy because self-injury is associated with various stressors and alcohol use. Because it is often performed secretly, increase awareness in the family, and in the community in general, and open discussion, may facilitate treatment.

Drug and Alcohol Abuse

Assessment and treatment for drug and alcohol abuse is a very deep subject. Substance abuse (SA) varies a great deal among communities and over time. The preference for various drugs varies over time and from community to community. According to a major SAMSA survey, 9.7% of teens had used an illicit drug in the 30 days preceding the survey. About 27.5% had used alcohol in the same period. Alcohol abuse occurs in a smaller percentage, and is roughly 27% higher in college students. (SAMSA 2000)

All clinicians should learn to assess for SA because it can occur in any population, from prison inmates to the elderly. Clinicians should have at least a general idea of the level of treatment required for various levels of abuse, and know resources in the community, including residential care, intensive outpatient treatment facilities, and individual providers. Getting an adolescent to accept and participate in treatment is tricky and depends on numerous factors. One of the more important ones is parental commitment and pre-planning. The more independent the teen is (for example, with a very strong peer group that is averse to treatment and enabling of SA) the less likely he or she is to consent to treatment.

A problem with intensive outpatient treatment is that it may not adequately insulate the child from peers, stressors, and circumstances that can lead to relapse. Inpatient treatment is much more expensive, but may sufficiently insulate the adolescent from availability of substances and substance abusing peers, that recovery will be more likely.

Beyond treatment, ongoing support is very important, and treatment providers generally provide excellent help in securing such support locally.

Cyber Issues

Use of digital media such as social media pose unique problems to families. This is a constantly evolving area. The knowledge of the adolescent regarding the technology may so far outstrip that of parents that the parents are not aware of what steps may be necessary to protect or discipline the child, or even what threats exist. Therapists should encourage parents to get at least a basic education in these matters. Monitoring of some kind should be maintained until at least late adolescence. One way to reduce the likelihood of trouble is to have the computer that the adolescent uses in a shared space. However, these media are so pervasive, that parents cannot insulate their children from them. Regular discussions between parents and children about the nature of online features and social media in particular keep communication open about this, and can be used as opportunities to sensitize children to ways that things can go wrong. These include things such as cyberstalking, public embarrassment or harassment, compromising photos going online and being downloaded and posted by many people, and predation by older individuals seeking sex or intending to cause other harm.

Special Focus: Delinquency

Although many adolescents engage in rule-breaking behavior or even rise to the level of delinquency, it is important not to assume that it is just a phase of development. About half of delinquent adolescents go on to adult sociopathic behavior. (Lytton, 1990) Delinquency is a precursor of adult criminality and sociopathy and is a prerequisite for a diagnosis of antisocial personality disorder in adults. The best predictor of adult antisocial behavior is the frequency of delinquent acts by the adolescent, and the earlier the emergence of such behavior, the greater the likelihood of it\'s persistence. (Lytton)

Environmental factors that most consistently correlate with teen antisocial behavior include, "inconsistent discipline, parental use of punishment as opposed to rewards, disrupted family life (especially father absence, family violence, alcoholic parent, or mentally ill parent), and low socioeconomic status." (Mealey, 1995) It is important to note that a common denominator in these variables is their tendency to handicap children in relation to their peers. These handicaps may include social skills, self-esteem, and academics. This creates a pressure in the individual to adopt sociopathic coping mechanisms and to affiliate with similarly disadvantaged and potentially sociopathic peers.

An important lens through which to view teen delinquency is as a collection of efforts to gain an advantage in a disadvantageous situation. Genetic and neurological factors are discussed elsewhere in this course. Advantages to be derived from a peer group in which the individual has more of a comparative advantage may include gaining access to resources including sexual opportunities, and to deter rivals. (Mealy, 1995)

While delinquency is less common in girls, the precursors for delinquency are the same. However, after menarche, girls who affiliate with older boys who engage in sociopathic behavior may emulate the behavior of those boys. This female population is more likely to outgrow the behavior with changes in peers.

The developmental course of delinquency can be important to treatment plan development. The later the development of the behavior, the greater the likelihood that situational variables may be primary and amenable to intervention. (Mealey, 1995)

Intervention

Psychosocial Interventions

It is very important that therapists learn and support the deployment of evidence-based interventions. Because this area is an emerging science, therapists must take note of such approaches as they are verified and gain training. Advocating for use of such approaches may be challenging because of the resistance of systems to change, and because of the resources some of these approaches are likely to require because of their likely emphasis on systemic integration and case management.

Although there are evidence-based interventions (treatment that is supported by replicated, controlled research) for a variety of problems in adolescence. However, the most widely used therapies that have been researched as to their application to adolescents have been shown to not be effective for adolescents. (Weiss, Catron, & Harris, 2000 ; Weisz & Jensen, 2001) Those that are supported, are not widely used in clinical practice. For some of the interventions, significant additional training or additional cost in conducting them pose barriers to adoption. In-depth discussion of treatment is outside the scope of this course. According to McClellan (2005), the following treatments have strong documented effectiveness:

• CBT for depression, anxiety, PTSD, and conduct problems
• Interpersonal psychotherapy for depression
• Parent training programs for parent-child interaction problems, enhanced parenting effectiveness, and reduced negative or coercive interactions or discipline
• Multisystemic therapy (MST) for more seriously impaired youth such as those with conduct problems and substance abuse. This approach uses "aggressive case management, comprehensive psychiatric
• services and targeted family interventions to maintain youth in their home communities." (McClellan) It is challenging to duplicate successful deployments of MST in new locations, because of difficulties in maintaining adequate treatment fidelity (consistent application of the treatment as specified). (McClellan)
• Various factors limit the usefulness of research, according to McClellan (2005). They include narrowly defined exclusion criteria and other factors that set the conditions of the study so far apart from actual clinical practice that it is not possible to confidently use the findings to support widespread adoption of the approach studied.

Various perspectives support the importance of improving support for adolescents in schools, in peer groups, and at home. This includes various studies and the emerging understanding of genetic vulnerabilities.

Psychoeducation

A psychoeducational intervention involves educating patients and caretakers or other relevant parties regarding the nature of the illness or problems, treatment, self-care, and coping in order to improve well-being and outcomes. Psychoeducation has been shown in numerous studies to benefit a wide variety of clients.

Psychoeducation can take place within the framework of cognitive behavioral therapy and in a family therapy format. The information provided must be relevant to the situation, and framed in a manner that is motivational to the clients. This means, in part, that great care is taken to match the wording used to the educational level and cultural background of the client. Psychoeducation is a highly developed and orchestrated component of manualized therapy (therapy that is very faithful to procedures spelled out in a manual) for some issues, such as dialectical behavior therapy and recovery programs for severe mental illness.

The therapist can use psychoeducation to assist parents in relations to their child. It can include factors such as how to negotiate with the teen without giving up parental authority, what constitutes developmentally-appropriate discipline, structure, and expectations, and difficult issues such as sex and drugs.

A frequent reason that parents and families see a therapist is conflict as their teen attempts to be more independent, particularly when the teen exercises poor judgment. It can be very valuable to train parents in managing this transition. This contrasts with facilitative approaches in which the emphasis is on enhancing communication and bringing issues to the surface so they can be dealt with. The therapist must determine how much of such therapeutic ingredients should go into the "recipe" for each family, based on a thorough assessment.

The issues of many families have gone far beyond developmental transitions and involve serious issues such as psychiatric disorders, legal problems, violence, and gang involvement. In these situations, a particularly heavy emphasis on psychoeducation, often with extensive case management, may be necessary to help parents avoid very serious additional negative outcomes. For example, in an effort to control a highly rebellious teen that has strong peer support outside of the home, a parent may find themselves charged with child abuse or domestic violence. This expensive and time-consuming ordeal can be prevented by helping parents understand the legal landscape, and to develop practical skills, specific protocols, and realistic expectations regarding their child.

Functional Family Therapy

Of the many schools of thought in family therapy, functional family therapy is a good example of an approach suited to highly challenging situations with adolescents. The approach includes a strong systems perspective and an organized approach to sequencing treatment. It was specifically developed for families with juvenile delinquents, and has shown efficacy in research (Sexton & Alexander, 2000) Its is applicable to a wider range of problems than families with juvenile delinquents. In contrast to this approach, however, this course recommends that working with community resources not be conceptualized as belonging in the late phase of treatment.

Expectations

Families and therapists regularly over- and underestimate adolescents. It is very difficult to predict the development of an adolescent, because this is a very malleable and potentially volatile period of life. One error is to assume that a criminal history, a diagnosis of a mental illness, or previous history of bad judgement or failing to live up to agreements indicate a lack of potential in a teen. Research has shown that individuals with these characteristics can be quite successful, and that this is not the exception to the rule. One study reviewed the course of life of individual in a housing program. The researchers found that those with criminal histories were just as likely to succeed as the other residents. (Malone, 2009) As with other research discussed above, this reinforces the belief that support can dramatically reduce impairment or destructive behavior in a vulnerable population. In this case, the resources in the housing project may have been the factor that reduced vulnerability. As much other research has shown, integrating support into troubled individuals\' lives can lead to much more adaptive behavior.

On the other hand, many parents have gotten into unbearable levels of personal and financial stress as a result to maintaining unrealistic expectations of their adolescent. This dynamic can have the appearance of an addiction. It appears that the unresolved grief pertaining to the child\'s problems, denial, and untethered parental instincts produce an inability to set and maintain realistic boundaries. The therapist can play a very important role in helping parents develop well-grounded boundaries, but must take great care not to alienate the parents by moving too quickly.

Methods such as motivational interviewing and behavioral experiments may help the parents make the transition. Also, desensitizing the parents\' feelings of being too inhumane or poor parents may help the parents reduce resistance to what others would consider to be effective parenting of difficult youth.

Impairments: One very valuable service in this regard is to educate parents as to the nature of any impairments of their child, and what needs arise from those impairments. This requires that there be a thorough assessment, and that the therapist be prepared with useful information and resources for the parents. An adequate understanding of impairment may have profound implications in managing home life, relationships, education, and career.

There is often great relief in understanding the nature of a child\'s impairments. It can also be a difficult transition for parents who are not well prepared to adapt to this information. The therapist must take the parents\' abilities into account in determining how to orient them to this information. There must be a strong emphasis on the potential and successes of individuals with the impairment. This should include the fact that there are resources available, and that there are known and proven strategies that help the given population. Parents may be concerned about some strategies, such as psychopharmacology or school accommodation. The therapist should be prepared to help parents resolve their concerns according to their values.

Confusion over sociopathy: One of the more difficult issues, though, is that of sociopathic traits. While the therapist does not want to unnecessarily stigmatize the child, it is crucial that parents understand the nature of sociopathy if their child truly fits the profile. To put it in plain English, the parents need to understand that sociopaths use people, and give little if any consideration to how this will harm other people, including their own parents.

Although sociopathy often comes with comorbitidies such as anxiety, depression, and ADD, it is important not to allow such traits to produce a false positive for sociopathy. Depression may be mistaken for a profound lack of empathy. The delayed development and resulting poor judgment or impulsiveness of ADD may be mistaken for sociopathic thrill seeking and criminality. The defensiveness and reactivity of a highly anxious child may be mistaken for the extreme denial, blaming, and deflection of responsibility of sociopathic delinquents. Even delinquency may be confused with sociopathy. There is a great range between people who commit crimes and true sociopaths. In other words, one does not have to be a sociopath to commit crimes. In one analysis, it was found that crime-prone individuals committed an average of 5 crimes per year, while sociopaths committed 50. (**cite)

Confusion about accommodation and support: There is much confusion about how much to help children and teens with neurological problems such as learning disabilities and ADD. There is a lingering sense, especially in the public, that it builds character to have these children experience natural consequences and moralistic judgements regarding their failings. Parents must be trained to accommodate children\'s impairments in such a way as to enhance their mastery and development. Generally, children with such difficulties work harder to accomplish less, and need to have specific kinds of support and skills training to improve their success. Much of the acting out and bad judgement seen in children with ADD is because of a lack of this kind of assistance. Children with impairments tend to retreat into fantasies and defenses in attempts to cope with their flagging self-esteem and the judgements and rejection that they experience. This often results in an overly passive and avoidant style of coping with certain types of problems and challenges. Some children, with more aggressive temperaments, will attempt to "blast through" their limitations or rejection in ways that can be disruptive or even violent.

Parents need to recognize the degree to which children with ADD are affected by their environment. (Parker, & Benedict, 2002) They can accomplish much more with external cues such as the parent keeping track of school assignments for them, and helping them organize their school papers. The initial reaction of the parent may be that this will create dependence and delay development of responsibility. However, these factors already exist because of the disability, whether it\'s mild or severe. A mild level of disability is most likely to be neglected, despite the repeated, negative consequences. The improved success that results from accommodations such as these help the child succeed in school and other areas of life as their nervous systems mature and they are able to adopt more and more of their own coping mechanisms. However, even as adults, many require continued support such as accommodations in college or coaching. Adolescents should be desensitized to the idea of requesting accommodations, as well as helped in staying in touch with their strengths, potential, and fundamental human dignity.

Those who have strong gifts generally use them to improve their success with people or with school. However, many of them hit an invisible ceiling as their responsibilities or academic challenges increase. This often occurs in college, when their academic career inexplicably falls apart as a result of distractions, lack of structure, greater demands, and liberal access to alcohol or drugs. Depression can be activated in the course of this, dramatically compounding the degree of failure.

Treatment Planning with Families

Full treatment planning for specialized adolescent psychiatric problems is outside the scope of this course. However, this section provides some general guidelines regarding treatment planing for families who have adolescents with behavior problems or conflict with the other family members.

Philosophy of Treatment

It is important to balance the needs of all family members. This can have a good effect on the well-being of all members. Not only should adolescents have a degree of dignity and rights at home, so should the parents. An important aspect of this is to generate change and learning that furthers the growth and well-being of the parents as well as other family members.

Prescribing actions: Therapists cannot ethically dictate the actions of parents. For example, it is ultimately up to the parents how far they will to in attempting to help their teenager with behavior problems. They may be unable to justify the cost of some plans. There may be too much risk for physical violence. The home may not have the resources to keep the teen at home. Placement may be a consideration. **FIX!!! However, parents that want to establish a good ongoing relationship with a teen that is displaying common problems such as neglecting chores and being disrespectful, can be brought into a negotiating frame of mind when privileges are made into bargaining chips. This is a non-professional variation on token economies used in clinical residential facilities.

Behavioral experiments can make treatment a much more conscious and productive experience. When there is a controversy over treatment plan elements, such as how much to trust the teen, this can be framed as an experiment. This makes it much easier to get parents to modify their behavior when the outcome is not as they expect. For example, if parents want to trust the child with a large amount of money at once, rather than doling it out when the teen complies with common-sense expectations, this can be framed as an experiment. A key element is to have a plan B that is agreed to prior to the experiment and that better incorporates the perspective of the therapist. If the parents\' experiment goes badly, they will try the agreed-upon plan B. There will be more motivation to put it in place because of the prior agreement and the evidence from the behavioral experiment that plan A is not yielding the desired results. An example of such as plan is that of enforcing a set of expectations that must be met in order for the teen to receive a weekly allowance. Parents can be trained to expect various legalistic and persuasive arguments from their child, and how to respond in order to maintain their resolve. Many parents need to be empowered to exercise more control over such matters.

Treatment Plan Areas

1. Parents\' Well-being

What aspects of parents\' well-being are affected or threatened? Examples include stress, health, and finances. Are the parents attempting to help their adult child in a manner that is in line with their values and capacities? What dynamics are preventing that? Has an unconscious agenda on the part of the parents sabotaged their boundaries? Has worry, stress, or concessions come to threaten the parents\' health or finances? The therapist must work with the parents on their well-being in this light.

2. Positive Family Structure

Evaluate the family structure. Can decision making be improved with changes in the balance of power? How intact is the parental subsystem? How effective is communication with other family members that can help? Are there additional family members that are realistic and can provide helpful understanding and information? Are other family members involved in a questionable manner? Is involving additional family members in therapy called for?

3. Adult Child\'s Well-being

What aspects of the adult child\'s well-being are affected or threatened? Because many adult children have multiple problem areas compounded by behaviors such as denial, this could become a bloated area of the treatment plan. However, many factors may need to be taken into consideration here because the parents are basing decisions on them.

Contract items can include, for example, "Compliance of adult child with agreements with parents." Sub-items could include, "Adult child will continue to attend classes regularly and provide specified documentation of this on a weekly basis."

Unlike a treatment plan for an adult child who is a client of the therapist, this component has two purposes. One is to support efforts to help the adult child. The other is to help parents adjust their behavior and plans, and to become more realistic and to adjust emotionally.

Diversity: Example Areas

GLBT Issues

Gay, lesbian, and bisexual teens, and those who are highly uncomfortable with their gender, are part of the diversity of the population. Family and cultural attitudes toward the GLBT population generate extraordinary levels of stress in GLBT adolescents. This has led to many suicides. This is particularly true for relatively isolated rural youth. However, the Internet is helping them find support.

It may not always be possible for therapists to resolve conflict in families over sexual orientation, because of the intensity of the bias and because of religious convictions. However, families may have misinformation that drives some of their actions. For example, there is the belief that homosexuality is a choice that can be reversed through counseling. Research has not supported this contention, although there may be some circumstances in which this, or something resembling this, has taken place. Information about the experiences gay teens may help parents adapt more effectively to their child\'s orientation.

Cultural Issues

As with any population, cultural issues must be taken into consideration. Therapists should be open about their familiarity or lack of familiarity with the cultural background of a given client. They should take reasonable steps to familiarize themselves with the culture of the client. Where adolescent behavior is concerned, families may have expectations that, for cultural reasons, differ a great deal from those of the therapist. Similarly, the expression of emotion may be much more or less pronounced than the therapist is used to, even to the point that it seems inappropriate to the therapist unfamiliar with the culture.



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