Eric P. Hazen

Adolescent Psychological Development : A Review

1. Eric Hazen, MD* 2. Steven Schlozman, MD† 3. Eugene Beresin, MD‡ 1. *Instructor in Psychiatry, Harvard Medical School, Boston, Mass 2. †Assistant Professor of Psychiatry, Harvard Medical School, Boston, Mass 3. ‡Professor of Psychiatry, Harvard Medical School, Boston, Mass After reading this article, readers should be able to: 1. Discuss the processes of physical, emotional, social, cognitive, and moral development in adolescence. 2. Know the contributions of major developmental theorists, including Erik Erikson, Jean Piaget, and Lawrence Kohlberg, to the understanding of adolescent development. 3. Describe the relationship between adolescent behavior and recent findings from studies of brain development. 4. Identify the primary tasks of adolescent development. Adolescent patients present a unique set of challenges to pediatricians. A polite, compliant child can appear to transform into a surly, rebellious teen before a doctors eyes. Adolescence can be a tumultuous time, even when it is unfolding in a healthy manner. For this reason, and because there is so much individual variation in adolescent development, it can be particularly challenging to determine what is “normal” in adolescent development. Although previously believed to be uniformly a time of turmoil, this view has not been substantiated by large-scale studies. (1) Most teenagers progress through this period of life with few obvious behavioral problems. However, a sound and trusting doctor-patient relationship is required to appreciate the inner struggles many adolescents endure. A working understanding of the developmental tasks of adolescence and the processes through which they are achieved provides the best tool for a pediatrician in evaluating an adolescents development. Any discussion of adolescent development should include a definition of adolescence itself. Determining the exact onset and conclusion of adolescent development can be difficult, with complex biologic, psychological, and social paradigms all playing roles. Cultural factors also must be considered in determining the developmental norms of adolescence. Normal development from one cultural perspective may appear aberrant when viewed through the lens of another culture, and in an increasingly multicultural society, such considerations are especially important. For example, an Asian youth who begins to question his parents’ values may …

Patient- and Practice-Related Determinants of Emergency Department Length of Stay for Patients With Psychiatric Illness

STUDY OBJECTIVE To identify patient and clinical management factors related to emergency department (ED) length of stay for psychiatric patients. METHODS This was a prospective study of 1,092 adults treated at one of 5 EDs between June 2008 and May 2009. Regression analyses were used to identify factors associated with ED length of stay and its 4 subcomponents. Secondary analyses considered patients discharged to home and those who were admitted or transferred separately. RESULTS The overall mean ED length of stay was 11.5 hours (median 8.2 hours). ED length of stay varied by discharge disposition, with patients discharged to home staying 8.6 hours (95% confidence interval 7.7 to 9.5 hours) and patients transferred to a hospital outside the system of care staying 15 hours (95% confidence interval 12.7 to 17.6 hours) on average. Older age and being uninsured were associated with increased ED length of stay, whereas race, sex, and homelessness had no association. Patients with a positive toxicology screen result for alcohol stayed an average of 6.2 hours longer than patients without toxicology screens, an effect observed primarily in the periods before disposition decision. Diagnostic imaging was associated with an average 3.2-hour greater length of stay, prolonging both early and late components of the ED stay. Restraint use had a similar effect, leading to a length of stay 4.2 hours longer than that of patients not requiring restraints. CONCLUSION Psychiatric patients spent more than 11 hours in the ED on average when seeking care. The need for hospitalization, restraint use, and the completion of diagnostic imaging had the greatest effect on postassessment boarding time, whereas the presence of alcohol on toxicology screening led to delays earlier in the ED stay. Identification and sharing of best practices associated with each of these factors would provide an opportunity for improvement in ED care for this population.

Sensory Symptoms in Autism Spectrum Disorders

The aim of this review is to summarize the recent literature regarding abnormalities in sensory functioning in individuals with autism spectrum disorder (ASD), including evidence regarding the neurobiological basis of these symptoms, their clinical correlates, and their treatment. Abnormalities in responses to sensory stimuli are highly prevalent in individuals with ASD. The underlying neurobiology of these symptoms is unclear, but several theories have been proposed linking possible etiologies of sensory dysfunction with known abnormalities in brain structure and function that are associated with ASD. In addition to the distress that sensory symptoms can cause patients and caregivers, these phenomena have been correlated with several other problematic symptoms and behaviors associated with ASD, including restrictive and repetitive behavior, self-injurious behavior, anxiety, inattention, and gastrointestinal complaints. It is unclear whether these correlations are causative in nature or whether they are due to shared underlying pathophysiology. The best-known treatments for sensory symptoms in ASD involve a program of occupational therapy that is specifically tailored to the needs of the individual and that may include sensory integration therapy, a sensory diet, and environmental modifications. While some empirical evidence supports these treatments, more research is needed to evaluate their efficacy, and other means of alleviating these symptoms, including possible psychopharmacological interventions, need to be explored. Additional research into the sensory symptoms associated with ASD has the potential to shed more light on the nature and pathophysiology of these disorders and to open new avenues of effective treatments.

Hospital Variability in Emergency Department Length of Stay for Adult Patients Receiving Psychiatric Consultation: A Prospective Study

STUDY OBJECTIVE We ascertain the components of emergency department (ED) length of stay for adult patients receiving psychiatric evaluation and to examine their variability across 5 hospitals within a health care system. METHODS This was a prospective study of 1,092 adults treated between June 2008 and May 2009. Research staff abstracted length of stay and clinical information from the medical records. Clinicians completed a time log for each patient contact. Main outcomes were median times for the overall ED length of stay and its 4 components, or time from triage to request for psychiatric evaluation, request to start of psychiatric evaluation, start to completion of psychiatric evaluation with a disposition decision, and disposition decision to discharge from the ED. RESULTS The overall median length of stay was more than 8 hours. Median times for the components were 1.8 hours from triage to request, 15 minutes from request to start of psychiatric evaluation, 75 minutes from start of psychiatric evaluation to disposition decision, and nearly 3 hours from disposition decision to ED discharge. The median disposition decision to discharge time was substantially shorter for patients who went home (40 minutes) than for patients who were admitted (2.5 hours) or transferred for psychiatric admission at other facilities (6.3 hours). When adjustments for patient and clinical factors were made, differences in ED length of stay persisted between hospitals. CONCLUSION ED length of stay for psychiatric patients varied greatly between hospitals, highlighting differences in the organization of psychiatric services and inpatient bed availability. Findings may not generalize to other settings or populations.

The nature of speech production impairments in anterior aphasics: an acoustic analysis of voicing in fricative consonants.

This study investigated the acoustic characteristics of voicing in English fricative consonants produced by anterior aphasics and the effects of phonetic context on these characteristics. Three patients produced voiced and voiceless fricative-vowel syllables in isolation, following a voiced velar stop, and following a voiceless velar stop. Acoustic analyses were conducted of the amplitude and patterning of glottal excitation, as well as fricative noise duration. Results showed that, although the patients are able to coordinate the articulatory gestures for voicing in fricative consonants, they demonstrated abnormal patterns of glottal excitation in the amplitude measures, owing to weaker amplitudes of glottal excitation in voiced fricatives. Context effects failed to emerge because of dysfluent speech. These results suggest that the locus of the speech production deficit of anterior aphasics is not at the higher stages of phoneme selection or planning but rather in articulatory implementation, one related to laryngeal control.

Changes in the Diagnostic Criteria for Autism in DSM-5: Controversies and Concerns

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published by the American Psychiatric Association (APA) in May 2013. The new edition introduced major revisions to the diagnostic criteria for autism spectrum disorder (ASD). These changes could have a significant impact on patients and families affected by ASD, as well as mental health providers and researchers working in the field of autism. In this article, we will review the changes and the rationale behind them. We will then discuss the concerns that have been raised about the new criteria and the evidence that relates to these concerns.

Successful treatment with duloxetine in a case of treatment refractory bulimia nervosa: a case report.

The authors report a case of treatment refractory bulimia nervosa successfully treated with duloxetine, a combined serotonin and norepinephrine reuptake inhibitor, with complete remission of the patients bingeing and purging behaviours. This case is discussed in the context of existing literature on the psychopharmacology of bulimia nervosa.

Case 18-2017 — An 11-Year-Old Girl with Difficulty Eating after a Choking Incident

An 11-year-old girl presented with difficulty eating and weight loss after a choking incident that had occurred 14 days earlier. She had always been a selective eater, but fear of choking led her to consume only a liquid diet. A diagnosis and management decisions were made.

Case records of the Massachusetts General Hospital. Case 10-2015. A 15-year-old girl with Graves’ disease and psychotic symptoms.

Dr. Emily K. Gray (Psychiatry): A 15-year-old girl with Graves’ disease was admitted to this hospital because of psychotic symptoms. The patient had been well until approximately 3 months before the current admission, when intermittent dizziness, palpitations, near syncope, diaphoresis, polyuria, polydipsia, diarrhea, chest and abdominal pain, headaches, and increasing protuberance of the eyes developed. Eleven weeks before this admission, she was evaluated at school, at an emergency department of another hospital, and at her pediatrician’s office. She had hypertension, with a blood pressure of up to 168/86 mm Hg, and tachycardia, with a pulse of up to 126 beats per minute. A complete blood count and the erythrocyte sedimentation rate were normal, as were blood levels of electrolytes, calcium, glucose, total protein, albumin, total bilirubin, urea nitrogen, and creatinine. Screening of the blood for toxins, Lyme disease, and antibodies against thyroglobulin, microsomes, and thyroperoxidase was negative, as was a urine pregnancy test; other test results are shown in Table 1. A few days later, 10.5 weeks before this admission, she was seen in the endocrinology clinic of this hospital. On evaluation, the patient reported no intolerance to heat or cold, tremor, or weight loss. She had had anemia as an infant and had undergone a cholecystectomy for cholelithiasis at 14 years of age. Menarche occurred at 11 years of age. She took no medications, her immunizations were up to date, and she had no known allergies. She was born in the Dominican Republic and came to the United States at 6 years of age. She lived with her parents, maternal grandmother, and two sisters. She was enrolled in an individualized education program in high school. She did not smoke, drink alcohol, or use illicit drugs. Her mother had celiac disease, a paternal aunt had hypothyroidism, her paternal grandmother had vitiligo and had undergone a thyroidectomy, and her father and siblings were healthy. On examination, the blood pressure was 110/72 mm Hg, and the pulse 114 beats per minute; the temperature and respiratory rate were normal. The height was 166.3 cm, the weight 81.1 kg, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) 29.3. Proptosis, a pronounced From the Departments of Psychiatry (E.P.H.), Pediatrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Psychiatry (E.P.H.), Pedi‐ atrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Harvard Medical School — both in Boston.

Case 10-2015

Dr. Emily K. Gray (Psychiatry): A 15-year-old girl with Graves’ disease was admitted to this hospital because of psychotic symptoms. The patient had been well until approximately 3 months before the current admission, when intermittent dizziness, palpitations, near syncope, diaphoresis, polyuria, polydipsia, diarrhea, chest and abdominal pain, headaches, and increasing protuberance of the eyes developed. Eleven weeks before this admission, she was evaluated at school, at an emergency department of another hospital, and at her pediatrician’s office. She had hypertension, with a blood pressure of up to 168/86 mm Hg, and tachycardia, with a pulse of up to 126 beats per minute. A complete blood count and the erythrocyte sedimentation rate were normal, as were blood levels of electrolytes, calcium, glucose, total protein, albumin, total bilirubin, urea nitrogen, and creatinine. Screening of the blood for toxins, Lyme disease, and antibodies against thyroglobulin, microsomes, and thyroperoxidase was negative, as was a urine pregnancy test; other test results are shown in Table 1. A few days later, 10.5 weeks before this admission, she was seen in the endocrinology clinic of this hospital. On evaluation, the patient reported no intolerance to heat or cold, tremor, or weight loss. She had had anemia as an infant and had undergone a cholecystectomy for cholelithiasis at 14 years of age. Menarche occurred at 11 years of age. She took no medications, her immunizations were up to date, and she had no known allergies. She was born in the Dominican Republic and came to the United States at 6 years of age. She lived with her parents, maternal grandmother, and two sisters. She was enrolled in an individualized education program in high school. She did not smoke, drink alcohol, or use illicit drugs. Her mother had celiac disease, a paternal aunt had hypothyroidism, her paternal grandmother had vitiligo and had undergone a thyroidectomy, and her father and siblings were healthy. On examination, the blood pressure was 110/72 mm Hg, and the pulse 114 beats per minute; the temperature and respiratory rate were normal. The height was 166.3 cm, the weight 81.1 kg, and the body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) 29.3. Proptosis, a pronounced From the Departments of Psychiatry (E.P.H.), Pediatrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Psychiatry (E.P.H.), Pedi‐ atrics (N.A.S.), Surgery (S.P.), Radiology (C.A.R.), and Pathology (P.M.S.), Harvard Medical School — both in Boston.