Hans Steiner

Posttraumatic Stress Disorder in Incarcerated Juvenile Delinquents

OBJECTIVE To assess the prevalence of posttraumatic stress disorder (PTSD) in severely delinquent subjects and to measure associated personality characteristics. METHOD Eighty-five incarcerated boys (mean age 16.6, SD = 1.2) with mostly violent offenses were studied. The sample was representative of the California Youth Authority population. They received a standard psychiatric screen, a semistructured interview for PTSD, and self-report questionnaires measuring personality traits and defenses. A nonclinical sex- and age-matched group was used for comparing psychometrics. RESULTS Subjects suffered from PTSD at higher rates than other adolescent community samples and at higher rates than those found in county probation camps. Thirty-two percent fulfilled criteria for PTSD, 20% partial criteria. One half of the subjects described the witnessing of interpersonal violence as the traumatizing event. Psychometric results converged in the predicted way: Subjects with PTSD showed elevated distress, anxiety, depression, and lowered restraint, impulse control, and suppression of aggression; they had high levels of immature defenses such as projection, somatization, conversion, dissociation, and withdrawal. CONCLUSIONS PTSD occurs at high rates in delinquents, and this finding has implications for management and treatment. Personality characteristics that might put individuals at risk for the development of PTSD were identified.

Psychiatric phenomenology of child and adolescent bipolar offspring.

OBJECTIVE To establish prodromal signs of and risk factors for childhood bipolar disorder (BD) by characterizing youths at high risk for BD. METHOD Structured diagnostic interviews were performed on 60 biological offspring of at least one parent with BD. Demographics, family histories, and parental history of childhood disruptive behavioral disorders were also assessed. RESULTS Fifty-one percent of bipolar offspring had a psychiatric disorder, most commonly attention-deficit/hyperactivity disorder (ADHD), major depression or dysthymia, and BD. BD in offspring tended to be associated with earlier parental symptom onset when compared with offspring without a psychiatric diagnosis. Bipolar parents with a history of childhood ADHD were more likely to have children with BD, but not ADHD. Offspring with bilineal risk had increased severity of depressed and irritable mood, lack of mood reactivity, and rejection sensitivity, while severity of grandiosity, euphoric mood, and decreased need for sleep were not preferentially associated with such offspring. CONCLUSIONS Bipolar offspring have high levels of psychopathology. Parental history of early-onset BD and/or childhood ADHD may increase the risk that their offspring will develop BD. Prodromal symptoms of childhood BD may include more subtle presentations of mood regulation difficulties and less presence of classic manic symptoms.

Body dissatisfaction and dieting in young children

OBJECTIVE To develop a broader understanding of young childrens knowledge and beliefs about dieting and body dissatisfaction. METHOD Sixty-two third through sixth-grade boys and girls completed audiotaped interviews and questionnaires regarding eating behavior, attitudes toward dieting, and body dissatisfaction. RESULTS Fifty percent of all children wanted to weigh less and 16% reported attempting weight loss. Children were well informed about dieting and were most likely to believe that dieting meant changing food choices and exercising as opposed to restricting intake. Their primary source of information was the family. Seventy-seven percent of children mentioned hearing about dieting from a family member, usually a parent. DISCUSSION Young children are knowledgeable about dieting and the concept of dieting does not necessarily mean caloric restriction to them. These data suggest that the family can play a powerful role in countering the development of eating concerns and body dissatisfaction in children.

Gay, Lesbian, and Bisexual Youth Risks for Emotional, Physical, and Social Problems: Results From a Community-Based Survey

OBJECTIVE Health problems of gay, lesbian, and bisexual (GLB) youth are reported as differing from those of heterosexual youth. Increased depression, suicide, substance use, homelessness, and school dropout have been reported. Most studies of GLB youth use clinical or convenience samples. The authors conducted a community school-based health survey that included an opportunity to self-identify as GLB. METHOD An anonymous self-report health care questionnaire was used during a community-based survey in 2 high schools in an upper middle class district. RESULTS Significantly increased health risks for self-identified GLB youth were found in mental health, sexual risk-taking, and general health risks compared with self-identified heterosexuals, but not in health domains associated with substance abuse, homelessness, or truancy. CONCLUSIONS Self-identified GLB youth in community settings are at greater risk for mental health, sexual risk-taking, and poorer general health maintenance than their heterosexual peers.

Practice Parameters for the Assessment and Treatment of Children and Adolescents with Conduct Disorder

These practice parameters address the diagnosis, treatment, and prevention of conduct disorder in children and adolescents. Voluminous literature addresses the problem from a developmental, epidemiological, and criminological perspective. Properly designed treatment outcome studies of modern psychiatric modalities are rare. Ethnic issues are mentioned but not fully addressed from a clinical perspective. Clinical features of youth with conduct disorder include predominance in males, low socioeconomic status, and familial aggregation. Important continuities to oppositional defiant disorder and antisocial personality disorder have been documented. Extensive comorbidity, especially with other externalizing disorders, depression, and substance abuse, has been documented and has significance for prognosis. Clinically significant subtypes exist according to age of onset, overt or covert conduct problems, and levels of restraint exhibited under stress. To be effective, treatment must be multimodal, address multiple foci, and continue over extensive periods of time. Early treatment and prevention seem to be more effective than later intervention.

Anorexia nervosa and bulimia nervosa in children and adolescents: a review of the past 10 years.

OBJECTIVE To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and treatment. METHOD Computerized search methods were combined with manual searches of the literature. A detailed review of the most salient articles is provided. Preference was given to studies involving children and adolescents that approached the subject from a developmental perspective. RESULTS The information from these studies is presented in a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent from the literature. Research specific to treatment of child and adolescent eating disorders remains rare. CONCLUSIONS Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is needed addressing normative data on the development of eating behavior and specific risk and resilience factors for pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence, long-term outcome in anorexia nervosa, and short-term treatment response in bulimia.

Violence Exposure, Posttraumatic Stress, and Personality in Juvenile Delinquents

OBJECTIVE To assess posttraumatic stress and its relationship to comorbid psychopathology, violence exposure, and personality traits in Russian male juvenile delinquents. METHOD Posttraumatic stress and comorbid psychopathology were assessed by a semistructured psychiatric interview (Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version) in 370 delinquent youths during winter-spring of 1999. In addition, violence exposure, personality, and psychopathology were assessed by self-reports. RESULTS Most delinquents reported some degree of posttraumatic stress: 156 subjects (42%) fulfilled partial criteria and 87 (25%) fulfilled full DSM-IV criteria for posttraumatic stress disorder (PTSD). Violence-related experiences (witnessing and victimization) were the most common types of trauma. Higher levels of posttraumatic stress were accompanied by higher rates of comorbid psychopathology, with the most striking differences occurring between the groups with full versus partial PTSD criteria. Violence exposure was related to temperamental behavior activation (novelty seeking), whereas PTSD symptom scores were predominantly related to behavior inhibition and poor coping (high harm avoidance and low self-directedness). CONCLUSIONS Similar to findings from American samples, Russian juvenile delinquents represent a severely traumatized population, mainly due to high levels of violence exposure. Those with full PTSD are the most severely traumatized and have highest rates of psychopathology, as compared to those with no or partial PTSD, and they require the most clinical attention and rehabilitation. Both exposure to violence and levels of posttraumatic stress are related to personality traits, which influence degree of exposure and individual perception of stress. The latter should be considered in individualized approaches to rehabilitation.

Trauma and Personality Correlates in Long Term Pediatric Cancer Survivors

To explore the relationship between PTSD and trauma-spectrum symptoms, including personality and functional correlates, in long term pediatric cancer survivors (N = 40), we assessed these constructs with a structured interview for PTSD, a clinical interview, and self-report questionnaires. Thirty-five out of 40 participants (88%) currently met at least one trauma symptom at a functionally significant level. These survivors demonstrate high levels of restraint and low levels of distress, representative of a repressive adaptive style. After more than 5 years since treatment completion, the relatively high levels of current trauma-spectrum symptoms may reflect the long-term deleterious impact of childhood cancer.

Mental health issues in unaccompanied refugee minors.

Previous studies about unaccompanied refugee minors (URMs) showed that they are a highly vulnerable group who have greater psychiatric morbidity than the general population. This review focuses on mental health issues among URMs. Articles in databases PsycINFO, Medline and PubMed from 1998 to 2008 addressing this topic were reviewed. The literature had a considerable emphasis on the assessment of PTSD symptoms. Results revealed higher levels of PTSD symptoms in comparison to the norm populations and accompanied refugee minors. In several studies, age and female gender predicted or influenced PTSD symptoms. The existing literature only permits limited conclusions on this very hard to reach population. Future research should include the analysis of long-term outcomes, stress management and a more thorough analysis of the whole range of psychopathology. Additionally, the development of culturally sensitive norms and standardized measures for diverse ethnic groups is of great importance.

Psychopharmacologic strategies for the treatment of aggression in juveniles.

Maladaptive aggression in youth is one of the most common and troublesome reasons for referrals to child psychiatrists. It has a complex relationship with psychopathology. There are several syndromes, which are primary disturbances of clustered maladaptive aggression, most notably oppositional defiant disorder and conduct disorder. However, problems with aggression also appear in a wide range of other disturbances, such as bipolar disorder, posttraumatic stress disorder, and mood disorders. Additionally, aggression is normative, serves an adaptive purpose and can be situationally induced. These complexities need to be carefully addressed before targeting maladaptive aggression psychopharmacologically. We summarize the literature on the psychopharmacology of maladaptive aggression in youth, focusing on disorders without cognitive impairment. We delineate the subtypes of aggression which are most likely to respond to medication (reactive-affective-defensive-impulsive in their acute and chronic form) and conclude with a discussion of specific medication strategies which are supported by controlled clinical trials and clinical experience.